Month: January 2019

BPC Good Eats: Stuffed Cabbage Klumpke

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28 January 2019

Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Stuffed Cabbage Klumpke. These recipes are my attempt, in a way, to bridge that Doctor’s adage of “Eat Better & Exercise More.” In this post, I will showcase a healthy meal made on a budget, my pictures are pretty decent, and that is how I got into this food endeavor.

Stuffed Cabbage Rolls
Prep Time: 45 minutes
Total Time: 8 hours
Adapted from: Original

Ingredients Filling
1 lb of ground beef
1 cups rice, uncooked (white or brown)
1 cup onion, minced
1 egg
½ tsp garlic powder
½ tsp pepper
1 tsp salt
1 tsp thyme
1 large green cabbage

Ingredients Sauce
2 (8 oz) cans tomato sauce
1 dash garlic powder
½ tsp thyme

Instructions
1) Bring large stock pot of water (½ filled) to boil.
2) Peel off any bad exterior cabbage leaves. Place whole cabbage in pot for 5 minutes.
3) Remove cabbage from pot. Carefully peel off cabbage leaves (try not to split them), until you reach leaves that are not cooked or do not peel easily off. Return the remaining cabbage ball to the pot and cook for 4-5 minutes.
4) Remove cabbage from pot. Reserve 2 cups of the cooking liquid. Peel additional leaves until you have approximately 12-15. With each large leaf take a knife flat against the leaf and trim off excess vein (the part that connects the leaf to the root). The goal is to have a flat, pliable leaf to work with.
5) Quarter the remaining heart of the cabbage, set aside. Mix together all of the filling ingredients in a medium bowl.
6) Lay out a large cabbage leaf. In the middle place about ¼ cup of filling. Starting with the vein side, fold the cabbage leaf over the filling. Then fold in the sides and roll until a small pouch is made. Secure the roll with a toothpick. Repeat with all remaining large leaves.
7) Heat a large skillet with a bit of oil (veggie or olive oil will work)
8) Place cabbage rolls in the skillet and cook until the cabbage is lightly browned. Flip and sear other side of the cabbage rolls. *This is the secret to really tasty Klumpke because the cabbage gains lots of flavor when browned!
9) After browning all of the rolls, place the rolls, cooking liquid, and sauce ingredients into a slow cooker on low setting for 6-8 hours.

 

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Avoid the Sneeze Pee

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18 January 2019

Adult Guide to Urine Incontinence

At my family medicine clinic, Beyond Primary Care, located in Ann Arbor Michigan, I see a fair number of individuals who experience urinary incontinence. Urinary incontinence is when urine leaks, from a number of causes, that becomes frequent or severe enough to be a problem. Incontinence happens in men and women. Unless I specifically ask some individuals, some may think that incontinence is an unavoidable part of getting older or a known consequence of child birth. I wanted to tell everyone that urinary incontinence can be addressed with both non-medication and medication intervention. In this guide, I talk about non-medication treatments.

Your Anatomy

The bladder is a hollow sac (like a balloon) with muscular walls. It sits behind the pelvic bone. The bladder is part of the urinary system, which includes two kidneys, two ureters, a bladder, and a urethra. The kidneys take waste and water out of your blood to make urine. The urine travels down your ureters to the bladder. When you’re ready to urinate, the urine empties through the urethra.

What is Average

It sounds like kind of a lot, but, depending on how much liquid you drink, peeing roughly 8 times during the day is average. Even though it’s annoying, getting up once to twice during the night is also considered normal. Most bladders hold about 2 cups of fluid (473 mL). A classic excuse among the frequent pee-ers: “I just have a small bladder!” Turns out, there’s some truth to that seemingly odd refrain. Anatomically, everybody can be different, just like some people are tall and some people are short.

Turn Perception into Measurements

If you’re irked by how much time you spend atop the throne, consider keeping a diary to chart your bathroom breaks. When you actually tally up your trips, what feels like a lot might be totally normal. Again, most bladders hold about 2 cups of fluid. If you’re going to the bathroom frequently and producing less than that, that may not be normal.  And yes, you should actually measure. Grab a container and see if you’re hitting 1.5 to 2 cups.

Existing Medications &  Other Causes

  • Take a look at your existing medications. Medications may lead to incontinence. As example, diuretics (water-pills) used to treat high blood pressure can cause the kidneys to make a lot of urine really quickly. Review your medications with your doctor. 
  • Diabetes: If you’ve ruled out other causes, there’s a chance your constant peeing is due to diabetes. If your blood sugar’s high, the kidneys won’t be able to process all of it, and some can spill into the urine. That sugar will essentially pull more water out of you, so you’ll be generating more pee. 
  • Urinary Tract Infection:  Signs of an infection may include pelvic pain, increased frequency, increased urgency, and possible blood in the urine.
  • Pelvic Support and Urinary Tract Problems: The pelvic organs are held in place by supportive tissues and muscles. Problems occur when these tissues are stretched, weakened, or altered by stool impaction, pregnancy, childbirth, abnormal growths, fistulas, or aging.

Treatment to Avoid the Sneeze Pee

Keep Drinking Fluids. Understandably, if you spend a lot of time thinking you have to pee, you might be inclined to dehydrate yourself just a touch. If you don’t drink as much, you won’t have to go as often, right? Turns out this way of thinking is bladder sabotage. When you drink less, the urine becomes more concentrated, and the more concentrated it is the more irritating it can be to the bladder, which can trigger the sensation that you have to go more often.”

Timed voids. The good news for the small bladdered is that you can train your bladder to hold more fluid. If you give into the urges too often, you are training the bladder not to hold as much (Just don’t hold it so long that it starts to hurt). You could be inadvertently doing this if you’ve preemptively started emptying your bladder more frequently in just-in-case scenarios, like in hopes of warding off leakage, say, before a workout.To train your small bladder to bulk up, implement “timed voiding”:

  • Urinate every 30 minutes for two days, whether you have to go or not.
  • Add 15 minutes to the regimen: Urinate every 45 minutes for two days.
  • Keep adding 15 minutes to this regimen, until over time you have trained your bladder.

Hitting the (pelvic floor) gym. The stronger those down-there muscles, the easier it is to hold urine in. It’s better to learn how to use your muscles to tighten the pelvic-floor area. Yes, we’re talking about Kegel exercises. If you don’t already know, the exercises are performed by tightening and releasing the muscles you’d use to stop the flow of urine without moving anything else in your body. Find your pelvic muscles by tightening the rectum as if trying not to pass gas or pinching off a stool. Done best after emptying the bladder. Tighten and hold for up to 3-5 seconds, then release and relax 5 seconds. As muscles get stronger, progress to 10 seconds. Do these exercises 10-20 times a session, 3 times a day. Remember to breath normally. It may take 4-6 weeks to notice results.

BPC Good Eats: Pizza Dough

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16 January 2019

Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Pizza Dough. These recipes are my attempt, in a way, to bridge that Doctor’s adage of “Eat Better & Exercise More.” In this post, I will showcase a healthy meal made on a budget, my pictures are pretty decent, and that is how I got into this food endeavor.

Pizza Dough
Prep Time: 30 minutes
Total time: 1 hour
Original Recipe

Ingredients
3 cups bread flour
1 (.25 oz) package active dry yeast
2 tablespoons olive oil
2 teaspoons salt
1 tablespoon white sugar
1 1/4 cup water
1 tablespoon garlic powder
1 teaspoon onion powder
2 teaspoons dried basil
2 teaspoons dried oregano
3 tablespoons honey, divided
1 cup cornmeal
1 cup unbleached flour (for rolling)

Instructions
1) Microwave water in measuring cup to 110 degrees F/ 45 degree C, time varies on microwave.
2) Stir sugar into warm water, then sprinkle yeast on top but do NOT stir. Allow to sit untouched for 10 minutes.
3) While waiting, sift bread flour, garlic powder, salt, and onion powder into mixer bowl. Add 1 tablespoon honey, basil, oregano directly to bowl.
4) Once yeast/water mixture has rested 10 minutes, turn mixer to slow and add water/yeast mixture slowly. This is a little bit of an art, add to quickly or too much and your dough will be soggy and clump. Add too little and your dough will be too dry.
5) Continue mixing until dough is elastic and smooth, about 10 minutes, for last 2 minutes turn mixer to faster speed.

6) Turn mixer off, let dough sit for a minimum 30 minutes before using. If longer times are allowed, refrigerate. Ideal is 4 hours to overnight. If refrigerating, take out and allow 30 minutes to return to room temperature before rolling.
7) When ready, preheat oven to 425F.
8) Once dough has rested, spread flour over clean counter space. Place dough on counter, use rolling pin spreading and flipping dough until desired consistency. Allow to rest for 5 minutes before transferring to pizza stone or pan.
9) Place cornmeal liberally on stone or pan before transfer pizza dough. Trim to desired length (use extra dough and re-roll for pizza sticks or a smaller pizza).
10) Crimp edges of pizza with hands. Use fork and poke multiple spots at pizza dough for aeration.
11) Bake pizza crust alone for 3-4 minutes. Take pizza dough out of oven, use remainder of honey and brush ends of pizza to create flavorful crust.
12) The pizza crust is all done, top per your favorite recipe!

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Neurontin, Gabapentin, Controlled Substance

Gabapentin as a Controlled Substance

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10 January 2019

This past Monday, 1/7/18, the state of Michigan classified Gabapentin (brand name Neurontin) as a controlled substance (C V) as it has been increasingly been reported abused by some patients.

Gabapentin is approved by the Food and Drug Administration (FDA) to treat epilepsy and neuropathic pain caused by shingles. That is it! However, as many people already recognize it is prescribed ‘off label’ by health care providers for various reasons including including depression, anxiety, migraine, fibromyalgia, muscle and joint pain, and bipolar disorder. According to some estimates, over 90% of Neurontin sales are for off-label uses. A report by IMS health found that 57 million prescriptions for Gabapentin were written in the U.S. in 2015, a 42% increase since 2011.

Many providers, including myself, have never screened for Gabapentin abuse in the past as this medication is not tracked by the state’s controlled substance tracking system nor is it typically detectable in most office-based urine drug screens. When Gabapentin is taken alone there is little potential for abuse. Yet, when taken with other drugs, such as opioids, muscle relaxants, and other anxiety medications, there are reports that Gabapentin can have a euphoric effect.

While I see the concern for making Gabapentin a controlled substance in Michigan, it is going to be a tremendous headache for everyone. The community, hospitals, treatment facilities, and doctor offices.

Isn’t it ironic that Michigan is locking up Gabapentin (which IS affordable and has good application when used appropriately) but legalizing marijuana?

It will eventually be easier for people to smoke a joint then get Gabapentin.

Currently, a month supply at Beyond Primary Care for 300 mg (90 pills) is $4.59. The street value for Gabapentin just went up because of this classification and that makes me concerned. Hell, the CDC lists Gabapentin as a non-opioid alternative treatment for pain control. This move by the State of Michigan makes my job as a physician, patient advocate, and provider certified in chronic pain management increasingly harder to deliver affordable and effective treatment to my patients.

Meatloaf

BPC Good Eats: Meatloaf

admin

6 January 2019

Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Meatloaf. These recipes are my attempt, in a way, to bridge that Doctor’s adage of “Eat Better & Exercise More.” In this post, I will showcase a healthy meal made on a budget, my pictures are pretty decent, and that is how I got into this food endeavor.

Meatloaf
Prep Time: 20 minutes
Total Time: 1 hr 15 minutes
Adapted from: Original

Ingredients Loaf
1.5 pounds ground beef
1.5 pounds ground pork
1 yellow onion, minced
½ cup apple sauce
½ cup bread crumbs
½ cup roasted red peppers, minced
1 egg
1 tsp garlic powder
Salt and pepper

Ingredients Sauce
½ cup chili sauce
½ cup ketchup
1 cup brown sugar
2 tsp Worcestershire sauce
1 tsp garlic powder

Instructions:
1) Preheat oven to 350.
2) Mix together all of the ingredients for the loaf. Add additional bread crumbs if too wet, but mixture should be moist.
3) Divide mixture into 4 separate loaves and place onto a foil-lined cookie sheet.
4) Bake loaves for 30 minutes. Meanwhile, mix sauce ingredients together.
5) After 30 minutes of baking, add sauce on top of the loaves. Bake for an additional 20 minutes.

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Virtual Home Medicine in Direct Primary Care

admin

3 January 2019

Hi, thank you for reading! My name is Dr. Jeff O’Boyle. I am a board certified family medicine physician. My clinic, Beyond Primary Care is located in Ann Arbor, Michigan. In this post I am answering a common question that I receive, and that is how does Direct Primary Care (DPC) take care of it’s members with virtual home medicine? Virtual home medicine, also referred to as telemedicine, is a where you connect with your doctor via phone or computer’s webcam without physically being in the doctor’s office.

The Exception rather than the Rule

Why is it nearly impossible to get a doctor to talk with you over the phone in a timely fashion? Because because certain services like virtual home medicine are typically not be reimbursed by private insurance carriers and government payers. Nearly 40% of what we do in medical offices the patient doesn’t actually have to be there. But why are you there? That is the only way for doctors in a fee-for-service system to get reimbursed for your care, is to actually make the patient physically come in to the brick-and-mortar office to be seen- no matter how routine (eg- common cold, urinary tract infection) or obscure (filling-out paperwork for FMLA or work) the visit seems.  

Standard of Care with DPC

Under the DPC model of care, we naturally provide such care – yet another freedom we enjoy together as a result of our independence from the restrictions of third-party payment. As noted by this Forbes article, telemedicine pairs well with DPC. Since DPC has opted out of insurance contracts altogether, and we contract directly with you, the patient. DPC offers our patients around-the-clock access to primary care medical needs in exchange for an average fee of $50-75 per month. Phone calls, emails, texts, FaceTime- are included in a patient’s membership. Patient are routinely connected with their doctors within minutes to hours when reaching out, versus days to weeks with fee-for-service doctors.

Benefits of Virtual Home Medicine

One of the defining characteristics of DPC is that we keep our practices small so we can spend more time with our patients. Because we have the increased time in our visits to know you well, we can streamline your care when you’re sick away from home or even at home. Many illnesses can be diagnosed and treated with a simple conversation by phone or computer webcam.

Say you are traveling out of state and feel sick. You have access to a conversation with your DPC doctor from your pocket. We will discuss your symptoms, discuss management, then we’ll locate the nearest pharmacy and order the medications most appropriate for your present circumstances.

As a doctor, there have been times where I have seen patients- with just the act of walking from the waiting room to the examination room- get winded or experience excruciating pain. Why would doctor offices allow this? Where is the concept ‘first, do no harm?’ If you are local, often times the DPC doctor may deliver the medications right to your address, saving you the hassle of a trip that may potentially worsen the condition.

Curbside Referral Consult

Adding more value the DPC membership at no additional cost to our patients is many DPC practices participate with electronic consults, or online consultations for speciality care. Primary care can handle nearly 80-90% of all medical conditions, but there are times when a condition may be past our scope of practice. Instead of rushing the patient to the nearest specialist, which will result in a bill likely through the patient’s insurance, many DPC practices seek medical advice on behalf of our patients through an online service call RubiconMD. Through this online service, many DPC practices pay a monthly fee where we can get medical advice on behalf of our patients from more than 100 medical specialities. The company guarantees a response time within twelve hours. The DPC physician fills out the necessary forms, get’s the response through the RubiconMD service, then will pass this medical information onto the patient- at no cost!