22 February 2019
One of the most common medical conditions I treat as a family medicine doctor is anxiety. You most likely know what anxiety is, or personally know someone who suffers from anxiety. At my family medicine clinic, Beyond Primary Care, located in Ann Arbor Michigan, all appointments are a minimum 30 minutes, with opportunities to increase the appointment time. This length of time is an important for the treatment of any mental health concern.
Anxiety has many faces. Among others, it is that feeling of stress, apprehension, relentless worrying, tightness in your stomach or chest, racing thoughts, restlessness, rapid breathing, diarrhea, lack of concentration, and insomnia.
Does a person have to experience all those symptoms to have anxiety?
Does having even just one symptom mean you need medical treatment?
The best answer is that it depends on you and the severity is.
Dr. Jeff O’Boyle (who is writing this posts) experiences anxiety, you (who is reading this post) have experienced anxiety. Everyone has experienced anxiety. I feel a bit like Oprah when I just wrote that. Regardless, the truth is we all experience anxiety from the moment we are born.
Think about your own children, or other children you knew as newborns. The frequent cycles of crying and calmness. The newborn doesn’t know why they are wet, why they are hungry, why they feel cold, why they can’t sleep. So they cry. This is in part- anxiety. Eventually, after a few weeks (or months for some parents), the newborn stops crying. Overtime when there is a dirty diaper, or it learns that it will be feed every 3 hours, or the baby starts connecting it’s sleep cycles and starts doing it’s nights- much to the relief of the parents- the crying and fits decrease. The point is, we all have anxiety as newborns. We develop coping mechanisms though, inherent within our own emotional control centers to deal with this anxiety.
Just as no two people are affected the exact same way by anxiety, there is no “one size fits all” treatment that cures this condition. What works for one person might not work for another. The best way to treat yourself is to become as informed as possible about the treatment options, and then tailor them to meet your needs.
In my professional opinion, becoming informed about anxiety does mean you have to be honest to yourself with how you feel. Extending that honesty to your family and friends you trust, and honest to your healthcare provider is crucial is knowing that your mental health is not something to deal with alone.
It also takes time to find the right treatment. It might take some trial and error to find the treatment and support that works best for you. Understand how these treatments work and that they don’t work immediately. Anxiety cannot be treated like a case of bronchitis, where you get a course of antibiotics and poof- you are better in 10 days. In today’s society, I feel we are so focused on instant gratification and grossly appreciable results that we lose focus on the long-term control and relief.
Your emotional system only knows where it is at right now based upon where it just was. This is why in this work we are constantly reassessing our intervention afterwards. Where are you now? Now we do something. Where are you now? So we know if we are being effective or not. Do you want to waste your time doing stuff if you don’t know it’s working? I don’t. I want to do more of the stuff that is working and less of it that isn’t. As a doctor I’m constantly measuring.
But measuring anxiety, or any other component of mental health is not done over minutes to days, but weeks to months. Again, patience is key to treatment.
19 February 2019
Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Brussels Sprout and Apple Pizza. 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.
Brussels Sprout and Apple Pizza
Prep Time: 30 minutes
Total time: 1 hour
Adapted from: Hello Veggie
1 prepared pizza crust
3/4 cup raw walnuts
3 tablespoons shredded parmesan cheese
2 tablespoons olive oil, divided
Salt and pepper to taste
4 ounces Brussels sprouts, trimmed and thinly sliced
1 large apple, cored and thinly sliced
1 tablespoon honey
1 tablespoon roughly chopped fresh thyme
3/4 cup shredded fontina
1 tablespoon balsamic glaze
1) Preheat oven to 425F
2) Place walnuts, parmesan cheese, and 1 tablespoon olive oil in a food processor and process until crumbly. Season with salt and pepper.
3) In a large skillet over medium-high heat, add 1 tablespoon oil. Once heated, add the brussels sprouts and apple splices; cooking about 10 minutes- until apples and sprouts being to brown.
4) Add the honey and thyme to the skillet and stir until mixed, then remove the skillet from the heat.
5) Top prepared pizza crust with walnut mixture, then the sauteed Brussels sprouts and apples. Top with shredded fontina cheese.
6) Bake for 10-15 minutes.
8 February 2019
Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Spinach and Cheese Ravioli with Meatballs. 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.
Creamy Spinach and Cheese Ravioli with Meatballs
Adapted from: Peas And Crayons
Prep Time: 20 minutes
Total Time: 40 minutes
1 lb prepared meatballs
1 (9 oz) package small refrigerated ravioli
2 teaspoons olive oil
1 medium red onion, chopped
4 cloves garlic, chopped
2 tablespoons butter
2 tablespoons all purpose flour
1 cup milk with extra to thin sauce as needed
½ cup parmesan cheese, grated
2 tablespoons pesto
Salt and pepper to taste
½ cup mozzarella cheese, grated
1) Bring a medium pot of water to a boil.Cook the ravioli according to package directions until al dente. Drain water ravioli, place ravioli in a bowl and set aside.
2) Place a saute pan over medium-high heat, cook the meatballs until tender.
3) While the pasta and meatballs cooks, heat the oil in a large stainless pan/skillet over medium-high heat. Add the onion and cook until tender and translucent, approx. 5 minutes. Add garlic for 2 minutes.
4) Add butter and garlic to the pan. Once butter has melted, add flour and whisk constantly with a metal whisk until the butter and flour are well combined and the mixture darkens in color a bit.
5) Pour in milk and whisk vigorously to combine. Whisk often until mixture thickens. Add parmesan, pesto salt, and pepper.
6) Once your sauce has reached desired thickness, fold in your chopped spinach and cooked ravioli and meatballs.
7) Thin sauce if desired with additional milk and adjust salt and pepper to taste. Remove from heat, top with grated mozzarella and cover with the pot’s lid to melt the cheese.
5 February 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 does Direct Primary Care (DPC) work with your insurance? The answer for a vast majority of DPC clinics is yes, DPC works with your insurance, but not for your insurance. This is an important distinction.
This is the essence of DPC, that it works directly for you- the patient! We forgo insurance payments in order to save our patients from the arbitrary, intrusive decisions that inevitably follow with third-party payers (health insurance). Furthermore, since DPC practices are independent, we are free from hospital contractual agreements and can offer reduced prices on laboratory tests, imaging, and medications. As noted by this Wall Street Journal article, hospital systems are ignorant of their actual costs. Instead, they often increase prices to meet profit margins.
While DPC’s goal is to cover the vast majority of healthcare needed for all individuals, there are many instances in which a patient may need to utilize their insurance to see providers or utilize services outside the membership.
This would be when a member needs to see a specialist for a condition that requires care past what could be offered in a family medicine clinic. Examples include physician specialist, psychiatrists, counselors, and physical therapists.
Say a member needs a referral to an oncologist- which is a doctor that specializes in the diagnosis and treatment of cancers. No one ever anticipates needing a such a doctor. But when called upon, a DPC doctor will work to find a doctor that accepts your insurance, help coordinate your care, while minimizing your financial impact. How do we minimize your financial impact? If that specialist requires imaging, medications, or blood work, DPC practices will work with you to find the lowest costs– often through our DPC clinics- that meet the needs of the health provider.
From time to time, accidents or serious medical conditions do occur and an elevated level of care is required where a member needs to be monitored 24/7 by a team of doctors and providers.
An example could be a member suffers a broken arm from falling and needs to be hospitalized for a major surgery. DPC will help communicate with your inpatient hospital team of providers making sure they know your current health status and working towards understanding your options for care upon discharge. While we may not be able to care for you in the hospital, we can certainly use virtual medicine (also known as telemedicine) to discuss your needs and questions. We can also give you helpful advice to make sure you won’t receive any unexpected bills from the hospital upon your discharge.
The following picture is a hospital bill from a patient who posted her hospital bill online. The patient was contemplating hurting themselves and walked into an Emergency Room seeking help. The patient states the “physician charges” are NOT shown that bring the grand total to over $18,000!
Here is some FREE Doctor Advice from Beyond Primary Care: In the hospital, ask to know the identity of every unfamiliar person who appears at your bedside. If you’re too ill, ask a companion to serve as gatekeeper. Write it down. What seems like a pleasantry may constitute a $700 consultation
One of the coolest features about DPC is many practices offer in-clinic dispensing of hundreds of generic medications, often at substantial price differences compared to retail pharmacies. Still, there are times a member needs or would benefit from a certain medication that is brand name only (very expensive) and would be best obtained through insurance that requires a prior-authorization from the insurance company.
In this scenario, we will work to fill out the necessary paperwork to get your needed medications at reduced costs or even reach out to the pharmaceutical companies seeking a reimbursement or free supplies on your behalf. A great example is we got one of our members Vivitrol, a vital medication for Medication Assisted Therapy in Addiction Medicine. This medication costs over $1,000 on the market, but we worked to get our member the medication FREE of charge with their insurance. Did I mention the office visit and the injection itself were included with the membership? So the patient literally paid $0. Saving money for our patients gets me so excited!
18 January 2019
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.
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.
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.
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.
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”:
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.
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.
Prep Time: 30 minutes
Total time: 1 hour
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)
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!
10 January 2019
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.
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.
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.
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.
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.
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.
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!
13 December 2018
Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Mexican Twice Baked Sweet Potato. 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
Mexican Twice Baked Sweet Potato
Prep: 1 hour
Total time: 1 hour, 10 min
Adapted from: Pinch of Yum
3 medium sweet potatoes
1 can corn
1 teaspoon salt
1.5 tablespoon cumin
1 can black beans, rinsed and drained
1 tablespoon butter
1 yellow onion, chopped
2-4 individual chipotle peppers in adobo sauce, minced or puréed
1 ounce cream cheese
1/4 cup sour cream
1/2 cup cilantro
6 tablespoons shredded cheese (pepper jack, cheddar, Colby)
1) Preheat oven to 350 degrees, bake sweet potatoes for 45-60 minutes
2) While sweet potatoes are baking, place corn in a heavy cast iron skillet over medium heat with no butter or oil. Add salt and cumin, sprinkling on top. Do not stir! Let corn roast for several minutes before stirring. Let it roast for a few more minutes before stirring again. Continue this for 10 minutes, until corn is browned on the outside. Set in bowl with the black beans.
3) Sauté the onion in the butter over medium heat until soft and translucent. Set aside
4) Remove sweet potatoes from the oven when fork-tender. Let cool for 5-10 minutes.
5) set oven to broil
6) Cut the sweet potatoes in half. Scrape the core of the sweet potatoes out, leaving the skins intact. Do not discard the skins!
7) Mix the core of the sweet potatoes with the cream cheese, sour cream, chipotle peppers, and salt. When well-mixed, gently stir in onions, black beans, corn, and cilantro.
8) scoop the filling into the skins and top with 1 tablespoon of shredded cheese. Broil for about 5 minutes or until cheese is melted
7 December 2018
Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Tuna Harvest Salad. 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.
Tuna Harvest Salad
Prep Time: 15 minutes
Total Time: 20 minutes
Adapted from: Damn Delicious
4 (2 oz) cans tuna in water, drained
1 cup greek yogurt
2 teaspoons lemon juice
2 teaspoons dijon mustard
½ cup carrots, diced
½ cup green onions, diced
½ teaspoon garlic powder
Salt and Pepper
4 leaves Bibb lettuce
2 apples, sliced
1 cucumber, sliced
1 (16 oz) package baby carrots
1 (16 oz) package raw almonds
1 lb red grapes, seedless
1) In a medium bowl, combine tuna, yogurt, lemon juice, dijon mustard, carrots, green onions, and garlic powder. Season with salt and pepper to taste.
2) Place lettuce leaves into meal prep container. Top with tuna mixture.
3) Arrange apples, cucumbers, baby carrots, almonds, and grapes around tuna mixture.