Blood Pressure Control

Yesterday a patient presented to my office requesting to be put back on her blood pressure medications. This is a rather unusual request, most patients are trying to stay or get off their medications. However she had been tracking her blood pressures since she stopped medication about six months previously. She was consistently running “bottom number” or diastolic pressures in the high 80’s or low 90’s. Fortunately she realized this was too high over time and came in to get hee prescription refilled.

There are good studies indicating that individuals who check their BPs routinely have better control[1]. I encourage my patients to have their own cuffs to check their pressures both at home and at work. They can bring their cuff to our office and calibrate it to make sure it is accurate. Then they can bring their “numbers” with them when they come in for appointments or just send them to me through the patient portal on, letting me know when they do so.

Together we can keep you healthy!

  1. Agarwal R, et sl. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension 2011;57:29–38.

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Patient Portal Success

“Doctor Nieder, my wife got this new smartphone and she wants to know why she can’t communicate with you using it. Can she?” This coming from a 70 something patient. I’d seen his wife a few days previously and she had a question about her medication. She wanted to know why she couldn’t just email me about it.

We talked a little bit about the insecurity of email and personal health information (PHI in my world). Then I happily explained that,  indeed she could communicate directly with me using her smartphone. I gave him my card with the RelayHealth information on it, directed him to look to the upper right-hand corner of the website and click “register”. This will take her to this page:

Relay Health Sign in


After finishing the registration process, pick a provider – me – and then RelayHealth sends me notification of the registration. After that she can directly communicate with me. He left the office happy to have good news for his wife.

I know many of my colleagues are hesitant to give patients direct access but consistently the portal has saved me more time than cost me. Patients ask thoughtful appropriate questions. If an appointment is needed a staff member calls them. Otherwise I can give an equally thoughtful response on my own time. As they say “It’s a win-win.”


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If it looks like a duck…

If it looks like a duck and quacks like a duck, it’s probably a duck. 32cm Giant DuckThis is a common expression in medicine that simply means, if a patient gives you symptoms that fit a particular disease, don’t go looking for another disease without a good reason. Today a patient presented with low back pain and morning stiffness. She is 80 years old. I thought of osteoarthritis but she was concerned about cancer. She has no history of cancer but she had looked on line and scared herself. After we spoke a little while, she was reassured. She’d spent the nasty winter being much less mobile than usual, then had immediately begun doing hard work in her yard, pulling weeds, mulching and mowing her grass. Of course I was impressed that this 80-year-old woman still did all those things. I was able to reassure her and have her try some walking and water exercises to try to loosen up her back muscles. If it doesn’t get better, we’ll consider other causes. So she agreed to do a little less bending and stooping and pulling until she’d limbered things up a bit with walking. I’ll see her back if necessary in a month. We both agreed that when you hear hoofbeats, you shouldn’t think of zebras.


Interesting–I have no idea why we use so many animal analogies in medicine….

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The Google Pre-consultation

Patients frequently preface a question with “I know doctors hate it when their patients look stuff up on the internet, but…” In typical doctor fashion I interrupt them at this point and say, “No I don’t, I like it when patients do that.” It takes a moment or two for that to take. Then they nod and ask whatever is worrying them that they’ve found on line.

The Google “pre-consultation” is a fact. According to research done by the Pew Research Center, 72% of internet users have searched the internet for health information.[1] Many doctors I know, or at least the ones on social media, will pro-actively ask their patients “what did you read about it online?” This often relieves a couple of anxieties. First, that the doctor will negatively judge the patient for checking on line and secondly, the patient can proceed to ask questions about what is worrying her or him.

So when you come in to see me, instead of the “petit papier” with all your questions, I’ll expect them to be in a list on your smart phone or tablet (the paper is OK too). And if you want to send them in ahead of time, be my guest! Go to, register and send me your questions before your appointment. We can save time and cover more ground that way.

Oh, and when you are researching on the web, be careful out there. You can find lots of wrong information, chicanery and just plain bad advice on the internet. Here are my recommended web sites for disease searches:

If you are looking for patients with similar conditions to yours, there are some great patient communities out there as well:

And always, if you think of a question you forgot to ask please contact me through


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#HCLDR Chat – May 7 2013 – Physician Burnout


Dr. Kathy NiederPhysician burnout is reported at an all time high. In August 2012, a study printed in JAMA:Internal Medicine cited a 10% higher rate of burnout than the general population, with those of us in primary care being among the highest at risk.[1] Medscape produced a similar study in March of this year with nearly 40% of surveyed physicians reporting symptoms of burnout.[2] These studies are unsurprising to patients and doctors, both experiencing the negative effects of providers who are irritable, inflexible and exhausted.

This past Wednesday KevinMd published a blog post on how Social Media recharged me and my ability to practice medicine. My Twitter feed lit up all day with comments as the post link was tweeted. It was startling to have hit a nerve so effectively. Lisa Fields and I reflected on why people identified with that post. Was it mainly physicians who connected with it? Or people…

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So Dizzy My Head is Spinnin’

It’s a common problem. At least once a month a patient presents to the office with two to five days of a spinning, nauseating sensation. Sometimes it is dramatic, with a miserable individual sitting in her chair, a garbage basket between her knees lest she move her head the wrong way and commence to throwing up.

Bad as these symptoms are, almost 99% of the time the episode will be short-lived and dissipate on its own. Physicians give symptomatic treatment like an anti-nausea pill to help the patient through the worst days but there are no pills that effectively treat  the problem.. The first two to three days are the worst, with milder symptoms that can last up to six weeks.

The problem is called vertigo and its cause is usually due to a disorder of the peripheral vestibular system, the equipment in your inner ear that tells your brain where you are in space. Usually the episodes occur when the patient moves his/her head in a specific direction. The medical term most common for this is Benign Paroxysmal Positional Vertigo (BPPV). Or sometimes we just call it labyrinthitis.

Occasionally this can become chronic and relapsing. There is a maneuver that the Ear, Nose and Throat doctors employ to help resolve severe or persistent cases called the Epley maneuver. Usually patients get resolution of their symptoms after the maneuver. It does tend to cause pretty significant symptoms during the procedure, so if you are already improving on your own, I don’t recommend this.

In the meantime:

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Your Walgreen’s Primary Care Provider Will See You Now

Unless someone is completely media averse, Walgreen’s decision to treat chronic diseases in their Take Care Clinics should not come as news. Patients rarely ask me how I feel about going to Immediate Care Centers or the “Quickie Mart” versions in retail pharmacies and grocery stores. Unfortunately as primary care physicians became harder to see at convenient hours, people went to physician-staffed Urgent Care Centers on the weekends and evenings originally. Then retail centers staffed by physician assistants and nurse practitioners opened for simple acute problems. Now Walgreens plans to care for patients’ chronic conditions, like hypertension, diabetes and asthma. They announced this as a way to “bridge the gap in patient care” and “improve care coordination”. Given that I have never received records on a patient treated in one of their Take Care Clinic, it makes me a bit skeptical of the latter.

Do I think this is optimal care? No. I’ve worked with many excellent nurse practitioners, one, in fact, who was better than many doctors. But she knew her limits and I worry that the staffing at these clinics will not have individuals of her caliber and experience in them. Will this worsen the fragmentation of medicine, a fragmentation that is exacerbating medical errors in an outrageous way? Yes. But I recognize that money and demand will out-trump best care most of the time. And I agree with Dr. Pho’s assessment that we brought this on ourselves(1).

My hope is that my patients will continue to seek care from me first. In turn I will try to develop other options to make myself more available. Presently I encourage patients to use my patient portal and soon, I hope to convince my employer to consider telemedicine capability.

It’s the future. I’d like to start the trip there now.



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Dietary Choices

Patients rarely ask me what diet I recommend but they frequently tell me what diet they are trying. Weight Watchers typically rises to the top of the list along with Atkin’s, straight calorie counting, and an occasional Paleo. No one has yet told me that they are trying the Mediterranean dietWhite board but the QR code on my white board is drawing some attention, so they are asking questions. Especially if they don’t have a smartphone scanner or aren’t quite sure how to use one.

A diet high in fish, especially oily fish, with lots of fresh fruits and vegetables, whole grains and olive oil is what I’m encouraging patients to eat these days. There’s good data behind it(1) and it’s delicious.

What more can you ask for?

1.Effect of a Mediterranean-Style Diet on Endothelial Dysfunction and Markers of Vascular Inflammation in the Metabolic Syndrome: A Randomized Trial.Esposito, MD, Katherine; et al. JAMA. 2004;292(12):1440-1446. doi:10.1001/jama.292.12.1440.

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Another Surreal Moment in Modern Medicine

A few months ago my office manager, Debbie, informed me that it was time for my annual “coding audit”. This is where my employer sends in a hired gun to determine if my choices of office codes for billing purposes are correctly done. Did I document enough to support a 99214? Did I code too many 99212s when my documentation should have been higher, and thus my reimbursement better? The audit is based on Medicare-guidelines, although the ten charts pulled were of patients of all ages and insurance types. Doctors generally approach these sessions with the same dread we felt getting our report cards in grade school.

The tiny blond that came in to discuss my results refused to sit down next to me. It was distracting and intimidating. Since I’m 5’10” it was also infuriating to have this schoolmarm personality towering over me while she explained why she’d flunked me. Seven out of ten charts did not pass her muster. Two of the explanations made sense – one was “overcoded” – not enough documentation to support the 99213 I’d coded and the other the opposite. Six charts were “complete physical exams” (CPE) done on healthy non-Medicare patients. Since Medicare does not pay for preventive exams why were they pulled for a Medicare audit? It got stranger. She told me that I’d flunked because there was no “chief complaint” on the physical form. What? There shouldn’t BE a chief complaint for someone who is having a physical. In fact, by definition, there shouldn’t be one because it is a preventive service. No amount of discussion would dissuade the woman that she was wrong. I didn’t have immediate access to my own specialty society’s information on the subject:

The comprehensive history and examination performed during a preventive medicine encounter are not the same as the comprehensive history and exam that are required for certain problem-oriented E/M codes (99201-99350) and defined in Medicare’s Documentation Guidelines for Evaluation & Management Services. In fact, the documentation guidelines don’t apply to preventive medicine services. The history associated with preventive medicine services is not problem-oriented and does not involve a chief complaint or history of present illness.

I gave up arguing, signed the form under written protest and she left. 

Here is the kicker–a week ago one of the people whose chart was audited called to tell us she received all her money back on her physical! She thought it was a mistake and  was upset. She argued with Debbie and insisted that my office take back the money saying “But Dr. Nieder did all that work and spent the time with me.” 

I am furious. This suggests to those six patients that I did something wrong. Ironically, this means my employer is out hundreds of dollars for work they paid me for and that should rightfully have been reimbursed. Jawdropping in it’s lunacy. Can anyone wonder why the concierge movement is such an attractive, viable alternative to this?


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Care-less Care and Telemedicine

One of my irritations with fast track care, especially Kroger’s Little Clinics, is the overuse of antibiotics. Living in Louisville, where allergies are king, a simple cold often turns into two weeks of miserably clogged sinuses from increased swelling in already perennially irritated mucous membranes.  A few days ago a new version of “careless care” appeared on my radar. Teladoc advertises itself as the first and largest telehealth provider in the US. Some insurance companies and employers pay for their members to utilize the service. This particular patient used it three times in six months, each time receiving and antibiotic for a “sinus” infection, despite the fact that each time she’d only had symptoms for four or five days. She finally came to see me because the medication the teledocs gave never seemed to help. Go figure.

We spent some time talking about the difference between viral infections and bacterial ones, and discussing the problem with bacterial resistance due to the overuse of antibiotics. She promised to see me with her next episode and appeared rueful that she’d not come in sooner with the previous episodes.

The fact that telemedicine can lead to the overuse of antibiotics has been studied[1]. I was unable to find any studies evaluating overprescribing in Urgent Care Centers so I can only relate my own experience. The ERs and the NP staffed Walgreen clinics in my area do a much better job than the Kroger “Little Clinics” where antibiotic prescribing seems to be more ubiquitous than high fructose corn syrup. 

As telemedicine and other forms of convenient care increase, the fragmentation of healthcare does the same. Did I get any patient information from the Teladoc physician? No, of course not. Almost never do I get documents from the Walgreens/Kroger/Walmart nurse practitioner. I can’t fight the convenience and know that as more and more patients have difficulties conveniently getting in to see their primary care doctors, this will only get worse. It is imperative that these groups communicate with patients’ physicians. The question is, do I have an imperative to educate the Board Certified Physician who works for Teladoc? And why do I suspect he/she might not appreciate that? The answer is, I need my healthcare system to allow me to use telemedicine to treat my own patients at their convenience.

1. Ateev Mehrotra, MD; Suzanne Paone, DHA; G. Daniel Martich, MD; Steven M. Albert, PhD; Grant J. Shevchik, MD JAMA Intern Med. 2013;173(1): 72-74.doi:10.1001/2013.jamainternmed.305

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