Dr. Danny Lee’s Blog

I just completed an interiew to be aired on the Jumping Monkeys Podcast on the TWiT network. The podcast is available on iTunes and at twit.tv. The topic of discussion was adolescent obesity. I think the episode number will be #65. I was pretty nervous and hope it comes off OK.

Summer vacations are running rampant in the office so we are short staffed most of the time. My schedule has been blocked to accomodate same day appointments. So if you are having a tough time getting an appointment, try calling in the morning at 8 AM and they should be able to put you into the schedule. Sorry no physicals/check ups will be done for the next week until we are staffed a bit better.

One of the differences from my old office is the presence of a nurse triage fro phone calls. I know many of you following me from the old practice are used to dealing only my receptionist, a medical assitant, and the doctor. Well this is fundamentally the except for the fact the nurse at my new office is actual RN and in many cases is able to answer questions before it reaches me. This is a great help to me and helps to diffuse my work load.  I still have to review the recommendations of every call pertaining to my patients and I have to sign off on their recommendations. I am fully aware of any issues that come up. What has become surprising me is that there has been some rather belligerant behavior by some of my patients. The phone triage is designed to give patients a faster answers to their questions and to facilitate health care delivery. This is a better solution that having to wait until the end of my day waiting for me to call everyone back.

This was my old system because I was so busy in the office I simply could not return call (except for emergencies) until I had completed all of my office visits. I know there are some of you who feel the phone triage system creates a barrier between you and your doctor. Your messages can still be passed onto me if you are not happy with the answers you recieve from the triage nurse. Some of you have found email a more direct way of communicating and I will answer all of those questions myself. I may not get answer all of my email right away, but I will definitely answer them by the end of the working day.

The rising cost of gas prices is affecting us all.  Many of our staff are feeling the pinch at the pump and Hopkins is sensitive to this issue. Therefore, there is an idea floating around the office to change each healthcare providers’ hours to 10 hours per day for 4 days. Instead of working 9 hours per day for 4.5 days per week. This would give our employees one fewer day they have to commute into the office and hopefully help them save fuel costs. This is just an idea/optional but one I am seriously considering for myself. If you any of you have any serious concerns or reservations of having me not available one less day per week, please e-mail me and let me know.

I am sorry if some of you having trouble getting in to see me. There are a bunch of doctors out of the office on vacation so I have been fairly busy. On an informal head count I think a third of the doctors are out on summer vacation and more will be away next week. The staff is delaying routine visits until after the July 4th holiday if possible and more acute visits are being placed in earlier. So appointment can be had but you must insist that you have to be seen. 

One question I get asked at least once a day [by my staff] is: “Mr./ Ms. [blank] is here and >30 min late for his/her appointment. Can you still see him/her?” This, more than anything else I face all day, really puts a monkey wrench into my day. My schedule is usually booked pretty solid everyday, so seeing a late arriving patient is no different than seeing a ‘fit in’ (AKA the walk in) patient. Before I answer, I try to look to see where I am in my day and who is going to impacted. A late show means someone else has to spend more time in the waiting room waiting for their turn to come back. I do try to accomodate everyone but I do try to draw a line somewhere. It also depends on the day of the week. Mondays and Fridays are by far my busiest days and I will not have wiggle room in my day to accomodate late arrivers. Most other times I do make every effort to get everyone seen. If I am running late, it’s most often due to trying to accomodate a person who has arrived late. So please, for my sanity and to be considerate of my other patients’ time, please arrive on time. Facing a sequential row of unhappy patients due long waits is not how I want to face my day.

As many of you know for the past several years, I have been a clinical instructor for the University of Maryland School of Nursing. You may have even had the pleasure of meeting my students in the office on one of your visits. I enjoy teaching and even though it is extra work for me I enjoy the intellectual challenge of teaching and sharing my knowledge with my students. Now that I have joined Johns Hopkins, I will teaching for both the school of medicine and the school of nursing. This summer, I will have a nurse practioner student working with me every Tuesday and Wednesday. So I will be seeing fewer patients (although not by much) on those days so I can have some time for instruction. You may even be asked if it would be alright if my student can start the visit and have me join in later on.  I will closely supervise everything my student does and nothing will be prescribed or ordered without my approval. I will, of course still see every patient that has an encounter with my student.

So if you need to come in please plan ahead and call for an appointment at least a week in advance.

I ran across this article in Slate.com. It addresses the prickly issue of antibiotics and its overuse. It also presents the dilemma of doing the right thing vs. meeting patient expectations. An issue that physicians (myself included) face on a daily basis.

http://www.slate.com/id/2191908/?from=rss

The FDA announced a recall for a brand of digoxin called Digitek. Digoxin is a heart medication and Digitek is often used by some pharmacy as the “generic” brand. The issue seems to be a dosing irregularity or inaccuracy. This can result in a person getting too much of the medication digoxin and possibly resulting in heart arrthymias. Therefore for those of you taking digoxin, you should check your prescription to see if your pills are covered under the recall. Most pharmacies are already callling those individuals covered under the recall.

In the meantime, I am writing for branded Lanoxin (the original brand of Digoxin) only until it is deemed safe to return to generic digoxin by the FDA.

For people on the blood thinner Coumadin (generic: warfarin) it can be confusing to know what foods will affect your levels. First, we should cover what is Coumadin (warfarin)? Coumadin is a medication that deprives the liver of vitamin K. Coumadin (warfarin) is a very slow acting medication. It takes up to 48 hours to see any change is your coagulation. Which is why when your physician changes your couamdin dose he or she will ask you to check your blood test again no earlier than 2 days from the time you changed the dose. If you are taking alternating doses, you might not be asked to repeat a test (INR) for a week.

We measure the effectiveness of the warfarin through a blood test called Protime or PT for short. Since different labs use differing methods of measuring protime, a standarize ratio was created called the INR which stands for INternational Ratio. This was we can measure the effective thinness of a persons blood no matter where they had it drawn. For people with blood clots, stroke, or irregular heart rhythms, the INR will needs to maintained between 2-3. For people with articifical heart valves, the INR is kept from 2.5-3.5. So when your doctor or nurse is calling to report your blood tests they will often quote an INR value and knowing what range your warfarin dose should be kept is helpful.

Vitamin K is important in the synthesis of some coagulation factors made by the liver. WIthout these factors, the blood ability to coagulate is impaired and therefore thinned. Now in truth people get a small amount of Vitamin K from the bacteria in their bowel, but the main source is from their diet. In addition, vitamin K is a fat soluble vitamin so we can store it in our fatty tissue.

So where do we find vitamin K? The typically associated with high levels of vitamin K are cabbage, cauliflower, spinach and other green leafy vegetables (e.g. kale, lettuce, swiss chard, endives, brussel sprouts, mustard greens, turnip greens, spinach, collard greens), asparagus, broccoli, scallions, pistachio nuts, sauerkraut, parsley and soybeans.