Comparing “board certification” to eggs

August 30th, 2014


The topic of “Board Certification” in pain management can seem to be about as confusing as trying to understand the label on a carton of eggs.  Your local grocery store has them all:  cage free, free range, vegetarian fed, no hormones, antibiotic free, and organic.  There are certainly differences in price for these types of eggs.  Are there health benefits to choosing one type of egg versus another?  If so, is it worth the price of the more expensive egg?

Should your physician be board-certified?

Perhaps the same questions should be applied to the field of medicine, and pain management in particular.  What does board certified mean?  Who is granting this title to physicians?  Is seeing a board certified physician better for your health?  Should physicians who are not board certified be paid less by insurers like Medicare and Blue Cross?

A few weeks ago, our local newspaper reported on a physician who let his board certification lapse, and it has brought this topic up for discussion.  The physician in question had advertised being board certified when, in fact, that certification had expired.  Why the fuss?  Should we be alarmed when a physician is not board certified?
The South Carolina Board of Medical Examiners states that physicians can only report being board certified if the agency granting that board certification is recognized by either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA).  In most medical specialties, there is only one board from which a medical doctor can obtain certification.  But it’s different with pain management.  It may come as a surprise to you that a pain management physician can declare board certification without any formal training in pain management.

The American Board of Anesthesiology

Since the American Board of Anesthesiology (ABA) is the only pain management credentialing organization currently recognized by the ABMS, it would follow that only physicians certified by the ABA can state they are board certified.  Well, it’s not that simple.  In 1992, the ABA developed a separate certification called a pain fellowship in order to provide physicians a specialized one-year program focusing on pain management.  This fellowship program was originally offered to any physician who had completed a 4 year residency in Anesthesiology, but was later amended to include physicians with residency training in Psychiatry, Neurology and Physical Medicine and Rehabilitation.  In an effort to offer a path for physicians to “grandfather” into pain management, the ABA gave anesthesiologists until 1999 to take a test and be certified, whether or not he or she had any training in pain medicine.

Boards not sanctioned by the ABMS

There are two pain management boards that are not recognized by the ABMS, the American Board of Pain Management (ABPM) and the American Academy of Pain Management (AAPM).  Neither one requires fellowship training, and the AAPM, allows homeopathic doctors and nurses to become board certified.

It seems healthcare is changing every day.  The Affordable Care Act not only imposed financial penalties on physicians for not adopting electronic medical records, but also on the public for not having health insurance.  Has the time also come to impose financial penalties on physicians who don’t have the most advanced training possible?  The regulators are controlling everything else.  Could it happen?  I don’t know but understanding eggs is probably easier.

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Can e-cigarettes help me quit smoking?

August 6th, 2014

Some of the concerns about smoking include cancer, nicotine, tar and carbon monoxide.  I have had several patients recently ask me if e-cigarettes would help them quit smoking tobacco, so I started looking into the data (and there’s lots of it out there – both pro and con).  Obviously, this is a very complicated topic and this blog entry should not serve as your only source of information.

Smokeless cigarettes have been around for years.

As reported recently in Consumer Reports, E-cigarettes are pitched as a smart alternative to tobacco cigarettes that are safer and a good bridge to quitting smoking, and even House Speaker John Boehner (R-Ohio) has reportedly been seen using one.

Although they were first marketed in the 1960s, the industry really caught on in 2005 when China started exporting them, and the demand has grown steadily since then to about $1.5 billion in 2013.

The device works through a battery that is activated when a person draws on the pipe.  This heats a nicotine cartridge, which then turns the nicotine into a vapor that is inhaled.  The user then exhales a cloud that quickly evaporates.

What does nicotine do?

The reason cigarettes are highly addictive is nicotine.  Nicotine is a stimulant that makes the blood vessels in the body constrict.  When this happens, it becomes difficult for the blood to travel though out the body.  The heart is forced to work harder to pump the blood.  The longer a person smokes, the greater the risk that the smoker will develop heart disease or high blood pressure, both of which can cause a heart attack or stroke.  The average cigarette in the United States contains about 9mg of nicotine. However, this is not the amount of nicotine that is ingested by the smoker. Cigarettes are burned and the smoke is inhaled by the person, so the nicotine is absorbed through the smoke. The amount of nicotine that actually enters the body in this manner is typically less than 1mg.

Nicotine can not only cause back pain but also prevent spinal injections from working as well as they do in non-smokers

There is growing evidence that the nerve pain that comes with sciatica and bulging discs is due to a reduced blood supply to the nerve.  So, since nicotine is a potent constrictor of blood vessels, the nerves have even more difficulty getting oxygen and nutrients.  This makes it much harder for epidural steroid injections to do their job and delays healing.

Tar is a sticky brown substance that irritates the windpipe and damages the tissue of the lungs,  It stains the teeth and keeps food from tasting as good as it does for people who do not smoke.

Carbon monoxide is a gas that takes the place of oxygen in the smoker’s blood.  When this happens, the smoker becomes very tired.

Safety concerns of e-cigarettes

While E-cigarettes don’t have tar or carbon monoxide in them, they might contain other worrisome chemicals.  A 2009 study by the Food and Drug Administration detected a dangerous chemical called diethylene glycol, which is used in antifreeze, in two brands of e-cigarettes.  And in some cases, it’s unknown what is used in the flavors of some cartridges.

E-cigarettes have some other safety concerns as well.  As reported in the New York Times in March 2014, there is unease over the use of the concentrated liquid nicotine vials to fill the e-cigs.  These liquids are apparently not regulated by federal authorities and pose specific risks to children.

Medical studies support both sides

So, with that background information, let’s look at whether these e-cigarettes can help smokers kick the habit.  In short, there are studies supporting both sides, so the jury is still out.  On the plus side is a study out of University College London in the UK, published in the journal Addiction, found that, among people who are trying to quit without professional help, those who use electronic cigarettes are 60% more likely to succeed, compared with those who use willpower or nicotine replacement therapies.

On the con side, there was a New Zealand study published in The Lancet of 657 smokers, e-cigs were about as effective as nicotine patches in helping people stop smoking after 6 months.  And a study from the University of California at San Francisco studied 40,000 youth around the country, and found that adolescents who used the devices were more likely to smoke cigarettes and less likely to quit.

What about carcinogens?

Lastly, there is the issue of carcinogens, which are any substances that are directly involved with causing cancer.  According to the Journal of the National Cancer Institute, there are 20 known carcinogens in tobacco smoke that convincingly cause lung tumors in laboratory animals or humans.  Nicotine is not yet considered to be one of those carcinogens.  If fact, the FDA recently relaxed restrictions on many nicotine products in November 2013.

So what about e-cigarettes?  Are they are safe?  There are many who say there is no cancer risk with using them since they are smokeless.  But, a recent paper in the journal Oncotarget details how nicotine is proving to be a formidable carcinogen.  In this research, compiled at Virginia Tech, the investigators caution that nicotine-infused cessation products may not be the safest way to help smokers quit.

What do the numbers on the nicotine cartridges mean?

Most cartridges come in 24mg/ml, 18mg/ml, 12mg/ml or 6mg/ml strengths.  But sometimes the liquids have a percentage on them.  That means, if the bottle says 1.2%, the solution contains 12mg/ml.  So, a 10ml bottle of 1.2% solution contains 120mg of nicotine.  And if you’re counting drops, there are roughly 20 drops in 1 ml.

So, in summary, it is evident that more research is needed.  Until then, my advice would be to work with your physician to come up with a plan that will work the best for your situation.  And, if you do use e-cigarettes, be careful when choosing the strength of nicotine cartridge.

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Savory Breakfast

July 3rd, 2014

As promised from the blog last week a savory healthy breakfast item.  I don’t think it really qualifies as a frittata.  Maybe more like a modified omelet.  Super fast and easy.  You will need the following items:

oven safe skillet or frying type pan

1 cup egg whites (I use the egg whites in a carton.  You certainly can separate from fresh eggs.)

small pat of butter (really small – keeps omelet from sticking)

2 large handfuls of greens of your choice ( I like fresh chopped spinach)

handful of chopped onions

handfull of chopped asparagus, mushrooms or anything you like in your omelet

1/4 cup feta cheese (or other)

salt and pepper

Ezekial Bread

1/4 avocado


Preheat oven to low broil.  Heat butter/olive oil on medium heat in oven safe skillet and saute the onions.  Add your asparagus, mushrooms or other and cook for 3-5 minutes.  Add greens and cook for 1-2 minutes.  Evenly spread ingredients in skillet and evenly pour egg whites over the cooked items.  Allow to cook at low to medium heat until bottom sets to a firm consistency.  Add a little cheese if desired. Place skillet on top rack in oven on low broil.  Remember the skillet handle is HOT.  Watch closely until top of omelet sets and cheese lighly browns.  Cooking time on all steps may vary so use your best judgement.  You don’t want runny egg whites but also don’t want the top to burn.  Handle still HOT.  Remove from oven and cut like a pizza or pie.  Serve on top of toasted Ezekial bread with avocado.  Enjoy with a glass of sparkling water and a side of fresh berries.


Frittata 1Frittata 2Frittata 3Frittata 4

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Time to Eat!

June 16th, 2014

My last post on how nutrition has an impact on pain only provided an overview. Food choices and what we take in our bodies play a tremendous role in how we fight off and manage disease processes.   Since I love being in the kitchen almost as much as I love taking care of patients in the office I am going to give you specific food choices with recipes including descriptions and pictures. So here goes with two breakfast choices avoiding pro-inflammatory ingredients and focusing on anti-inflammatory food items. One is sweet and one is savory. The first is homemade granola, fresh fruit and non-fat Greek yogurt. The second is an eggwhite omelet with greens (for next weeks post).  Enjoy and I will share more lunch and dinner items later.  The link below also provides more information on diet and inflammation.  Now the disclaimer.  I am not a nutritionist or your primary care physician so listen to them regarding your diet and any other illnesses or dietary restrictions you may have.  I am taking off my doctor hat on these posts!

Breakfast Granola

3 1/2 cups traditional old fashioned oats (not the quick cooking kind)

1/3 cup honey

1/3 cup orange juice (preferably fresh)

splash of vanilla extract

zest of 1 orange

1/4 cup sweetened grated coconut

large cookie sheet with raised sides

Preheat oven to 325 degrees. In a large bowl mix the oats and orange zest. Place the orange juice, honey and vanilla extract in a microwaveable container and heat few a few seconds until the honey thins. Pour into the bowl with oats and mix thoroughly. Spread evenly on cookie sheet. Bake for 12 minutes at 325 degrees. Remove from oven and sprinkle coconut over oats. Mix and evenly spread on cookie sheet. Bake for 12 minutes at 325 degrees. Remove and allow to cool. Add non-fat Greek yogurt and fresh fruit and you are ready for breakfast.  By the way I add blueberries, raspberries, craisins, and walnuts.  My wife likes apples (pink lady are the best), and raspberries.

granola ingredients granola in panfinished yogurt

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Office-based injections more affordable

June 6th, 2014

It’s no secret that hospitals have been aggressively purchasing physician medical practices over the past 5 years.  One reason for this is that hospital administrators have found new sources of revenue to support their large overhead.  Much of this revenue is in the form of facility fees and subtle changes in the way services are billed to you and your insurance.

Hospital monopolies

According to the Center for Studying Health System Change, a non-partisan think tank that studies the healthcare industry, hospital acquisition of physician practices has led to higher prices.  So, unfortunately, these hospital monopolies are driving up medical costs rather than the other way around, making healthcare less affordable than ever for the average American family.

For example, last spring the Denver Post reported on a patient who received two heart stress tests performed by the same cardiologist, before and after that physician was purchased by a local hospital.  The fee soared from $2,100 to over $8,000.  This is due to something hospitals call a “facility fee”, and it can add hundreds (if not thousands) of dollars to your medical bill.  And you thought the Affordable Care Act was supposed to save taxpayers money.

Hospitals driving up medical costs?

And it’s not just procedures that are more expensive, it’s regular office visits too.  In March 2013, a report by the Medicare Payment Advisory Commission (MedPAC), an independent Congressional panel that oversees Medicare, confirmed that an office visit with a physician in a hospital outpatient department was reimbursed 80% higher than the same visit performed in a physician’s office.  Why the difference?  Well, once a physician’s practice is purchased by a hospital, all services provided by that physician are billed under the hospital’s umbrella.  So even though you may see that physician in what seems like the same private office setting you have always used, the visit is actually billed to your insurance (and Medicare) as being provided in a Hospital Out Patient Department (OPD).   This subtle billing difference results in higher reimbursements for providing the same service.  The MedPAC report stated “that care is being shifted from a lower to a higher cost site of care without any identifiable improvement in quality.”

The numbers are staggering.  In 2011, for E/M services (evaluation and management visits) and heart echocardiograms alone, Medicare paid hospitals $1.5 billion more than if the same services had been performed in a physician’s office.

The argument in favor of these practice acquisitions is that the medical care will be more efficient.  One of the primary areas of improved efficiency is reported to be in reducing the chances that a patient will be readmitted to the hospital within 30 days of discharge.  So in some cases hospital care has become more efficient.  But in 2012, the Robert Wood Johnson Foundation released their Synthesis Project which found that physician-hospital consolidation has not led to either improved quality or reduced costs.

Making health care more affordable

If you have a high insurance deductible, an insurance policy that limits the number of nerve blocks or epidural steroid injections you can get per year, or you don’t have insurance at all, we can save you $500-1000.  Getting your nerve block or epidural steroid injection in our office gives you access to the same high quality service without costing you (and our country) an arm and a leg.

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Use of steroids in epidural injections

April 26th, 2014

Dr. Joye administering an epidural

The use of steroids in epidural injections has been considered “off-label” for many years, but it shouldn’t detract from the fact that there have been several properly conducted randomized trials and systematic reviews (as well as guidelines), showing significant long-term effectiveness of using them. Hundreds of thousands of patients every year avoid potentially unnecessary spine surgery and lead active and productive lives.

“Off label” medical innovations

The use of medications and procedures considered “off-label” by the FDA has led to medical innovations that likely would have been unrealized (or at least significantly delayed) otherwise. To the best of my knowledge, the FDA considers the use of vein grafts “off-label” for heart bypass operations, yet more than 200,000 patients undergo this surgery every year in this country.  In general, physicians are more concerned about whether a medication or device will work for a patient’s specific condition rather than whether or not the use of the medication or device is “off-label”.


Standard of Care

An “off-label” designation for a medication or device doesn’t mean that it is illegal, or is being used in the wrong way, or is “contraindicated”, or is not consistent with standard of care .  It simply means it is being used in a way that is not part of its FDA clinical approval.  By the time most patients reach me, they have exhausted conservative care options.  They are seeking relief of pain, and I am tasked with using my best medical judgment to make a positive difference in their lives.

Safety alert

Yet this week, the FDA issued a safety alert warning that injections of corticosteroids into the epidural space of the spine may result in rare but serious neurological problems. In addition, the advisory also stated that epidural steroid injections are not effective. While the FDA is justified in issuing such warnings, this specific warning is based on inappropriate interpretation of data.

Oral opioid overdoses cause 16,000 deaths per year

To be sure, there are potential complications with epidural steroid injections, which primarily involve infection, bleeding, where the injection is placed, and the choice of medication used in the injection. Risks are considered every day by physicians who, not only treat conditions using medical procedures, but also the use of oral medications. Opioid overdose deaths are about 16,000 per year, more than motor vehicle accidents. But the FDA has recently approved, under considerable opposition, a new combination opioid, Zohydro, despite their own advisory panel voting 11 to 2 against it (without a single scientist or physician voting for it).

Merits of epidural steroid injections

In issuing this warning, the FDA has sparked a good national debate on the merits of epidural steroid injections. But let’s also look at a key safety issue that, unfortunately, the FDA has failed to adequately address - nurse anesthetists (and other medical providers) performing these injections without advanced medical training. Perhaps the administration could also give us its opinion on proper selection criteria and appropriate provider training to safely perform these injections too.

Benefits far outweigh risks for many patients with chronic pain

No doctor (or patient) ever wants a serious complication to occur. These injections, when properly performed under fluoroscopic guidance by highly trained physicians, help hundreds of thousands of patients every year lead productive lives and avoid potentially unnecessary spine surgery.

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Vitamin D

June 15th, 2013

Along with calcium, vitamin D helps maintain bone health by ensuring that the body creates and reabsorbs bone tissue at roughly the same rate, thus avoiding a net loss of bone.  About 8% of Americans are deficient in vitamin D, and most of these are elderly.  While adequate (but not excessive) intake of calcium and vitamin D has been proven to maintain good bone health, the evidence is less clear when it comes to other medical conditions.  Among those are unproven claims of vitamin D lowering the risk of the common cold, high blood pressure and even cancer.

Another commonly held belief is that the supplemental use of vitamin D would slow the progression of osteoarthritis.  However, a recent study published in the Journal of the American Medical Association found that vitamin D supplements given to people with osteoarthritis of the knee were not effective in relieving their knee pain or slowing the damage to the knee joint.

Osteoarthritis is often a mild condition and is widely known as “wear and tear” arthritis.  It may cause no symptoms or only occasional joint pain and stiffness.  The most severe form of osteoarthritis is the type that affects the joints that bear the body’s weight, such as hips and knees, which can progress to a point which makes walking difficult.

If you have osteoarthritis of the hip or knee and are obese or overweight, losing weight often can be the most effective treatment.  Weight loss should be achieved through a combination of diet and exercise.  Exercise should put an affected joint through its full range of motion while gently avoiding excessive stress on the joint.  Swimming and walking are particularly helpful, but avoid running on hard surfaces, which can aggravate the condition.

If your pain persists despite weight loss and gentle exercise, oral medications also can be used to treat the pain of osteoarthritis.

It is important to remember that other conditions can have similar symptoms.  These include rheumatoid arthritis, gout and joint infection.  Accordingly, if you have a joint that is suddenly swollen, or one that is hot and red, with a fever higher than 100 degrees, seek medical attention immediately.

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Prescription Pain Killer Roberries

February 5th, 2013

We have a prescription drug problem in our country, as illustrated in Sunday’s Post & Courier cover story on pain pills, and it is not an easy fix.  Americans make up only 4.6% of the world’s population, but we consume 99% of the global supply of hydrocodone (Lortab, Vicoden), and 80% of the global supply of all pain medications.  As physicians, we share some of the fault for this problem, but there’s plenty of blame to go around.

The use of pain killers accelerated in 1999 when, prompted by a couple of pain societies, one of the primary healthcare oversight organizations (JCAHO) mandated that pain be given equal importance as heart rate, blood pressure, temperature and oxygen saturation.  They promoted pain as the “Fifth Vital Sign”.  Hospitals and healthcare providers had to prove they were recognizing and treating pain appropriately or face penalties.  But there was a conflict of interest.  The very pain societies pushing for these new regulations were being funded by the pharmaceutical companies manufacturing pain killers.

What must not be lost in this discussion is that many patients depend on prescription pain killers to relieve horribly debilitating pain that has eroded their quality of life.  These medications are also vital in treating acute pain, such as after surgery.  The vast majority of these patients use their medications appropriately and as prescribed.  But, we do worry about doctor shopping, patient deception and forged or altered prescriptions.  Just last week, a new patient came to my office wanting a prescription for oxycodone.  A computer search revealed the patient not only was receiving fairly large quantities of this medication from one of my local pain management colleagues, but was also doctor shopping in Florida and Georgia for the same drug.

These medications are frequently prescribed in amounts that lead patients to save unused amounts in the medicine cabinet for later use.  Recently I had surgery and was given 85 pain killers and used only 30.  What about the patient who was given 30 pills for a kidney stone, tooth extraction or back injection?  If my experience is typical of most (and I think it is), then there are a lot of pain killers stored in the home, which increases the chance of one of our children using them recreationally.  Prescription pain killers are increasingly becoming the drug of choice for our children.  Every day, approximately 2,500 teens use prescription drugs to get high for the first time, and more than half of them are under the age of 15.  They are easy to get from our homes and are perceived to be safer because they are a prescription product from an FDA regulated industry.

Healthcare providers have little, if any, training in controlled substances. It wasn’t offered to me in my 8 years of medical school and anesthesiology residency, or my one year pain fellowship.  To the best of my knowledge, it still isn’t offered now in any medical or pharmacy training programs.

Disposal of prescription medications has been confusing.  Many patients don’t want to throw unused or expired medications away, or flush them down the toilet, for fear of the medications winding up in our water supply.

The public, in general, has become more insistent on getting prescriptions for our ailments, particularly antibiotics and pain killers.  A 2005 CASA (National Center on Addiction and Substance Abuse) study identified that about half of all physicians surveyed thought patients tried to pressure them into prescribing a controlled drug.

Fortunately, there has been some progress on addressing this epidemic.  Most states, including South Carolina, have privacy-protected prescription monitoring programs, allowing physicians to rule out doctor shopping in most instances.  In 2005, Congress passed a bill (NASPER) to allow states to share their databases.  And last year, the state of Washington implemented a promising, but controversial, law requiring doctors (and other prescribers) with patients who surpass a preset pain pill limit to seek a second opinion from a pain specialist.  If Washington’s law proves successful, many other states will likely follow.

Lastly, there are efforts underway to allow pharmacies to collect unused or expired medications.  For the time being, however, the DEA holds Drug Take Back programs across the country.  Twice a year, the general public can take these medications to their local police station, where a DEA agent will collect and dispose of them properly, no question asked.

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Whiplash Injuries

January 9th, 2013

Whiplash is a term that describes injury to the neck that most often occurs as a result of a motor vehicle accident in which a vehicle is rear ended, but can also result from a side impact collision or a fall injury.  In a typical case, the victim’s body is initially pushed forward, causing the head to move up and backward, which can stretch or tear muscles, tendons and ligaments.  Then the head snaps forward very quickly, further stretching these structures.  This traumatic over-stretching may take several months to heal.

A whiplash injury usually takes 12-24 hours to develop.  Typical symptoms include neck stiffness and pain, headaches and reduced range of motion of the neck.  Other possible symptoms are dizziness, ringing in the ears, blurred vision, fatigue, muscle spasms, sleep disturbances and pain in the arms.

There are several factors that affect the body’s ability to withstand a whiplash injury:  good posture at impact, good overall physical condition, awareness of impending impact and male gender.

A common misconception about whiplash injury is that if the vehicle does not sustain damage in a low speed impact, then whiplash injury to the occupant does not occur.  In reality, low impact collisions can produce correspondingly higher dynamic loading on the  occupants because the lack of crushing metal to absorb the forces results in a greater force applied to items or occupants within the vehicle.

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Sciatica Pain and Weakness: Is Surgery The Answer?

November 29th, 2012

When patients seek medical care for a painful disc herniation and a motor deficit (muscle weakness, limping, or a dropped foot), the motor deficit sometimes becomes an overriding concern, steering patients toward early surgery.  A recent Netherlands study has disputed that notion.  While the motor deficit did improve significantly faster with surgery, the long term recovery was the same.  At one year, complete recovery of motor deficit was found in 79% of subjects treated surgically and 83% of subjects receiving conservative nonsurgical treatment.  However, these results do not apply to all patients with motor deficits.  Patients with cauda equina syndrome (severe compression of nerves below the spinal cord) and rapidly progressing motor problems often do require earlier surgery to resolve.

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