More Office Updates

As we're continuing into the holiday season, I wanted to share a few more office updates and plans I'm looking forward to.
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New services for migraines and neuropathy

I have recently shared a few new additions to my practice:

• Alpha-stim electro cranial stimulation (in-office and medical devices to use at home) for anxiety, insomnia, and pain.
  

• Hormone pellets (estrogen and testosterone) as an additional hormone replacement therapy option.
  

• Ketamine prescribing. I have a few patients interested, so I will get together what I need to on my end in order to offer this. I'm not a psychotherapist, I'm just a healthcare provider who sees patients who may benefit from ketamine's medical use (such as for treatment-resistant depression), and can offer this option as a more convenient at-home treatment in conjunction with one's on-going therapy, at a fraction of the IV ketamine clinics' prices. I'll update you all as I have more information on this topic.
  

Because I am always learning more, in order to best help my patients, I will soon be offering a few more new services:

​Botox injections for migraines

"migraine-headache-pain.jpg" by r.nial.bradshaw is licensed under CC BY 2.0.

Now, I'm not an esthetic (medi-spa) practitioner. I like your grey hair and wrinkles.

AND, the current migraine treatments available are often... lacking.
Even doing my best to help migraines using Naturopathic therapeutics, medications, well.... migraine meds often just suck.

It is often hard for someone experiencing migraines to find a migraine med that works well, that doesn't knock them out with side effects.

So, introducing: botox injections. Now, this is nothing new. The FDA approved the use of botox injections for migraines back in 2010. And in the Portland area, historically I have had a few neurologists who I could refer to for this service.

But (as those of you who also live in Salem may know), when I'm looking for a specialty service like this in Salem... it's often nowhere to be found. I joke that Salem is a really big small town. But when it comes to the unavailability of specialized care, that's just no joke for any of us.

Since I know just about every other injection procedure under the sun, my training on this will be very fast. I'll be learning from some injection instructors in Arizona next month, and I'll be able to start offering this service starting January at the latest.

​Small fiber neuropathy - further evaluation now available in Salem

Small fiber neuropathy (SFN) appears to be more common among those who have Ehlers-Danlos syndrome, Mast Cell Activation Syndrome, Postural Orthostatic Tachycardia Syndrome (POTS), Lupus, other autoimmune diseases, Fibromyalgia, other rheumatic diseases, Interstitial Cystitis and other chronic, complex conditions.

While this announcement is perhaps not relevant for many of my patients, an increasing number do have one or more of the above conditions, so I didn't want anyone to miss out on finding out about this.

So again, just because I got fed up with not being able to find anyone in Salem who can work up my patients for small fiber neuropathy (SFN), I will start offering biopsy evaluation for this concern at both of my clinics.

Dr. Menk Otto (who also practices at my Portland location), has been offering these for a little while, as do a few others I know of in Portland. But in Salem... it's been... just crickets.

For those who are curious, SFN is a condition that affects the nerves, usually starting in the skin of the hands and/or feet. Someone may have neuropathy (nerve pain and/or sensory changes) due to a known condition (such as diabetes), temporary deficiency (hypothyroidism, low vitamin B12 or copper) or a past injury.

If the reason for the neuropathy is not known, sometimes this condition needs to be evaluated.

The best way to evaluate this condition is with a skin biopsy, comparing the number, shape, and density of nerves in the upper and lower legs.

I will still be referring out patients for biopsies for other conditions (such as uterine or skin conditions), I am not trying to be the expert in all things for all people. But for this specific condition, it has been difficult to find experts to refer out for in the Salem area.

This too will be available starting in January. If this is a concern for you (maybe we've tried and failed to find a local practitioner to do this biopsy?), then first things first is an in-office evaluation focusing on a neurologic workup. Then, if we decide to go forward with the biopsy, that visit must happen in the morning (due to the very specific nature of the biopsy procedure and the very particular way that it needs to be shipped).

Further reading:
About SFN:
https://www.hopkinsmedicine.org/neurology-neurosurgery/specialty-areas/peripheral-nerve/small-fiber-sensory-neuropathy
https://www.medicalnewstoday.com/articles/small-fiber-neuropathy#causes

Scientific articles on SFN:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086960/

And on that note, just two more little bits of news…

​additional care, outside of office visits

I try not to be too much of a Luddite when it comes to technology. But also, I was trained in the paper chart era. In-office visits with paper charts, having staff return phone call messages, that was the extent of my medical training as it pertained to avenues of delivering care.

So while I have known about these "online digital evaluation and management" service codes for a year or two, I just didn't know how they would benefit my patients, nor how they could get integrated into the care I offer.

As more and more systems are digital, and many care basics can and are handled before and after visits, these digital care codes are starting to make more sense.

There are three codes (99421, 99422, 99423) and they indicate 5-10 minutes, 11-20 minutes, and more than 20 minutes respectively.

Here are a few examples of where I can handle some aspects of care outside of an office visit, so where these codes may be used in place of a visit:

• reviewing labs that were ordered by another provider, in order to take over management/ refill of an existing medication or create a new lab order
• reviewing records from outside facilities, in order to make a referral or substantiate medical documentation such as for work accommodations or FMLA
• creating medical documentation (that was not a part of a previous visit)

These codes are definitely no replacement for face-to-face care, whether that is in-person or via telehealth.

This type of care is limited to what I can do on my own, essentially without having a conversation with you. If I need to ask you questions, discuss treatment alternatives, side effects, etc. - conversations still need to happen within visits.

And, no matter how well things are going, and how good you feel, the management of many prescriptions still requires 1-2 visits per year (no matter what our opinions may be on the matter), along with whatever lab evaluation is standard to that management.

This may open the door to patients getting a few straight-forward needs met between their visits. So if you may find this helpful, you can check with your insurance as to coverage for those codes.

​I am not punctual

"muji watch" by hirotomo is licensed under CC BY-SA 2.0.

Hi, my name's Angela, and I am running behind on visits most of the time.
I apologize.

I actually used to be very punctual. No, really!
Back when insurers paid for longer visits, the visit times were scheduled longer.
I was known for my punctuality and even started visits early when I could.

Now, they don't cover that time. So we don't schedule for that length of visits.

Add to that a new dynamic in my practice... The depth and complexity of what I can evaluate and treat for patients has exponentially developed over the last 5 or so years.

I used to refer out for many chronic, complex conditions that I am now known as being the go-to expert. Well, the expert in Salem. There are still many great experts in the Portland area (though they may be scheduling far out for new patient visits, not taking new patients right now, or have dropped all insurance contracts - it's strange being in the medical field right now).

A few of those conditions are those I mentioned above, such as Ehlers-Danlos syndrome (I'm most experienced with hEDS), Mast cell activation syndrome, Postural orthostatic tachycardia syndrome (POTS), Fibromyalgia, autoimmune, neurologic, rheumatic and other chronic, complex conditions.

You know, the kind of conditions and concerns that when you bring them up, the typical "5 minutes and I'm out" provider gets wide-eyed, panicked, and starts looking for the door.

I'm over here, leaning in, asking you to speak more about it.
That's my style, and that's how I figure out where we can go next.

And, in all my excitement to discuss new tests, treatments, and options my patient has often never heard of (the patient who had practically given up all hope), my timing starts to fall really, really behind.

I do apologize.
I do recognize being punctual is a form of respect. But in the course of respecting patients with really tricky, complex conditions, I end up disrespecting the timing of the patient who comes afterward.

I get that. And I feel stuck.
Because I can't cut patients off after their first 1-3 symptoms like other clinics who literally post this policy at the reception desk.

I just don't do medicine that way.

So, if you want me at my most timely, ask for the first appointment of the day (or the first appointment after my lunch break). It is extremely rare that I start my appointments late from the get-go.

It's just that I fall behind providing the care I want to deliver within the confines that insurers place on my practice.

One new thing I'm bringing into my clinic to help with my timeliness is digital transcription. I am going to start using a program that helps me chart. The program will be listening, but it's a HIPAA-compliant computer program, not a person. It then helps with my notes, and only those notes are kept. No recording. So, no one will be listening, and no recording will be stored anywhere. And also, this program is separated from the private, identifying information we keep on patients, so none of that is associated with my dictation.

And although in my trials I have seen how it will help in the efficacy of my charting and creating treatment plans for patients, I also realize that new technology like this will not be desired by all. If you wish for me to not use this during our visits, please just ask (though I really hope the patients who do ask this don't also have Alexa, Facebook app, or any other number of tech gadgets listening to you in order to sell you things if you ask for this level of tech privacy).
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​dang it, and I thought this would be a short one

I am just wordy. There's no helping it.

I hope you are staying warm during our transition to winter. I'm going to try to take a little downtime this week, with some hot tea, blankets and a good book.

Take care for now, and I hope you also find some relaxing quality time this week,
Dr. Angela Cortal