Archive for the ‘Blog’ Category

Patient Portal Instructions Redux

Wednesday, December 16, 2015 // Patient Portal

These are the instructions for retrieving your blood test results from the secure patient portal.

Here is it how it works:

  1. We collect your personal email address and enter that into our computer system
  2. We register you for the Patient Portal and assign you your own unique PIN.
  3. To complete the registration process, log into the CGM PATIENTPORTAL at a. Please use Chrome as the web browser of choice for this site.
  4. The first time you access the Patient Portal, you will be required to “Create your account”, which is where you will need your PIN (noted below). a. If you lose your PIN, you may contact your doctor’s office to have it provided to you.
  5. Select “Create your account”, where you will be asked to enter your PIN, the first three letters of your first name, the first three letters of your last name, and your date of birth. a. NOTE: when creating your account or when using the Forgot Password function are the only two times that you need your PIN. Your password is used for login to the portal.
  6. Click “Next”, and you will be asked to create a password for your Patient Portal account.
    1. Enter a Password that you will remember.
    2. If you forget your password, you may select the “Forgot Password?” link on the homepage of the Patient Portal. i. NOTE: Your doctor’s office will not know your password and will not be able to change it for you. You must use the “Forgot Password?” link to recover your password.
  1. Back at the login screen you will enter the following details to login:
    1. Email Address = your personal email address that you provided to your doctor’s office.
    2. Password = the password you just created.
  1. You now have access to the Patient Portal, and you are on your way to communicating directly, and securely, with your doctor! a. NOTE: You may only send messages from the Patient Portal to someone who has a specific secure email address.

Every time we send you a secure message via the Patient Portal, you will receive a notification in your personal email account. This way, you know when you have something new in your Patient Portal in-box. In these emails sent to your personal account, you are provided with the URL/hyperlink to the Patient Portal. Each time you access the Patient Portal (after your initial login) you are asked to login with your personal email address and your password (the password you entered during account creation at first login).

  • The URL for the Patient Portal is
  • REMEMBER: The Patient Portal is not the place to report to us any emergency concerns. If you are experiencing any emergency, please dial 911. The Patient Portal messages we receive from you will be checked throughout the day on regular business days.
  • We can use the Patient Portal for the following purposes and as applicable:
    • Sending you a summary of your recent office visit
    • Providing you with a URL to review any patient-specific education resources
    • Informing you of other medical items, such as lab results

We look forward to communicating with you on-line!

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New Mammography Guidelines

Wednesday, December 16, 2015 // Women's Health

Here is a summary from the publication Journal Watch:

American Cancer Society Updates Mammography Guidelines for Average-Risk Women
American Cancer Society Updates Mammography Guidelines for Average-Risk WomenRecommendations move closer to those of the USPSTF — but differences remain.
Recommendations move closer to those of the USPSTF — but differences remain.
Andrew M. Kaunitz, MD

Based on input from clinicians, public health specialists, laypeople, and a commissioned review, the American Cancer Society (ACS) has issued its first guideline update since 2003 regarding screening mammography for average-risk women (no personal history of breast cancer, known mutation associated with excess risk, or history of chest wall radiation at a young age). Recommendations are delineated as strong (consensus that the benefits of adhering to the recommendation outweigh undesirable effects) or qualified (clear evidence of benefits but less certainty about benefit–harm balance or women’s preferences that could influence their decisions). The new guidelines are as follows:Age

  • Age 40–44: Optional annual screening mammography (qualified)
  • Age 45: Begin screening (strong)
  • Age 45–54: Annual screening (qualified)
  • Age ≥55: Biennial screening with option to continue annual screens (qualified)
  • Continue screening as long as overall health is good and life expectancy is ≥10 years (qualified).
  • Any age: Clinical breast examination (CBE) for screening is not recommended (qualified).

Comment: The updated ACS recommendations reduce the potential for harms (overdiagnosis and unnecessary additional imaging and biopsies) and move closer to the guidelines of the U.S. Preventive Services Task Force (USPSTF; i.e., begin biennial screening at age 50; NEJM JW Womens Heath Dec 2009 and Ann Intern Med 2009; 151:716).As one editorialist points out, the ACS recommendation to begin screening at age 45 is based on observational comparisons between screened and unscreened cohorts, a type of analysis the USPSTF does not consider because of concerns about bias. The ACS’s recommendation for annual screening in women aged 45–54 is based in part on the findings of a recent study showing that, for premenopausal (but not postmenopausal) women, tumor stage was higher and size larger for screen-detected lesions among women undergoing biennial screens. The ACS recommendation against screening CBE, stemming from the absence of data supporting CBE’s benefits (alone or with screening mammography), represents a dramatic change from the society’s prior stance. Moreover, in leaving their 2003 guidance regarding breast self-examination unchanged, the ACS continues to recommend against this latter practice. Overall, these updated guidelines should result in more women starting screening mammograms later in life as well as opting for biennial screening, meaning fewer lifetime screens. Also, fewer breast examinations during well-woman visits will allow clinicians more time to assess family history and other risk factors for breast cancer, as well as to maintain dialog about screening recommendations. In my practice, I will continue to encourage screening per USPSTF guidance (begin biennial screens at age 50) for my average-risk patients, while recognizing that many will be more comfortable starting screening at an earlier age and annually thereafter. – See more at:

My two cents from Dr. Jennifer Wallace:

Previously the standard of practice was for women to have annual mammograms starting at age 40. We now have two agencies who have recommended reduced frequency of screening mammograms for average risk women. The difficulty with screening procedures, as always, is to find the right balance between screening frequently enough to detect problems at an easily curable stage vs. screening too often, leading to further possibly unnecessary testing and anxiety.

Previously the standard of practice was for women to have annual mammograms starting at age 40. We now have two agencies who have recommended reduced frequency of screening mammograms for average risk women. The difficulty with screening procedures, as always, is to find the right balance between screening frequently enough to detect problems at an easily curable stage vs. screening too often, leading to further possibly unnecessary testing and anxiety.

The new recommendations by the American Cancer Society for less frequent mammograms are somewhat “soft”, leaving us a lot of wiggle room. Their recommendations, other than to start screening at age 45, are “qualified”, meaning that the benefits are known, but there is less certainty about whether the harms of screening on the proposed schedule outweigh the benefits. Further, since we have recently started using “3D mammograms”, which are less likely to miss small or early cancers, I wonder if the “benefit vs. harm” calculation could possibly change in favor of annual screening again.

Unfortunately, it may take years before the harms, if any, of the reduced screening are known. I will look forward to finding out those results. Meanwhile, for now I am leaning toward continuing annual mammograms, particularly in women who are taking postmenopausal hormone replacement. As always, I will be open to discussion with my patients about their preferences, and stay open to change as more information becomes available.

Jennifer Wallace MD

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Insurance Conundrum

Wednesday, December 16, 2015 // Insurance

BCBS (Blue Cross Blue Shield) has canceled all their PPO plans in Texas and are only offering HMO plans through the federal website, In addition, other insurers are canceling their PPO products. This will leave patients with more restrictions on the doctors that they are able to see. From our standpoint, HMO’s are less desirable because they require us to obtain authorizations or referrals for our patients to see any other physician. If many of our patients choose HMO’s we will have to hire someone to just take care of the paperwork. It is like having an unfunded mandate from Congress. It increases the hassle factor of obtaining needed care. If you are having difficulty obtaining insurance, I think it makes sense to use an agent. There are a number of independent insurance agencies which have agents who can assist in sorting through all the options. Wortham, Catto and Catto and Sanger and Altgelt all have agents who can assist in this. The key points are: 1) to look at a plan’s website and see if we are on it. It seems logical that we would know every plan that we are on, but that’s not the case given the turmoil in this industry. 2) Look for something that contains the phrase “Open Access”. This generous access to specialists than a traditional HMO.

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New Pneumonia Vaccine Guidelines for Patients Over 65

Friday, January 23, 2015 // News, Vaccines

These recommendations have been in the works for a long time. What the CDC didn’t mention is that Medicare hasn’t decided whether to pay for the PCV13 vaccine or not. Patients anxious to get the vaccine are getting confusing information from pharmacies. Some are trying to give them the PPSV23 when the ask for the PCV13 which goes by the brand name Prevnar. Until the dust settles, I’m not ordering any.

The Advisory Committee on Immunization Practices (ACIP) recommends that the 13-valent pneumococcal conjugate vaccine (PCV13,Prevnar) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23,Pneumovax) should be routinely administered in series to all adults who are at least 65 years of age, the CDC announced last week.

Adults in this age group who have not previously received a pneumococcal vaccine or who do not know their vaccination history should receive a dose of PCV13, followed by a dose of PPSV23 6 to 12 months later. The 2 vaccines should not be administered together, and the minimum acceptable interval between them is 8 weeks, the ACIP said.

Adults in this age group who have previously received 1 or more doses of PPSV23 should receive a dose of PCV13 if they not already done so. This dose should be given at least 1 year after the most recent PPSV23 dose was received. Patients in whom another dose of PPSV23 is indicated should receive it 6 to 12 months after PCV13 and 5 or more years after the most recent dose of PPSV23.

The recommendations were published in the Sept. 19 Morbidity and Mortality Weekly.


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Friday, January 23, 2015 // Medication, News

Vicodin (hydrocodone/APAP) a potent pain killer has been changed by the Federal government from a Class III drug for which a prescription can be written or called in to a special prescription which can’t be called in and has to be written on a special prescription. This is in an effort to reduce abuse of prescription drugs. There is also a reduction in the number of days for which a prescription can be written. It goes from 180 days to 90 days. A prescription for it will now necessitate a trip to the doctor’s office.

We’ll see how this plan works. It will be challenging for patients with chronic conditions which necessitate the regular use of this medication.


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Stress Testing

Friday, January 23, 2015 // News

Stress testing may be useful to screen for heart disease, assess exercise tolerance and blood pressure response to exercise, but the American College of Cardiology does not recommend doing it in patients at low risk for coronary artery disease because a positive test, which may indicate underlying heart disease, is more likely to be a false positive in these individuals.  The patient may then have to go through additional testing to prove what isn’t wrong with them.  It may be useful in stratifying risk is patients who have multiple risk factors for heart disease.  I will continue to utilize it in those select individuals.


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Flu Vaccine

Friday, January 23, 2015 // Flu, News

Most patients have received their flu vaccine by now. Unfortunately, it’s not a great match with the strain that is circulating now as the following article from Journal Watch outlines, but it is all we have available and offers some protection.


Flu Vaccine Not a Perfect Match to Circulating Viruses

By Kelly Young Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS Roughly half of the circulating influenza A (H3N2) viruses collected in the U.S. early this flu season are antigenically different from the H3N2 virus included in this year’s vaccine, prompting CDC officials to remind healthcare providers about using neuraminidase inhibitors to treat and prevent influenza. H3N2 has been present in about 90% of influenza-positive tests this flu season. Years with high H3N2 activity tend to see higher flu morbidity and mortality. The World Health Organization recommended components for the Northern Hemisphere vaccine in February. Antigenically drifted H3N2 viruses were detected in March and became more prevalent in September, too late to change the vaccine. “They’re different enough that we’re concerned that protection from vaccination … may be lower than we usually see,” CDC Director Tom Frieden told reporters on Thursday.The CDC is still recommending that people get vaccinated against the flu because it provides partial protection and the B strains are well matched. But Frieden said that if clinicians suspect influenza in high-risk patients, they should start neuraminidase inhibitor treatment without waiting for confirmatory test results. – See more here.

I was very surprised by the recommendation of the Tamiflu-like medications (neuraminidase inhibitors) given recent articles on their lack of efficacy. Again, from Journal Watch.


Tamiflu, Relenza Data Show Little Clinical Benefit Against Flu
By Joe Elia

The neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) have only marginal benefits in the treatment and prevention of influenza, a series of BMJ articles concludes. Investigators reviewed documents submitted to regulatory agencies concerning both drugs. Tamiflu data showed it reduced symptom duration by roughly 17 hours but made no difference in hospital admissions or rates of carefully defined pneumonia. Tamiflu increased nausea and vomiting. As prophylaxis, it greatly reduced symptomatic (but not asymptomatic) cases. The Relenza analysis similarly showed a modest reduction in symptom duration (14 hours) and no effect on pneumonia. As prophylaxis, it acted like Tamiflu and had fewer side effects. Editorialists observe that the analyses show “with greater clarity than ever” that the current system for drug regulation is broken. And one commented that, given these results, “it is difficult to conceive that many patients would actively seek treatment.”. NEJM Journal Watch Infectious Diseases associate editor Stephen Baum wrote: “Clean out your medicine cabinet: these reviews call into question the drugs’ efficacy and side effects, as well as the ways in which data were selectively used to promote them.” – See more here

Still, most people who are sick would gladly shorten their sickness by 17 hours. If you have headache, fever and a cough you can call, email or text. Make sure to do it in the first 48 hours. It is not considered good medical practice to prescribe medications for people who are not your patients. It is also a big liability to prescribe drugs with potential side effects for people with whose medical history you are not familiar.. For those reasons I don’t call in Tamiflu for non patients, and recommend calling their physician.



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New Associate: Dr. Jennifer Wallace

Friday, January 23, 2015 // News

When I opened this practice 12 years ago, I designed the space for two physicians. I felt confident that I would locate someone who would be a good match. That didn’t happen, I got used to the quiet along with the patients and staff and I didn’t actively seek another physician. Now, I have finally identified someone who is a good fit. I worked with Dr. Jennifer Wallace in my old practice and she has agreed to come on board starting in the spring of 2015. Dr. Wallace graduated from Texas A+M. She received her medical degree from the University of Texas Health Science Center at San Antonio and did her residency there in Internal Medicine. She is board certified in Internal Medicine. She is married, is a stepmother and plays the piano.

She is currently accepting new patients so if you wish to refer a friend or family member to Dr. Wallace, you can call Sieglinde at 210-822-2004. Her email address is [email protected]. Forms are available on this page. She will start April 1st. No fooling. I think having another physician in the office will improve coverage when I am out of town and will allow us to take care of more of our existing patients, families and friends than we would otherwise have been able to.



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