Thursday, December 25, 2014

How to Obtain a Second Medical Opinion?

Obtaining a second medical opinion is very important, specially when the medical problem that a person is dealing with is complicated, chronic or needs aggressive and expensive medical care. The primary care provider and the specialist who sees you or your relative may be very good, but ultimately, the body belongs to you and not only you must be seeking  care, but also making sure it is good care.

Here are some steps that may be followed:

1. If you are thinking about obtaining a second medical opinion, you must make up your mind first. If the last medical visit was left with more questions than answers, or you need reassurance, it is always a good habit to give the physician who saw you a call in order to clarify things. Keep in mind that time is not a luxury of doctors these days, so they might just need more time to talk to you. If after talking to the doctor again, questions remain unanswered, then, there is a good case to look for a second opinion.

2. Once the decision is made, you should contact your insurance company in order to see if second medical opinions are covered by your plan and in case they are, to see what physicians can provide it. 

3. When the options are provided, the physicians’ credentials must be verified. You can look into the specific Specialty Board’s website to check the physician’s background and experience.

4. If the choices do not satisfy you, there can be other physicians available. Look into medical schools, hospitals and friends and family recommendations. Do a thorough internet search and verify credentials. Be prepared to pay out of pocket money in these cases.

5. Once the second opinion is obtained, request a written report. This is important because it will give you a document to refer to and will help you when going back to your original physicians. It can contain valuable information and it can help you and your doctor in the developing of the plan of care.

Although requesting a second medical opinion is a right, some physicians may be offended by the fact that you are doing it. Reassure your physician by saying that this is meant for you to be further educated about your condition and its treatment options.

Marco A. Ramos MD

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Thursday, November 20, 2014

The Importance of Organ Donation

Organ donation is extremely important. Many people are currently in waiting lists for kidney, liver, heart, lung, pancreas and intestine transplants. A significant percentage of these patients, pass away before receiving the transplant.

The situation for every organ is different. While people in need for a kidney transplant or a liver transplant can receive an organ (or part of it) from a living donor (provided that the donor is immunologically compatible with the recipient), the other organs need the donor to be a deceased person. Also, while people with kidney insufficiency can undergo dialysis treatments while waiting for a kidney transplant, the situation is different for the other organs because besides medical treatment, there is no effective way of replacing the organ functions. 

How to become an organ donor? There are a couple of ways. Any person, at the time of registering for an state ID or (renewing it) can register as an organ donor. In addition, there are state organ donation registries, accessible through the internet. It is important to carry a card that can provide consent for a donation of organs in the event of sudden death. Living donation is also possible in the event of a friend or relative needing an organ. There are also “paired donation programs” by which, in the event the donor is not compatible with the intended recipient, there could be a “cross donation” by which an organ will be given to a compatible recipient provided that this recipient has a donor compatible with the first recipient.

There are medical conditions that a living donor must not have in order to qualify to donate an organ . These are HIV disease, diabetes mellitus, malignancies or any chronic infectious problem. Also, the donor must not have any condition that may be worsened by organ donation like, for example, chronic kidney disease.

Finally, it is important to say that for the transplant recipient, the problems are not over after receiving the donated organ. They have to continue with lifelong immunosuppressive therapy which has risks of their own. However, overall, it is a second chance for enjoying life.

For further information visit:

Marco A. Ramos MD

Thursday, October 23, 2014

The Many Functions of the Kidney

The kidney has many vital functions. They can be altered by disease, trauma, medications or intoxications. Although the kidney is widely recognized as the organ which “makes urine” and in the process “cleaning the body from unnecessary substances”, it has many other functions.

The kidney regulates the level of fluid the body has. This function is closely tied with the regulation of the sodium and water contents of the body and with the blood pressure control. If this property fails, the could be high blood pressure, low blood pressure, high sodium or low sodium levels in the blood.

The body is alive because it can keep a tightly regulated pH (or acid-base status). If the blood pH drops below 6.8 or goes higher than 7.6 life is not sustainable. The kidney (together with the lung) is key in the control of the blood acid-base status.

The body needs a sensor to be able to create more red blood cells when they are needed. This sensor is the kidney. There is a hormone called erythropoietin which is secreted when there are less red blood cells or when the blood carries less oxygen.

The bone metabolism needs the kidney to produce activated vitamin D. This hormone is essential for the absorption of calcium from the intestine and to suppress another hormone called PTH, which if not suppressed it can lead to loss of bone mass and loss of phosphorus though the urine.

The body needs to keep a tight control of the potassium concentration in the extracellular fluid. The kidney is in charge to determine how much potassium should be allowed in the urine and how much should be retained.

The kidney has to be able to filtrate certain substances and to keep others. If the kidney were to let all substances be filtered, we would lose important proteins such as albumin and immunoglobulins (antibodies) though the urine.

By doing this quick summary, it is obvious that the kidney is a complex organ. The available forms of dialysis do a good job trying to mimic the function of the kidney, however, they are far away from perfect. The proof of this is how much better the results of kidney transplantation are compared to the results of dialysis.

Marco A. Ramos MD

Monday, September 29, 2014

The Importance of Individualized Medical Care

In our days, due to the pressures of the health insurance companies (private and public), the legal system, the physician shortage and academia there is a push towards standardizing the medical care at all levels. This would work well if everyone of us were genetically and culturally equal, with the same responses to infectious agents, dietary habits  and the stresses of life in general. However, as you probably already concluded, this is not the case.

Health insurance companies base their profit models in statistics. They use averages, standard deviations and trends in order to make decisions. An individual with a unique problem, who does not fit in the pattern usually creates some degree of stress in the system that needs time to be solved. In many occasions, neither the physician nor the bureaucrats have the time to actually solve the issues.

The legal system uses the “standard of care” as the standard to compare the practicing behaviors of physicians with at the time of malpractice litigation. Because of this, the practicing patterns of physicians tend to be similar regardless of the patients’ uniqueness. This is one of the characteristics of “defensive” medical practice, which increases the cost of care without necessarily increasing its effectiveness.

The physician shortage has created a situation by which physicians do not have enough time to analyze the situation of a particular patient, specially if the problem is complex. This is one of the reasons, why diagnoses of rare conditions can take longer than they would if the physicians had the necessary time to study the rare and complex cases.

Academia has pushed for the practice of “evidence-based medicine”. While this is a great concept specially at the time of gathering knowledge, it can become a problem if the practitioner applies the conclusions of research to patients who do not fit the inclusion criteria of the same research.

There is no simple fix for the healthcare system as a whole. Individuals have to take responsibility of their own healthcare and use the available resources in order to solve their problems, specially if they are complex. for example,there are the private-pay “concierge” practices. These physicians can offer more time to patients and they would definitely make the patient understand his or her own issues. There are also several second medical opinion services, which can provide access to specialists who can dedicate their time to analyze the patient’s case in detail. These services, I believe, understand better the need for individualized medical care.

Marco A. Ramos MD

Saturday, August 30, 2014

What I Wish I’d Known About Kidney Stones Before I Had One by Dr. Mary

Have you ever had a kidney stone? I did, in college. Kidney stone pain is very similar to labor, but passing a kidney stone is continuously miserable, whereas the pain of labor comes and goes. Needless to say, I don’t want another one.

With a personal history of kidney stones, I started to get concerned that my morning smoothie might be putting me at risk. Smoothies have a high concentration of oxalates, and about about 80% of kidney stones are made up of calcium oxalate.

Oxalates are naturally present in our bodies. They are also present in varying levels in certain plant foods. Some other symptoms, such as fatigue and vaginal pain, are associated with dietary oxalates, but these associations are unproven. Low-oxalate diets are sometimes recommended to decrease the kidney stone development.

There are only nine foods that are shown to significantly increase urinary concentrations of oxalates:
Wheat bran

This is a big surprise, since many other vegetables are high in oxalates. (Check out the content of your fave veggie here.)

Why do some foods that are high in oxalates not increase the amount of oxalate in the urine?
It’s probably because greens, fruits, and vegetables are very high in calcium, too. Calcium binds the oxalates in the food while it’s still in the intestine, limiting the absorption and allowing the potentially harmful oxalates to be excreted from your precious, beautiful body.

Why do vegetarians have half the risk of kidney stones compared to omnivores?

There are two good reasons for this finding:
1. Meat consumption results in increased acidity in the urine.
The body responds to the increased acidity by adding calcium to the urine, much in the same way my mom takes a Tums when her stomach hurts. The increased calcium in the acidic urine binds the oxalate and whammy! A stone is formed. Keeping the urine alkaline with proteins (from grains and beans) reduces the calcium in the urine and minimizes the risk of calcium-oxalate stones.

2. Collagen in meat supplies the amino acid hydroxyproline, which is metabolized to oxalate.
The daily turnover of collagen from your own body is a major source of hyroxyproline. Just turning over your own collagen accounts for 5 to 20% of the urinary oxalate daily. Dr. John Knight of Wake Forest University School of Medicine in Winston-Salem, N.C. compared oxalate levels in the urine after feeding people diets loaded with gelatin (made from the cow skeleton and loaded with collagen) versus whey, which is a protein by-product of the cheese industry. Those who ate gelatin had much higher levels of urinary oxalate for the next 24 hours.

Just eating 5 to 10 grams of gelatin significantly increased oxalates in the urine for six hours.
How much collagen is in meat? Samples of lean meats contain from 2.5 to 5% collagen by weight and hamburgers are up to 7.1%. Hot dogs and sausages, made from scraps and pieces, are up to 19% collagen by weight. Meat that contains 7% collagen will have 7 grams per serving and 10 grams per about one third of a pound. Meat servings in the range of a hot dog or quarter pounder will increase urinary oxalates for an entire day after consumption.

Several dietary supplements promoted for skin, bone, and joint health also contain gelatin at 10 grams per recommended dose.

What should a person who wants to limit their dietary oxalates do?
Urinary oxalate is predominantly caused by the oxalate created in your own body from collagen breakdown, but it may also be affected by dietary intake of oxalate and calcium.

Although oxalate-rich foods enhanced excretion of urinary oxalate in normal volunteers, the increase was not proportional to the oxalate content of the food. Fruits and veggies that are high in oxalates are often high in calcium too, which prevents the absorption of the oxalate by binding it up in the intestine.

Increased dietary calcium intake may reduce urinary oxalate excretion by binding more oxalate in the gut.

Collagen in meats break down into hydroxyproline, which then breaks down into oxalates. Meat represents a significant source for oxalates in omnivores. One serving of meat increases urinary oxalate levels for 24 hours.

Decreasing meats and processed dairy cuts the risk of kidney stone by 40%. Check out your supplements and reconsider gelatin-containing products. Avoid gelatin-containing foods and desserts.

This first appeared on

 The article was reproduced with authorization of the author, Dr. Mary Wendt. Click the link for the original article. See Dr. Mary's website at:

Tuesday, July 29, 2014

The 15 Minute Visit to the Doctor's Office

Medical problems can be complex. They have the potential of altering our lives completely and for good and even the power of terminating life. Physicians have devoted a huge proportion of their lives to understand medical issues and to learn the art of palliate if not cure disease. 

Ideally, we should visit a doctor for prevention, advise end general education regarding health problems. The duration of the visit should be determined by the nature of the problem and by the complexity of the tools needed to solve it. Nowadays, in most settings, it is almost impossible to do that. Physicians watch the clock, not because they want to leave and go home, but because there is another patient waiting. And after that patient, there is another and another. All of them can carry problems of similar complexity. Is it fair to squeeze the 13 years of training that a specialist has (not counting the many years of experience after that) into 15 minutes of patient talk? 

An office visit, has the following elements: conversation with the doctor, physical exam, analysis of laboratory values, another conversation to report the physician’s ideas, prescription of medications, ordering further tests, documentation of the encounter and in many occasions, an interaction with the insurance companies to seek approval for certain medications or tests. Is it possible that a good job could be accomplished in 15 minutes?, in 30 minutes? 

This is one of the reasons why the doctor’s office has become a revolving door of patients who come for a prescription refill from a doctor who struggles to keep the practice afloat due to low insurance reimbursements. This is the reason why many complex problems remain unanswered, this is the reason why diagnosis can take longer to be achieved and the reason why so many unnecessary  tests are ordered. This is one of the reason of polypharmacy, medication side effects and medication errors.

What can be done? Nothings substitutes good professional advice. This is why, in order to have a question properly answered, the internet should not be used. It should only serve to seek for a good physician. Second medical opinions provided by doctors that devote the proper amount of time to the medical problems are an invaluable tool that will help not only the person looking for the answer, but also the primary care physician who initially did not have the right amount of time to deal with the issue.

Marco A. Ramos MD

Tuesday, June 10, 2014

Why a Second Medical Opinion?

The doctor-patient encounter has traditionally been a strict relationship between a physician and the patient requesting the services. However, there were always concerns regarding the cost of the services and how accessible the services were. Starting some decades ago, insurance companies (private and government owned) started to participate in the relationship in an effort to make it more efficient. This had the consequence of spreading the risk and making healthcare more available to people. 

As time passed, healthcare became more dependent on the wellbeing of the insurance programs or companies. In order to be able to provide for all enrollees, the reimbursements to the providers started to decrease and, as a consequence of that, the time that the providers give to the patients also started to decrease (because they had to see more patients in less time so as to pay for overheads and remain profitable.) 

The natural result of this is that people remain with more unanswered questions and more doubts regarding their conditions or diseases. In this current world of gigantic leaps in the development of pharmaceuticals, surgical techniques, gene therapy, amongst others, the explanations that professionals (primary care providers and specialists) need to give their patients are complex. Many patients try to enhance their knowledge by using the internet. This is risky. The internet is filled with unreviewed information posted by un-credentialed people who might confuse or even misguide the patient who needs more answers.

A second medical opinion is a tool that will enable patients to be better informed, to be more reassured regarding their conditions and to bring up the possibility of more educated and effective communication with their doctors. For complex problems, two minds are better than one.

Marco A. Ramos MD