Scheduling Preventive Versus "Problem" Appointments

By: Monica Duvall, M.D.

At Rittenhouse Internal Medicine, we recognize that the health care and medical insurance industries can be confusing to navigate for many of our patients.  Our goal is to make the process of seeing a provider as smooth and as simple as possible.  Part of that process is ensuring that you, our patients, are aware of the different appointment types that we offer so that the proper appointment is scheduled to fit your needs at a given time.  We also recommend reviewing your insurance policy, so that you can be aware of how/if the different appointment types are covered ahead of time to avoid surprises (and large bills!).

"Annual Physicals", also called "Routine Medical Exams", "Health Maintenance Exams" or "General Checkups", are preventive health exams that are typically covered by an insurance provider no more than once a year.  The purpose of the annual physical is to is to review a patient's health history, family history, and social habits, to make sure she is caught up on routine vaccinations and recommended age-appropriate health screenings such as colon cancer screening, cholesterol testing, mammograms, etc.   It is also an opportunity for the provider to make specific recommendations that would reduce a patient's risk of poor health outcomes down the road--such as advising an increase in certain types of exercise, or cutting back on the amount of alcohol a patient is drinking.   The goal of this appointment type is to prevent disease by identifying factors in a patient's history/lifestyle that could put their health in jeopardy if not addressed and modified. 

The "Annual Gynecological Exam", also called a "GYN Exam" or "Women's Health Exam", is another type of preventive visit.  This type of appointment is also typically covered by insurance providers no more than once annually.  It differs from the Annual Physical in its more narrow focus; the exam exclusively focuses on preventing adverse gynecological health outcomes.   Items addressed in an annual gyn exam may include cervical cancer screening (the Pap smear), breast cancer screening, birth control/family planning, or preventing/screening for low bone mass.  

All visits that do not fit into the above categories are classified as "Problem" visits.  Most insurance companies do not put a limit on the number of problem visits that can be scheduled in a calendar year; but they typically will require you to pay a copay for each of these visits (even if the problems are addressed during a preventive visit--which we discourage, due to time constraints).   Problem visits (which may be referred to as "Follow up visits", "Sick visits" or "Annual medication checks", depending on the reason for the appointment) are made to address one or more specific health issues or symptoms.   Problem visits are not preventive health exams, and they are scheduled separately from preventive visits to allow adequate time for evaluation and management of the symptoms prompting the appointment.   These may be new, acute symptoms--such as a sore throat, a new rash, or a vaginal discharge--or chronic issues, such as high blood pressure, depression, or managing thyroid medication.   Additional testing or medication may be advised; these may or may not be covered by your insurance company (again, reviewing/knowing the details of your insurance plan coverage ahead of time is advised, as we are not privy to these details).  

Hopefully this is a helpful guide to scheduling your next appointment with us; our call center staff is always available to help you schedule the correct appointment type if you have any questions or need further clarification.

March is Patient Safety Month!

By: Maria Daly, Practice Manager

As March is patient safety month we wanted to share a few ways we work to ensure patient safety in our practice!
Although we are just a little internal medicine office and not a huge hospital, there are still plenty of steps we take to try and keep our patients safe.

  1)      Employee Training: All of our employees receive various trainings on an annual basis. We provide our staff with training on HIPAA so that they become highly familiar with how to treat private health information. We also host a CPR training for our staff so that we always have employees who are able to provide emergency care. On an as needed basis, our MAs also receive refresher courses on best practice for venipuncture and any other procedures.

  2)      Processes: As a medical practice we have a few processes in place to ensure patient safety. All of our MA stations have label machines connected to our EMRs that allow our medical assistants to print legible labels for any laboratory samples collected at our practice. This is the best way to reduce any possibility of mislabeled specimens and potentially giving patients incorrect lab results. We also have specific sterilization processes for our different instruments – weather they need to be packaged or cleaned at a different temperature – these processes ensure that instruments we use in the office are not a source of infection for our patients.

  3)      Equipment: You may have noticed that we have gloves available in all of our exam rooms – gloves are an important barrier to keep our patients safe as well as keep our staff safe! We also have hand sanitizer available all over the building which is our go-to, especially during flu season!

  4)      Building Safety: There are a few safety measures we have taken to make our facility safer for patients also. Our entryway steps now have treads which makes them much easier to walk on in wet weather; the same goes for our carpeted staircase. During snowstorms, our staff regularly shovels and salts the sidewalk in front of our building and we try to mop our waiting room regularly also to get up any water that had been trekked in so that there are no slips in our waiting room.

Although a lot of these items may seem obvious, they all go a long way in ensuring the safety and well-being of our patients. We review these processes regularly and consider employee and patient input to find any problems or improvements that can be made. Please know that we are always doing our best not only to treat you but also to keep you safe physically and psychologically whenever you visit our practice. Thank you for being our patient and have a safe and happy March!

Is Going Vegan Good For You?

By: Angela Luciani, Nutritionist 

Many people choose to go vegan for one reason or another – perhaps it is concern for the treatment of animals, environmental factors or perhaps they are trying to become healthier.

A vegan diet is a type of vegetarian diet that excludes all meat, fish, poultry and dairy products as well as foods that are processed using animal products. While becoming vegan can reap some health benefits, it is not for everyone and there are some important factors to consider before making the decision to switch.

Vegan diets are typically higher in nutrients such as fiber (which can help lower cholesterol), magnesium, potassium, vitamins C& E, iron, antioxidants and overall tends to be lower calorie and lower in saturated fat; however, it involves more planning and discipline to ensure you are getting all the nutrients you need.

Common nutrient deficiencies with a vegan diet include calcium, Vitamin D, omega-3, B12 and folate. Because you are eliminating food groups as a vegan, you are eliminating food groups that have these important nutrients. It is important to replace these nutrients so that your body is able to function properly. All vegans need to take some form of B12 whether it is through a supplement or nutrient rich food such as nutritional yeast.

Because a vegan diet is “plant-based,” there is the benefit of reducing risk of cardiovascular disease and the complications associated with diabetes.

Ensuring a well balanced meal by incorporating all of the essential nutrients to nourish your body is important for your health and just like any diet – failure to plan successfully and safely can lead to poor outcomes.

Four Ways To Love Your Heart Back

By: Maria Mazzotti D.O.

February is heart healthy month. There has long been a debate about which organ is more important, your heart or your brain. While both may take equal importance, February's focus on the heart has us talking about what we can do to keep our heart healthy.

At the top of the list is exercise. Even if you do not need to lose weight, cardiovascular exercise for 30 minutes, five times per week will keep your heart healthy. Besides burning calories and helping with keeping your blood pressure controlled, cardiovascular exercise helps build extra blood vessels which can save your life if any blood vessel becomes occluded. By having alternative blood vessels supplying blood to the same area of the heart that is not receiving a normal supply of blood, you avoid any permanent damage to that part of the heart.

Next and just as important is getting the proper amount of sleep. Recent studies show that getting less than 7-8 hours of sleep nightly may cause hormonal dysfunction that contribute to weight gain and elevated blood sugars. Even more obvious is that your heart rate decreases while sleeping, giving your heart time to recover from your day.

Diet is also clearly another key aspect to keeping your heart healthy. It is widely agreed that the Mediterranean diet is a heart healthy diet. The key components of this diet are: low fat proteins (beans, white meat, Tahini, low fat cheeses), olive oil, whole grains, nuts, bread (whole grain), veggies and fruit (instead of dessert). These foods should be fresh, not processed. Adding Mediterranean spices decreases the need for higher amounts of salt. An added plus is that some spices like Coriander and Rosemary are also antioxidants. To top off the diet: wine - another proven antioxidant. Because this diet is healthier and lower in calories, it often times produces weight loss. Antioxidant-rich foods are also brain friendly which keeps your brain sharper.

Hydration is another key element of heart health, especially in females who typically have lower blood pressure than men. Not being well hydrated can damage all of your organs - especially your heart. If your blood pressure is low and you are not well hydrated, you are at higher risk of getting dizzy and passing out.

While going about your days in February, let the red around you remind you that just like the four chambers in your heart, there are four easy things that you can do every day to keep your heart healthy. By giving love back to your heart, it will keep you healthy and will lead to a happy body and heart relationship!



By: Dana Shanis, MD

ThermiVa® is a non-surgical, safe and effective procedure that uses radiofrequency heat to tighten loose, sagging skin and increase blood flow and nerve sensitivity in the vaginal area.  This procedure is used to treat many common vaginal complaints, including:

1·  Vaginal and labial laxity

Stretching of the vaginal tissues and muscles is common after childbirth and can occur with normal aging.  This can cause decreased sexual satisfaction, discomfort with exercise and bothersome urinary symptoms.   The labia (external lips around vagina) also experience sagging over time, which can cause rubbing and irritation and cause many women to feel self-conscious.  ThermiVa® can be used both internally and externally for these concerns.  The heat applied during the procedure causes the tissues to contract and increases the amount of collagen in the area.

2·  Vaginal dryness

Many medications, as well as the normal aging process can cause vaginal dryness for many women. This dryness often becomes severe after menopause or cancer treatments, causing daily discomfort and making sex painful.  Without exposure to hormones, the ThermiVa® procedure increases blood flow in the area which increases vaginal moisture and lubrication during sexual activity.

3·  Urinary incontinence and overactive bladder

Urinary complaints are common in women of all ages, most commonly incontinence (leaking urine) and overactive bladder.  The radiofrequency applied to the vaginal tissues during the ThermiVa procedure can help tighten the tissue under the urethra, which decreases the rate of leaking with cough, sneeze or exercise.  The procedure also increases nerve growth around the bladder, which can decrease bladder irritation that causes the urgency experienced in overactive bladder.

4·  Painful sex

ThermiVa® helps reduce muscle spasms in the pelvic floor that are commonly a cause of pain with sex.  Many women also report an improvement in their desire, arousal and ability to orgasm after the treatment.  Due to the small probe size, most women report little to no discomfort during the procedure even if they are unable to tolerate penetration during sex due to pain.

How is it performed?

During the procedure, a small wand is slowly moved over the areas of concern, gradually heating the tissue.  The procedure takes less than an hour, during which most women report feeling only a warm sensation and no pain.  There is no down time once completed, women can return to exercise and sexual activity immediately.  A total of three treatments, scheduled a month apart, are recommended for optimal results.

When will I see results?

While each woman’s experience may differ, many women notice a difference within hours to days after their first treatment.  For some women it takes longer or multiple treatments.  The effects of the treatments continue to improve for several weeks and lasts up to one year on average.  A touchup session is often needed after a year to maintain the effect.

Is it safe?

Over 50,000 procedures have been performed with this technology worldwide, and no burns or significant adverse outcomes have been reported.

If you are dealing with any of these issues, you do not have to live with the discomfort any longer. Schedule a consultation with one of our Women’s Health providers to review your concerns, discuss alternative treatment options and determine if you may benefit from this procedure.  

January is National Blood Donor Month

By: Monica Duvall, MD

The start of the new year heralds the American Red Cross's annual effort to raise awareness of the critical need for blood and blood products through the winter months. Blood donations typically go down during this period, due to illness of potential donors, cancellations of blood drives due to inclement weather, and other reasons.   It is estimated that 38% of the US population is eligible to donate blood, but less than 10% of that eligible population donates, according to the Red Cross.  National Blood Donor Awareness month aims to remind the public that the need for blood is real, and to motivate first-time and previous donors to give blood or support blood donation efforts in other ways.

Over 20 million blood products are transfused in the US annually; 40% of these products come from volunteer donors to the American Red Cross.   Every 2 seconds, someone in the US needs blood, and an average transfusion requires 3 pints of blood.  A victim of a car accident may need as many as 100 pints of blood!  A typical blood donation takes about a pint of blood out of the approximately 10 pints in the average adult body--plenty for a healthy adult to spare.  Each donation can help multiple people, as components of whole blood can be separated out for different uses.  Red blood cells carry oxygen to tissues in the body, and are used in trauma, surgery, and in the treatment of severe blood loss.  Platelets are cell fragments that help with clotting--these are used in surgeries and cancer treatments.  Plasma is a clear liquid that contains proteins and clotting factors; it is commonly used in burn patients and bleeding disorders.   Although donors of all blood types are needed, certain blood types are usually in shorter supply because their blood products can be used for patients of any blood type (critical in emergency situations, when a patient may need blood before his/her blood type is known); these are Type O negative, the "universal donor" for red blood cells, and type AB positive, the "universal donor" for plasma.  Only 7% and 3% of the US population, respectively, has these blood types.

Giving blood is safe for most healthy adults, and a single donor can give blood multiple times annually.  General eligibility requirements are that donors must be at least 17 years of age, and weigh at least 100 pounds.  Additional eligibility/exclusion criteria can be found on the American Red Cross website.  To donate blood, you can download the ARC blood donor app, visit, or call 1-800-RED-CROSS (733-2767).   If you do not meet current eligibility criteria, you can still support blood donation efforts by spreading the word about Blood Donor Awareness month, by donating to the Red Cross, or by hosting a blood drive through your workplace or community group (such community efforts provide about 80% of Red Cross blood donations!).   Giving blood is giving the gift of life to someone in need--please consider donating this winter.

Improving Your Emotional Awareness

By Courtney N. Liggera, Psy. D.

“Educating the mind without educating the heart is no education at all.” - Aristotle

Generally, society discourages us from being in touch with our emotions.  Social media seems to encourage us only to show a happy face to the world.  Professional work environments appear to promote those who act dispassionately.

However, being in touch with your feelings--both positive and negative--will make you a better and more complete person. By understanding your emotions, you will feel better about yourself.  You will improve your confidence, knowing that you are not hiding behind a false front.

What does it mean to get in touch with your emotions?

One interpretation is being able to communicate emotions to others. A large part of emotional security is validating your own feelings by expressing them to other people.

When we choose to not to express our feelings, we punish ourselves and others. We may no longer make ourselves available to others and may withdraw, or just not be fully engaged when we do spend time with other people. At other times, if we choose not to express our emotions, we may react inappropriately because our emotions are pulling us in a different direction from where we really want or need to go. When we can express how we truly feel in healthy ways, we can solve problems, improve relationships, and enjoy life. In addition, we end up viewing our lives more positively because we are not holding on to unhealed or confusing feelings.

There are many reasons why we might feel the need to hold in our true feelings. We may feel we can’t express them without causing embarrassment or harm to another.  We may not want to unleash our feelings out of fear that once we start, we will not be able to stop. But by letting our feelings out, we are letting out what hurts, while making more room for positive thoughts and feelings. Expressing our negative emotions in a way that is considerate of others people’s feelings is actually a good way to free us from them.

We can get better at knowing what we are feeling and why.  This skill is called emotional awareness. Understanding our emotions can help us relate to other people, know what we want, and make choices. Even emotions we consider "negative" (like anger or sadness) can give us insight into ourselves and others.

Although emotional awareness comes more easily to some people than others, it is a skill that anyone can work on. Here are a few ways to improve your emotional awareness:

  1. Notice and name your emotions. Start by just noticing different emotions as you feel them. Name them to yourself.
  2. Track one emotion. Pick a familiar emotion — like happiness — and track it throughout the day. Notice how often you feel it and when. Whenever that emotion shows up, you can simply make a mental note to yourself or jot it down in a journal. Notice where you are, who you're with, and what you're doing when that emotion is present. Note whether the emotion is mild, medium, or strong and if it has different intensities at different times.
  3. Build your emotional vocabulary. Try going through the alphabet and thinking of one emotion for each letter.
  4. Think of related emotions that vary in intensity. See how many you can come up with.
  5. Keep a feelings journal. Take a few minutes each day to write about how you feel and why. Journaling about your experiences and feelings builds emotional awareness. You also can express an emotion creatively. Make art, write poetry, or compose music that captures a specific emotion you're feeling.
We all have emotions every day, even when we do not realize it. When we are able to be in tune with our emotions, we remain true to ourselves, and we help ourselves receive the support we need. Ignoring our feelings may be the easy choice in the moment, but it can have serious repercussions for our relationships and our mental health.  Being in touch with our emotions can help us be more empathetic, know our strengths and weaknesses, make better decisions, and ask for what we need.

Healthy New Year's Resolutions for 2018

By: Elizabeth Galbrecht, MSN, AGNP-C, WHNP-BC

Move More

Exercise is one of the most powerful things that you can use in your day-to-day life to improve your cardiovascular health, manage your weight, strengthen your bones, reduce stress, and possibly even prevent certain types of cancer. I tell all of my patients that exercise is truly like medicine for your body and for your mind. The ultimate exercise goal is to get at least 150 minutes of moderate-intensity physical activity (i.e. brisk walking) or 75 minutes of vigorous-intensity activity (i.e. jogging or running) per week, in addition to muscle-strengthening activities on 2 days out of the week. This might sound intimidating at first, but the good news is that you can spread out this time over the week in a way that is most convenient for your schedule. Even exercising just 10 minutes at a time is beneficial. You can also get creative – brisk walking and jogging aren't the only ways to exercise. Anything that gets your body moving counts as exercise, so find something that makes you happy – anything from aerial yoga to zumba - and roll with it!

Eat Better

New Years is always the time of year when trendy crash or fad diets start to surge in popularity. These are never the most effective or sustainable options and are often times flat-out unhealthy. When it comes to your diet, small changes over time can make a big difference. One of the simplest ways to modify your diet and improve your health is to focus on increasing your consumption of fruits and vegetables. It is well-known that a diet rich in fruits and vegetables can decrease the risk of heart disease, stroke, high blood pressure, and diabetes. Another strategy for the New Year is to cook at home more and eat out less. That way, you have control over portion size and also all of the ingredients (including salt, oils, butter, etc.) involved in preparing your meal. For further dietary guidance and support, you can always schedule an appointment with one of our nutritionists at RWWC.

Drink Less

Alcohol is everywhere in our culture, and drinking is encouraged on many levels. We are constantly bombarded with promotional messaging about alcohol and it can be easy to get caught up in drinking habits that might, in actuality, be harmful to your health. The Centers for Disease Control and Prevention define “heavy drinking” for women as 8 drinks or more per week. One drink is defined as either 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of hard alcohol. “Binge drinking” for women is defined as having more than 3 drinks on one occasion. Heavy drinking has many short-term and long-term consequences for women, and in many cases these consequences are more pronounced than they are in men. These include increased risk for alcohol-related liver disease, memory loss and shrinkage of the brain, osteoporosis, and breast cancer. There are, however, beneficial effects of certain types of alcohol that are well-documented, such as improvement in cholesterol and cardiovascular health - the key here is moderation.

Quit Smoking

It should be no surprise to anyone that smoking is extremely harmful to your health and will shorten your life. Any degree of tobacco use, whether it's smoking a pack per day or social smoking, has serious consequences. Many are aware of the risks of lung and head/neck cancers caused by smoking, but some may not know that smoking damages many other organ systems. For example, smoking is the single most common preventable risk factor for bladder and kidney cancer, which are highly aggressive malignancies with few available treatment options. Toxic carcinogens inhaled during smoking do not only contact the upper airway and lung tissue, they are also absorbed into the blood stream and penetrate into virtually every organ. The kidney and bladder are particularly susceptible to damage from smoking because these toxins are concentrated in the urine and literally bathe the kidneys and bladder before they are excreted in the urine. Even if they are discovered early, often radical and disfiguring surgeries are required to control cancers of the genitourinary tract. With regards to women's health in particular, cigarette smoking increases the risk of HPV-related cancers of the cervix and vulva and also increases the risk for recurrent vaginitis, especially bacterial vaginosis (also known as BV). If you smoke, quitting is the #1 best thing that you could do for yourself. We are here to help you if you are ready to quit smoking, so please do not hesitate to discuss this with your healthcare provider at your next visit.

Establish Care

If you have not had an annual wellness visit or gynecologic exam in some time, please be sure to put this on your to-do list for 2018. Even if you feel healthy and have not had any changes to your health in the last several years, there are likely to be preventive health measures that you might be missing out on. We can help to make sure you are up-to-date with your immunizations, cancer screenings, and routine bloodwork so that you stay as healthy as possible in the years to come.

Cannabis Education

Gov. Tom Wolf signed a law legalizing medical cannabis in Pennsylvania in April, 2016. One of the medical marijuana facts for Pennsylvania that frustrated supporters of legalization was that it took so long to happen. The Pennsylvania Senate first approved a bill legalizing medical weed in 2015, but it was not approved by the entire legislature until March, 2016. Several technical changes needed to be made before both chambers could finally agree on a final bill.

In order to be able to recommend cannabis to their patients, physicians need to complete a four-hour course. They must sign a certificate stating that the patient not only has a qualifying condition, but also that the doctor believes that patient will be able to benefit from medical cannabis use.

There are several forms of cannabis that patients can use, including oils, pills, creams, ointments, liquids, gels and more. Vaporization is allowed, but not smoking of the plant. While dispensaries are not allowed to sell edible forms of weed, the law allows patients to mix medicinal cannabis into drinks or food in order to help them ingest it.

If you are a patient in another state, you are not allowed to access medical weed in Pennsylvania.

The different types of IUDs

By: Allison Andrews WHNP

There are two different types of IUDs: hormonal and non-hormonal.
We want to answer the 2 main questions that many women ask themselves when considering an IUD:  What is the difference? Which one is right for me?

Mirena is the hormonal IUD that has been around the longest, and is currently approved for up to 5 years. Mirena was originally intended for women who have had children. However, studies have shown that it is perfectly safe and effective for women who have never been pregnant. Mirena is recommended to help manage women who suffer from heavy or painful periods. Most women on Mirena have reported that their periods get significantly lighter or go away completely. About one in five Mirena users stop having a period after a year, and one in three if they use it for a longer period of time.

Liletta is very similar to Mirena. It contains the same dose of hormone and is approved for use up to 4 years. This IUD has also been approved for women who have never had children. Like the Mirena, your periods can get significantly lighter or go away completely.

Kyleena is smaller in size then the Mirena and has a lower dose of hormone then the Mirena/Liletta. Like the Mirena the Kyleena is approved for up to 5 years and about 1 in 8 women who use it will stop having periods after a year.

All hormonal IUDs prevent pregnancy by releasing a small amount of a progestin hormone called levonorgestrel each day. The progestin acts locally in the uterus to prevent pregnancy. Hormonal IUDs do not contain estrogen and typically have fewer hormonal side effects than methods that do contain estrogen.

ParaGard contains no hormones and is approved for up 10 years. Since this device does not contain hormones, most people who use ParaGard can experience heavier, longer, or painful periods. Studies have shown that after 6 months, many ParaGard users’ periods return to normal. If you already have really heavy or painful periods, you will most likely benefit more from a hormonal IUD.

The non-hormonal IUD prevents pregnancy by using a tiny copper filament wrapped around the T. ParaGard, making the uterus a hostile environment.

IUDs are safe, effective, and reversible. There are many different kinds of IUDs and they are not a one-size-fits all. Call today to schedule a consultation with one of our nurse practitioners and together we can decide which is best for you!

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