All posts by Dr. Josh

Meningitis Vaccine Update

Many of you and your kids appropriately received vaccines to get protected from Bacterial Meningitis. The original guidelines recommended that adolescents get a one time shot around 11 years old, which many did. In November 2015 a new recommendation came from the Centers for Disease Control .(  Now, a booster (a 2nd shot) is now strongly recommended for all teenagers, especially those who are going to be living in dormitories away at college or those going into the military.  While these are higher risk groups based on potential exposure, SHFM recommends ALL teens (16 and over) get a SECOND shot – regardless of their post High School plans.  Bacterial meningitis can kill quickly. There are VERY few circumstances where getting the shot isn’t recommended. Talk to your (or your child’s) doctor at the next visit about getting the booster.



Depression is a very common condition. Most patients who suffer with depression get their initial treatment through primary care and the majority of patients get all of their mental health from their PCPs. For various reasons – including cost, convenience, stigma of actually going to a “real” mental health professional – depression is often addressed in the primary care setting.

As a physician, I regard depression as an illness like another – one that has certain demographics, tendencies, treatments, prognoses, etc. That said, if one does not look for something, it might not get found. While no-one would question the value of doing a blood pressure in a person who is not known to have high blood pressure, or doing routine bloodwork to screen for cholesterol, many clinicians and patients are wary of screening for mental illness – especially depression.

At SHFM, we often do depression screens – either in the form of written questionnaires or by carefully interviewing our patients. This process is so important to us and various regulatory bodies – such as the US Joint Task Force (USJTF) and the Centers for Medicare and Medicaid Services (CMMS), that we routinely use a code that can be attached to the electronic charts of our patients. This allows us to avoid missing those who might benefit. It is EXTREMELY important for our patients to understand that being screened for a disease does not mean that they have it or even that we suspect that they have it. Again, I cite the blood pressure example. Of course, should a patient “screen positive” for depression, a competent primary care provider would know how to delve deeper and guide treatment, if needed.

Depression screening is one of the many services that primary care performs. If depression is not an issue for you personally, it is likely that the screen will only take a few moments and you might not even notice it happened – just like you might not have noticed your PCP checking your posture or walk when you came in. So, if you see a note of DEPRESSION SCREEN in your chart or some paperwork, it does not mean that you have been labeled with a diagnosis – just that your PCP is doing his or her work.

should you want some additional information:

Zung Depression Screening tool

PHQ -9 depression (University of Wisconsin)




Letter to Patients about longterm pain medicine usage

This is a copy of the letter that we are giving to our patients who use opiate pain medicine as part of their treatment:


Dear Patient-

                We are writing to you because part of your care involves opioid medicines. As you likely know, there is an epidemic of prescription drug misuse in this area of the country. Opioid pain medicines are not inherently evil but they do have certain properties that (like all medicines, really) can cause problems for people – even if they are taken as directed. Of course, if one takes these medicines in ways other than intended, or takes more than directed or mixes with other substances – it can be very dangerous!

                One of the ways that we can help protect patients and ourselves is through having a thorough understanding of expectations. Therefore, if you have not filled out a Pain Medicine Contract you will likely be asked to do so shortly. Additionally, it is our policy to ask patients who use opioid medicines regularly to submit random toxicology tests. Please understand that this is NOT an accusation or personal issue, it simply safe protocol at SHFM.

                Additionally, should you any concerns about your medicines at all – whether about usage, over-usage, alternatives, and especially if have questions of tolerance or addiction, feel free to ask at anytime. We are very willing to help and it is always better for all if patients broach the subject rather than the providers do. We have resources to assist patients who may require them.


Joshua M. Usen, DO          Angelika Snyder, DO         Jennifer J Barwell, PA-C       Dawn M Dolan, PA-C


Ebola and the Flu

The Ebola virus is out there. It does kill about half the people that get it. The virus is in the US. Yes, those are scary facts.   But should you be actively worrying about it? Sure, but there are other things – things that you can actually control – that you should be doing. At this time of year, pretty much everyone should be getting their seasonal flu shot. While the seasonal flu (parainfluenza a) does not have the impressive mortality percentage that Ebola does, I assure you that the flu will kill WAY more Americans in the next six months than the Ebola ever will. Over the past 20 years or so, the flu kills approximately 30000 Americans per year.(1)

A key point to know is the mode by which the two viruses are transmitted. Ebola requires contact with bodily fluids of a person who is actively sick. Flu is a respiratory virus – which means that it can be coughed and sneezed onto people. It is significantly easier for respiratory viruses to be transmitted than those which require direct contact. Case in point, look at all of the concern about the passengers who were on the planes with those who ended up being stricken with Ebola – how many of them ended up contracting the disease – ZERO. Think how many times you’ve caught the cold that “everyone had at work.” – why? Respiratory transmission!

Some of the concerns you may have:

  1. You cannot get the flu from getting the shot (except POSSIBLY from the FluMIST nasal spray, because it is a live virus – although EXTREMELY weakened) because there is no live flu virus. What could happen is that you MIGHT experience some mild “flu like” symptoms. However, this is your body mounting an immune response. As bad as this might be, which shouldn’t be bad anyway, it will be way better than getting the actual flu.
  2. Even if you personally would survive a bout of the Flu, and feel that you don’t need to immunize yourself, part of the way a community protects itself is by blocking transmission. In a way, I feel that we all have somewhat of responsibility to help keep the health of our community as high as possible. Hypothetically, you could get the flu, head to the supermarket to get some ibuprofen and orange juice and while there you cough on some nice senior citizen who was not able to get the shot. Guess what, you might have just killed someone!
  3. Flu shots are not a government conspiracy. Pharmaceutical companies don’t make a lot of money on shots – that’s why so few make them. Doctors only make a few bucks on the shots and the pharmacies often lose They hope you buy something else when you’re in the store that they DO make money on.

What should YOU do? Except in rare cases, get a flu shot. You doctor, pharmacist, nurse will review the list of people who shouldn’t get the shot. But, again, just about everyone SHOULD get immunized. Now.






Shingles, also known as herpes zoster, is a painful skin rash.  This most commonly occurs in older adults, but can affect anyone who has ever had chicken pox.  The chicken pox virus lies dormant in a nerve root and at certain times becomes active again in the form of shingles.  This can occur during times of illness, stress, or when the body’s immune system is compromised.  Sometimes, there is no real reason why the virus becomes active again.  In many people, the virus will never become active again and they will never have shingles.

The blistery rash usually appears in a strip or line on one side of the body after a few days of pain or tingling in that same area.  Over days the clusters of blisters fill with fluid, then open and crust over.  It may take weeks for the rash to fully resolve.  The rash can occur on any part of the body, but is most dangerous if it occurs on the face, near the eyes.  Treatment for shingles includes antiviral pills and pain medications.  Most people with shingles get better and will never have shingles again.  However, there is a possibility for scarring, vision loss (if the rash is in the eye area) and long term pain, also called post-herpetic neuralgia.  Depending on the severity of the shingles, patients may experience pain for over a year after the rash heals.

Many people are concerned about “spreading” spreading shingles to others.  Generally, people who get shingles do not “catch” it from someone else.  It is their own previous chicken pox virus “waking up” again in their body.  There is however, a slight chance the virus may be spread to someone who has never had chicken pox or had the chicken pox vaccine it in the past- if they come in contact with an active shingles rash.

A shingles vaccine is available for those who are 60 years old and over.  Though this vaccine does not guarantee you will never get shingles, it does significantly reduce your chance of getting shingles, the severity of the shingles case and chance of developing long term pain.  Those who have already had shingles can still get the shingles vaccine, as there is a small chance shingles may be recurrent.



Understanding Carbohydrates

Carbohydrates fall into a three broad categories :

Simple sugars – usually taste sweet and cause a rapid rise in blood glucose levels.  These tend to evoke a rapid sharp peak in insulin secretion that dissipates relatively quickly.  Table sugar (sucrose), milk sugar (maltose), fruit sugar, honey, etc. are examples.  A common misconception is that the sugars in fruit are somehow ‘better for you.’  All carbs in the category cause the body to react essentially the same.

Starches are found the grains, including wheat, corn, rice, potatoes, etc.  These are the complex carbohydrates. They tend to cause a  slower and lower rise in blood sugar when they are consumed.  However, the insulin excursion is significantly prolonged, which ultimately results in a bigger total secretion of insulin. Interestingly, from a carbohydrate content, bananas are more like a grain than a fruit.

Fibers are long chains and weaves of carbohydrates that are primarily derived from the cell walls of plants.  As they are not well digested, the carbohydrates aren’t absorbed to any significant degree and thus don’t cause a rise in blood glucose or insulin.  These carbohydrates are not to be counted toward the daily load.

Fiber is extremely important in the diet.  The Insoluble Fiber cleanses the digestive track, promotes a feeling of ‘fullness’ and helps with bowel movements. The soluble variety binds several elements in the diet and the body, including cholesterol. The soluble fiber in Cheeriosâ is partially what confers its ability to lower cholesterol.

The carbohydrates themselves are not in of themselves ‘bad.’  It is the body’s response the carbohydrates, namely the insulin that the body has to secrete to get the sugars into the cells of the body that is the process that needs to be addressed.

To appreciate some of the carbohydrate values of foods, start by understanding table sugar (sucrose.)  Sucrose is a simple sugar.  A teaspoon (the amount that is one pack) of sugar is 4g of carbohydrates, 16 calories.   A slice of white bread is about 100 calories. Of that, about 80 calories are carbohydrates.  It is a blend of simple sugars and complex. A common misconception is that whole wheat bread is ‘better’ for you than white bread. While whole grain foods may have more nutrients but it has the same amount of carbohydrates.  While some whole grain breads may have a slightly higher fiber content, the simple and starch carbohydrates contents are still about the same.  The same is true with respect to whole grain or wild rice, whole wheat pasta, etc. For the purposes of carbohydrate management, a grain is a grain. Same is true of organic foods.  The body’s insulinogenic response is the same regardless of the ‘quality’ of the grains. Remember, corn is a grain – not a vegetable.

A key focus of dietary adjustment as part of the SHWW program is the decrease in the total carbohydrates

Understanding that the carbohydrates are what drive the secretion of insulin, the main strategy in dietary adjustment involves carbohydrate reduction both in total quantity and in percentage of daily calories.

Using a typical 2000 calorie diet as an example, about half (1000) of the calories come from carbohydrates. 1000 calories is equivalent to 250g of carbohydrate.  By decreasing the carbohydrate load to 200g per day, that lowers the carbohydrate calories to 800 and the percentage of carbohydrates drops to 40% – but the total calories have not changed – nor has the actual amount of food!

Using a standard ‘carbohydrate counter’ guide, the clinician and patient should add up and analyze the carbohydrate load for a few focused days of the week that patient feels are ‘typical.’  Interestingly, the carbohydrate (and calorie) loads do not vary much day-to-day, week-to-week for most people.

Participants are often surprised to see what they are actually consuming – with regards to quantity, types and frequency of certain foods

The SHWW clinicians have made several observations and seen several reproducible patterns:

  1. Most diets are high (around 50% or more) in carbohydrate as total calories.
  2. Many people have some form of carbohydrates at every meal.
  3. Of the carbohydrates people do eat, most are in the form of complex carbohydrates, especially bread items.
  4. Between meal snacks are almost all carbohydrates.
  5. Beverages have more carbohydrates (simple sugars) than most people realize.

Often, just the awareness of these facts can cause changes in eating patterns that can change metabolism and improve weight loss.