More Than Just a Doctor's Office ...

Imagine a healthcare facility where ...

  • You will never be told "There's nothing wrong with you" if you're not feeling well. Healthcare is ever evolving and just because something doesn't fit within today's standards of care doesn't mean your problems aren't real.
  • You can speak openly with a doctor that listens. Your health is complex and governed by many variables. The first step in helping you is to understand your symptoms from your perspective.
  • You'll learn how to distinguish legitimate medical solutions from cons and scams. We'll teach you how to recognize when supplements, devices or other alternative treatments are medically sound and why.
  • Your doctor is board certified and skilled in mainstream medicine but also recoginizes it's biases and faults. We embrace modern medicine but today's healthcare is guided by so many non-medical entities that innovative, evidence-based methods are often restricted. We practice modern medicine but our objective is to make you well, even if the best treatment is outside the scope of standards.

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Our Philosophy

In today's fast-paced digital world, healthcare terms and phrases are frequently mixed and matched. This often cooincides with the current best-seller list, a drug commercial or the latest medical break-through being passed around on social media. But ... do we really understand the concepts behind these trends and how they apply to our personal health? What do alternative medicine, holistic care or integrated health really mean and how do they compare to mainstream medical standards of care?

Diagram showing integrative medicine as convergence of modern and alternative medicine.
Integrative methods utilize both mainstream medicine and alternative medicine. This allows the best of both to be tailored to a patient’s needs and philosophy of care.

Although, each medical discipline may provide some benefit, rarely do they offer a complete and total healthcare solution. Our systems are complex and what works for one person often doesn't work for someone else. A good provider knows when a serious condition or life-altering event can only be managed through the use of mainstream medicine. However, they also know when a functional health approach to treatment can fix a root problem once and for all versus continually applying "band aids." This approach may require dietary supplements, blood tests not be covered by insurance and a significant change in diet and lifestyle. Not everyone can afford to do functional health but patients should be offered the choice and given the ability to decide. At The Knight Center, when evaluating our patients, we consider everything including alternative treatment options ... if applicable.

Evaluating "bias"

Bias collageh
it's important to consider "bias" when considering a treatment plan.

Scientific researchers work hard to overcome bias but it's impossible to completely eliminate. As such, we need to be aware of it ... and acknowledge it. Physicians should always ask themselves "Is there bias in my recommendation?" At The Knight Center, we strive to provide advice with integrity. As a responsible patient, you should always consider provider bias when evaluating treatment plans. We minimize our bias by reducing options to two mathematical variables ... risk and reward. It's our practice philosophy to go with lowest risk first and treat the root cause when known.

Think about it from a basic and simple perspective. For example, if you consult with a surgeon, expect their treatment to involve surgery. If you don’t want surgery, then don’t see a surgeon, at least not until you explore other options. If surgery is a consideration, ask about the probability of success and be sure to understand recovery and post-recovery reccomendations, as well as the potential need for future surgeries.

On the other hand, know that such things as supplements aren't subject to the same research and regulation criteria as pharmaceuticals and are not guaranteed to be without side effects. Supplements have their place, but they're also the original "snake oil" products. Due to their higher potencies, pharmaceuticals also bring risk and despite going through stringent random, double-blind clinical trials before FDA approval, they may have side-affects for some users

We like to think that all health care providers have chosen this field as a career because they love to help people. Most are, but they may also be biased, so you should always pause and consider how that might affect their advice.


I want to do it naturally ...

Burning candles and orchids
It's important to know what "natural" means ... and it's not necessarily "safe".

A lot of physicians are quick to reach for their prescription pad. Some patients think too quick ... especially after their "doctor visit" was no more than a few minutes. It's reasonable, then, that many people are skeptical about prescription drugs. After all, most drugs are created in a lab and mass-produced in a factory, not exactly what comes to mind when we think "natural". We've also all seen the drug commercials and their long lists of side-effects. It’s not surprising, then, that those looking to manage their health naturally often reject traditional medicine.

But, most people wanting natural don’t really understand what that means, either. The definition of "natural" is "as it occurs in nature." Take estrogen for example. Premarin, the first commercially available estrogen product, is pregnant mare urine. You even see it referenced in the drug's name! That would be, by definition, natural because it retains the same structure found in nature (never mind that the horse makes 17 different kinds of estrogen and we, as we humans, only make 3 ... plus we're talking about horse pee!) In comparison, "bioidentical hormones" used to replicate the molecular structure of estradiol, estrone and estriol, the three estrogens humans make, cannot be found in nature. They are, therefore, synthesized in a lab to be identical to our hormones. Although they're not “natural products” our bodies can't tell the difference and behave just as if they were our own. We're OK with that.

We bring this up because it gets more complicated when we talk about thyroid products. When discussing Synthroid (a bioidentical hormone) vs. Nature-thyroid or Whole Thyroid products, we often hear patients say that they want the natural one. They are generally referring to Whole Thyroid as "natural" over the synthetic Synthroid (levothyroxine). They would be correct, Whole Thyroid is natural like Premarin but instead of coming from horses, it comes from pigs. However, it is not “bio-identical” and will contain "pig" proteins. Synthroid, though, is exactly what our bodies produce and is very effective in treating Hypothyroidism, even though it's not "natural."


Can't I just get a prescription?

Packaged pills and tablets
Medication usage can often be reduced or eliminated through exercise and lifestyle changes.

Yes, you can. That’s your choice. You always have the option to tell us, "Forget it, give me a pill" rather than changing your lifestyle. It would actually be a lot easier for us. Drugs can be a short term fix but sometimes we need them if we’re not ready to face what may be significant changes in our habits. They will still be available if you change your mind later.

Keep in mind, though, if pills worked for weight loss, everyone would be thin. If you’re purchasing a supplement to lose weight then, sorry, but you're probably getting ripped off. We don’t believe any of them (as in zero!) will result in long-term weight loss. We can analyze your DNA and give you recommendations for making your system work better but you will still have to change your diet, exercise and possibly remediate a moldy house in order to lose weight. (Yes, moldy environments can cause weight gain.) Stimulants make great appetite suppressants and, at first, may help you lose weight. Eventually, though, your body will burn less energy and it will take fewer calories to gain weight. There is no champagne in the champagne room!

We can see if hormones or other metabolic factors are making it harder to lose weight than it should be, but we haven’t found the miracle pill yet. For those prepared to do the work, we have a program that will help with weight loss and ... guess what? You don’t have to exercise to lose weight! What??? That’s right! But ... you have to exercise to keep it off. Studies show that those who have been successful in keeping weight off all exercises at least 3 hours and 20 minutes a week. You can change your lifestyle, it’s not easy because habits are hard to break and there may be some tough decisions, but we can work together and hold each other accountable to get you there.


The real deal

Men in a boat fishing at sunset
Taking an active role in our own well-being is the first step towards a healthier, more fulfilling existence.

We tend to stop searching for solutions to our health problems when we think we've found the answer we're looking for. We may even have some initial success. Unfortunately, the "quick and easy" way rarely works in the long run. So, after throwing in the towel on one failed method, we pick ourselves up and go looking for the next shortcut to a healthy life... without taking any real steps to become healthier!

The truth is, exercise and good nutrition may reduce or even eliminate many of the medications people use. Research shows that maintaining a healthy diet, working out and keeping a positive mental attitude can have a tremendous beneficial impact on our health. In fact, a recent study on the effects of emotional vitality by Dr. Laura Kubzansky of Harvard's Chan School of Public Health found that enthusiasm, hope and a strong sense of purpose substantially reduces the risk of heart attack and stroke. It turns out the "glass half full" types are on to something after all! We firmly believe attitude is everything.



Your partner in Health and Wellness

White figures working together on jigsaw puzzle
The patient plays a crucial role in what we feel is a partnership.

Some see it differently. They take their car to a mechanic when it's broken, they call a plumber when they spot a leak, why can't they just go to the doctor and get fixed when they're sick? If you want someone to tell you what to do and not take your opinion or input into consideration there are plenty of doctors out there perfect for you. Go to one of them. That's just not a style we're comfortable with and that's fine. We know we're not the right place for everyone.

We believe our most important duty as healthcare providers is to educate our patients. Our goal is to provide a thorough explanation about their health concerns/symptoms and present any available options along with their pros and cons. The patient decides what plan to follow, we just want to make sure they have the information necessary to make an informed decision. We’ll provide the medical expertise, guidance and support but the patient plays a crucial role in what we feel is a partnership between patient and provider. We have no problem when patients bring their own theories and patients are encouraged to bring along or forward ahead of time any research they feel relates to their condition.


OK...then what is Integrative Medicine?

Integrative Medicine is a method that emphasizes treatment of the whole person ... including one's biological, emotional and spiritual health. It emphasizes a therapuetic partnership between the patient and healthcare provider. It also acknowledges that one shoe doesn't fit all and that patient autonomy is important. It may be best charcterized by the following guidelines:

    Principles of Integrative Medicine

  • The patient and practitioner are partners in the healing process.
  • All factors that influence health, wellness and disease are taken into consideration, including body, mind, spirit and community.
  • Providers use or value all healing sciences to facilitate the body’s innate healing response.
  • Effective interventions that are lower risk and less invasive are used whenever possible.
  • Good medicine is based in good science. It is inquiry driven and open to new paradigms.
  • Alongside the concept of treatment, the broader concepts of health promotion and the prevention of illness are paramount.
  • The care is personalized to best address the individual’s unique conditions, needs and circumstances.
  • Practitioners of integrative medicine exemplify its principles and commit themselves to self-exploration and self-development.
"Integrative Medicine is not synonymous with complementary and alternative medicine. It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship."
- Dr. Andrew Weil

Now we're getting it!

Brightly lit light bulb
"Aha!"

Integrative medicine integrates mainstream medicine and functional health in a way that promotes wellness, prevents disease and treats illness. It is a healing-oriented method that draws upon all therapeutic systems to form a comprehensive approach that includes both the art and science of medicine and is managed under the support and guidance of a physician partner.

The goal is to establish and maintain health and wellness throughout one's life. The provider learns and understands the unique circumstances that are exclusive to each patient and examine the physical, emotional, mental, social, spiritual and environmental influences that affect their overall well-being.


Wait ...then what is Integrated Health?

Integrated health is where healthcare providers that share common beliefs and core values deliver health care services collaboratively. We strive to understand our patients beyond the scope of "now". Our practitioners work together closely to ensure a consistent continuity of care driven by a patient-centered priority. Caregivers meet on a regular basis to establish and review a comprehensive treatment plan that addresses the patient's physical and biological needs, as well as their psychological and social needs. We like to think that our patients are being treated by an entire team of caregivers, even if they're only seeing one.

"Integrated Health is a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency."
- World Health Organization

A team-based approach ...

Skydivers forming a circle
Integrated Health combines a group of healthcare practitioners that collaborate with the primary care provider.

After all that talk about partnership and the role and responsibility you have in your personal health, you may ask "what does the doctor do?” Good question! Think of the doctor as a "quarterback" who relies on knowledge, experience and skill to evaluate and diagnose your condition and runs the necessary "plays" to reach the goal. The goal, of course, is to take care of you in the best way possible as determined by you and your doctor together ... but you are the team owner. Just as a quarterback counts on specialized position players to reach the goal, Integrated Health uses a similar, team-based approach for delivering health care.


Putting it all together ...

Fundamentals consideration for risk evaluation and decision making
It's important to validate risks, probabilities and financial factors when considering health care options.

Who are we? We are the medical office that takes on the problems that most others can't or won’t. We often attract what are called end-of-the-line-seekers when no mainstream approach has worked. Don’t worry, we follow mainstream medicine methods when they are the best option, we just don't consider them the final outcome if they're unsuccessful. Our goal is to find the key to your recovery and guide you on a quest to become the healthiest you can be.

White figures working together on jigsaw puzzle
Guiding you on your journey to a healthier, happier life.

We feel our model avoids treatment conflicts and improves time to recovery. Our practice is more holistic than a solo provider suggesting only supplements, more integrated than physicians with a "concierge" practice recommending a separate primary care provider and more integrative than doctors focusing exclusively on environmental medicine and nothing else. We take care of everything.

Because our current healthcare system is set up to make money when people are sick, many are seeking holistic substitutes. This has led to an explosion of alternative healthcare products and providers, often with little or no substantial evidence to support the results they claim to deliver. There are new scams and pitches flooding our digitally-connected world each day with new "miracle" drugs or services. Conversely, there are also new medical discoveries and technologies being implemented just as frequently. We're here to help patients separate the "seeds from the chaff."

Some medical professionals may have issue with some of the subject matter on this site, which is fine, but we felt it would be best to put our approach to healthcare out there ... just to avoid any misconceptions. As we point out on our landing page, health is complex. As such, our philsophy can be simply stated as "we know a lot but we know that we don't know everything and that what we once learned may have changed." This means we follow, but do not limit ourselves to standard methods when they don't work. We don't tell someone their problem is "in their head" if a textbook method doesn't have the expected results. We work hard to find solutions that fix our patients and help guide them to a healthier, happier life.

Our History

Keep it between the ditches!

Northwestern University's famous campus arch
Northwestern University's famous campus arch

Rebecca Knight was angry that she was just a few tenths of a grade point shy of becoming her East Leyden high school class valedictorian. It would have been a sure thing had she managed to get an "A" in Driver's Ed. Leyden was in Franklin Park, IL, a Northwest Chicago suburb nestled between O'Hare Airport and the city proper. It's an industrial town most noted for the convergence of multiple rail lines at town center. That, along with the traffic that's typical for any community butted up against a major city, didn't help but ... c'mon ... everybody gets an "A" in Driver's Ed! Says who? She eventually accepted her salutatorian status but still carries a bit of a grudge.

It was actually an English Composition teacher that suggested she think about engineering as a career. Up to that point, she'd been planning on applying to nursing school. To this day she is still unsure if her teacher's encouragement was due to her outstanding math skills or just wise advice from someone who'd been grading her writing for a semester. Either way, she loved her Apple IIe and computers sounded like a worthy challenge. So, being a competitive over-acheiever, she applied for and was accepted into the Computer Science program at Northwestern's McCormick School of Engineering. English composition be damned ... this is science!


The "Gift" ...

Gift wrapped box
Some of us are born with certain "skills."

It was between her sophomore and junior year while working for IBM in a university co-op program when she discovered the "gift." She found that she had a knack for rooting out bugs and vulnerabilities in software by producing catastrophic system failures. It turned out that she was really good at crashing systems ... even if she wasn't quite sure how she did it.

She soon realized, though, that working in a cubicle was not her cup of tea. She talked way too much and knew she'd be miserable working in a "cube farm". Still trying to figure out what she wanted to be when she grew up, she visited Northwestern's career counseling center when she returned to school. An early predecessor to what are now common online career selection applications indicated Rebecca would make a good doctor. OK...she refocused her engineering major to biomedical engineering to she could knock out some of the medical school pre-requisites and the rest is hsitory. Today, despite computers having much better crash protection and behind-the-scenescorrections and recovery, Rebecca's "gift" is still intact and her relationship with computers remains one of love and hate.


MCAT? But I'm a dog person...

Cat behind crossed out circle

Rebecca returned to Northwestern for her last two years and was awarded a degree in Biomedical Engineering but the majority of her time was spent preparing for med school. She worked hard, aced the Medical College Admission Test and was accepted to the University of Illinois School of Medicine. She started med school the fall immediately following graduation.


Is this Kansas?

Farm scen with barn, silos and filed
Guess we're not in Chicago anymore ..

During the first year of the U of I School of Medicine, students either attend classes at the main campus in Champaign, IL, located about 120 miles south of Chicago or the Chicago campus. The second year, the Champaign class was split between Rockford and Peoria. Today, the Peoria campus is home to a full four-year program but in 1998 the campus for second-year med students was chosen through a lottery system. Rebecca's drawn ticket sent her to another place she'd never been to..."Peoria," the current headquarters location for The Knight Center.

She would soon need to pick a discipline. Although she hadn't made a final decision on a specialty, she knew she wanted to be involved with helping women. She toyed with the idea of becoming an OB/Gyne but eventually decided she could do more good as an Internist, a primary care provider for adults. She felt it would expose her to a broader range of medicine ... plus she wouldn't have to get out of bed at 3AM to deliver babies. What she liked most about Internal Medicine was making actual case presentations and competing to be the first to come up with a correct diagnosis, especially the really tough ones. Remember overachiever?


What is this Integrated Health thing?

Pill bottle and tablets on green leaf
Focusing on Women's Health

Four years of medical school and three years of residency later, now a bona fide Doctor of Internal Medicine, Dr. Knight wanted to further broaden her knowledge-base, especially in the often misunderstood field of Women's Health. She went on to attend the University of Wisonsin in Madison where she completed a Fellowship in Women's Health in addition to earning a Master's Degree in Epidemiology, the study of disease trends and their effect on public health. It was here where the concept of The Knight Center for Integrated Health was born.


The Knight Center for Integrated Health

Jigsaw puzzle pieces
The pieces started coming together...

Early on in medical school Dr. Rebecca Knight came to realize that medical research completely ignored women or simply viewed them as smaller men. Her post-graduate studies at the University of Wisconsin, however, included a multi-disciplinary approach that was achieving very effective outcomes, yet was unique in practice. During her tenure, she was engaged in a weekly women’s health forum attended by Internists, Geriatrics, Family Practice, Surgeons, Psychiatrists and Advanced Practice Nurses. She also worked with alternative practitioners specializing in Acupuncture and Massage as well as a compounding pharmacy. She quickly saw how much a patient can benefit from the collaboration of a primary doctor and practitioners of complimentary disciplines and/or techniques. The results she was seeing Madision were so outstanding she returned to Peoria, eager to make a difference.


In the beginning...

Sunset in Madison, WI
Let's get it started!

Dr. Knight's career started at Proctor Hospital in 1998 when she was hired to develop and direct a clinic exclusively dedicated to Woman's Health. Simultaneously, she took over the practice of Proctor physician, Dr. David Anzulda. Anzulda, an integrative medicine practitioner, was moving out of the area. Although Dr. Knight specialized in women's health, Anzulda's practice also included men. As an internist, Rebecca was also trained and qualified to treat men and agreed to continue including men in the patient population "as long as they were in touch with their feminine side," she jokes. Today men make up 29% of her practice. Dr. Anzulda also stuck around for Dr. Knight's first 90 days to help with the transition and provide specialized training. Family Practice doctors learn many procedures that aren't included in an Internist's training. Dr. Anzulda cared about his patients and wanted to make sure they were left in the hands of a qualified practitioner and access to the same services he'd always provided. Ever the eager student, Dr. Knight became an expert in surgical techniques she still uses regularly ... 22 years later!

After Dr. Anzulda left, Dr. Knight managed his former practice full-time while developing and implementing a Domestic Violence training program for Proctor Hospital staff and planning a women's focused clinic. Meanwhile, time moved on and Proctor wasn't taking any further steps to get the clinic established. In 2000, with no further progress on the clinic by Proctor, Rebecca exercised a clause in her contract allowing her to get out and voiding any non-competing arrangements. Proctor willingly agreed and sold the practice to her for $1. She was now on her own as an independent physician.

As this acquisition played out, Rebecca was also a partner in a clinical research firm and working as Principal Investigator for studies in variety of areas including migraines, menopause, depression, osteoporosis and fibromyalgia. In the same year, she also took over a massage school/clinic with an enrollment of 150+ students.

Yes, even the mighty meet their match and Rebecca had met hers...at least temporarily. The massage school/clinic was more than she could handle and she divested from it in 2004. However, her methods and curriculum evolved into what became today's Illinois Community College Licensed Massage Therapist Certification Program. In 2004, Dr. Knight reincorporated her practice as Knight Medical & Rehab Center, Ltd. which currently does business as The Knight Center for Integrated Health.


This place looks familiar...

White figures working together on jigsaw puzzle
Dèjavú at Proctor Professional Building!

In 2009, The Knight Center moved back to the Proctor Professional Building, the same place where Dr. Knight began her career. This time, though, she was just a tenant, not an employee. Always eager for a plunge (she'd become quite the avid triathlete by now) she felt "If you're going to make a change, change big and get it over with!" The office was closed on a Friday and moved over the weekend with the expectation of opening for business on Monday. Oh yeah, Monday was also a go live date for a new (and first) electronic medical records system and a new VOIP phone system (also a first). Go big or go home??!!!

Hospital room
We maintain hospital privilges but we rarely have patients in the hospital.

Until fairly recently, primary care doctors usually treated their own patients in hospitals. Weekend "call" groups were often formed so doctors with large numbers of hospital patients could get a day off once in a while. The "on-call" doctor in the group would see his or her patients along with those of all the other doctors in the group. Each would take turns being "on call." Dr. Knight rarely had hospital patients and soon found every third weekend was given up to see the patients of other physicians. By 2014 the hospitals began employing legions of doctors to care for admitted patients. These were known as "Hospitalists" and it became difficult for independent primary care physicians to keep privileges without a significant number of admissions. Seems somewhat counter-intuitive ... doctors being penalized for keeping their patients out of the hospital! Due to low admissions and external pressure, Dr. Knight relinquished active hospital priviledges in 2016 but maintains complimentary status to all area hospitals giving her access to all records, orders, medications and notes.


Continuing to learn and grow

Women doing yoga at sunset

In addition to primary care for adults and a specialization in Women's Health, from 2009 to 2018, Dr. Knight studied Environmental Medicine including mold illness, Lyme disease and other areas that the mainstream medical community has been slow to formally acknowledge. She currently treats patients from a five state area.

In 2018, The Knight Center purchased a 3-story, 15,000 square foot facility at 4300 Brandywine Drive in Peoria, IL and Dr. Knight continues to see patients that struggle to be taken seriously elsewhere. Having been in practice now for over 21 years and having treated thousands of people, even a casual observer could arguably agree that Dr. Knight has, indeed, made a difference in Central Illinois and hopes to continue doing so.

Our Mission

Mission Statement

Provide exceptional healthcare by fostering a patient/provider partnership built on a foundation of expert medical guidance, shared decision-making and mutual responsibility.

Our Values

Core Values

  • Provide quality care above all else
  • Embrace integrity in all we do
  • Strive to deliver an exceptional patient experience
  • Create a passionate and fulfilling work-life environment
  • Endorse the truth, dispel the hype
  • Hold ourselves and our patients accountable
  • Promote teamwork and collaboration through open, effective communications
  • Personalize care to address the individual’s unique conditions, needs and circumstances.
  • Encourage fiscal and environmental responsibility

Performance Values

  • Maximize efficiency through continuous process improvement
  • Retain a current and relative knowledge base
  • Educate rather than command
  • Over-communicate
  • Become functional experts
  • Be personal but professional
  • Be available and responsive
  • Quantify and measure everything
  • Incorporate technology whenever feasible

primary care

Dr. Rebecca Knight

Rebecca A. Knight, MD, MS, LMT

Dr. Knight has been practicing medicine for over 20 years. In addition to Internal Medicine, she specializes in Women's Health, Hormone Treatment and Biotoxin Related Illnesses.She is also an adjunct professor at the University of Illinois School of Medicine. Dr. Knight has done extensive research on Women's Health related issues and has acted as Principal Investigator in over 200 clinical trials.

Education

  • Medical Doctorate • Internal Medicine • University of Illinois College of Medicine
  • Fellowship • Women's Health • University of Wisconsin School of Medicine and Public Health
  • Masters of Science • Epidemiology • University of Wisconsin School of Medicine and Public Health
  • Bachelors of Science • Biomedical Engineering • Northwestern University

Licenses

  • Licensed Physician and Surgeon • #036.091883 • Illinois Department of Professional Regulation
  • Controlled Substance II III IV V • #336.053401 • Illinois Department of Professional Regulation
  • Controlled Substance Registration • #BK5022746 • US Drug Enforcement Administration
  • Licensed Massage Therapist • #038.011932 • Illinois Department of Professional Regulation

Areas of Research

  • Domestic Violence Education
  • Menopausal Syndrome
  • Fibromyalgia
  • Lyme Disease
  • Mold Sickness
  • Osteoporosis
  • Urinary Incontinence
  • Chronic Pain
  • Adult ADD
  • Diabtetes

Published & Featured In ...

  • Journal of Women's Health
  • Wisconsin Medical Journal
  • Peoria Journal Star
  • Ladies First
  • WMBD News

Processes

Scheduling
Labs & Testing
referrals
prescriptions
cancellations
medical records


Pen laying on appointment calendar
Provide details about the reason for your appointment

When scheduling an appointment, please be concise and complete about the reason for your visit. If you are vague or withhold relevant details it will prevent us from properly preparing and may end up requiring additional visits. You won't be scheduled if you refuse to provide a reason or purpose for your appointment. Intentionally providing false information may lead to your dismissal from the practice.

Please let the scheduler know about ALL issues you want to talk about during your appointment. This determines the type of appointment slot you'll be given. It's unfair to our staff AND other patients if you have a long list of issues but only mention one when scheduling your visit. It's no different than getting stuck behind someone with a full cart in the "10 items or less" check out line. It will be noted if or when this happens. Frequent abusers may be barred from certain appointment types or dismissed from the practice.

New Patients

Office folders on file shelf
To get started as a patient download our New Patient packet

Potential new patients must first complete and return a new patient packet. These can be downloaded here or you can contact our office and request that one be mailed to you. They can be returned via email to scheduling@theknightcenter.com or mailed to our office.

Our new patient intake form is very comprehensive. Some questions are intimately personal but, we assure you, they're necessary for a thorough risk assessment. Your response to these questions will help us determine within statistical ranges probabilities of the presence or susceptibility to certain health conditions. Although you may have never experienced episodes related to these conditions, they need to be identified and ruled out. The same holds true for family history and prior medically-related incidents or injuries. The more detail you provide, the better and faster we'll be able to address your issues and concerns. Withholding information can lead to uneccesary testing for things that may, otherwise, be explained by past or current habits. Don't worry, we've seen it all. We're legally bound to contain your personal information and, honestly, hiding sensitive details will make our job much more difficult. It can also lead to extra appointments, increase your costs and delay or prevent us from helping you. We can only be as good as the information you give us.

Each packet also includes a form providing your authorization for previous healthcare provider(s) to release your medical records and our financial agreement. Please make sure everything is completed and signed or it will be returned for updating.

It's also very important to provide accurate and thorough insurance information and demographic data. This information will be validated before scheduling your first appointment. The packet will be returned for updating and/or clarification if we are unable to verify your residence or confirm your insurance eligibility.

When we receive your completed packet and have verified demographic and insurance information, a doctor will review your medical paperwork. Based on the information you've given, your provider will select baseline lab tests and those that may be necessary for a preliminary diagnosis. Doing this before your initial appointment will give us time to retrieve and review beforehand. This will make your first visit much more productive.

Please understand, we do not accept every patient that submits a completed packet. There are some people that won't integrate well with our treatment style, those with insurance plans that we do not accept or simply those that don't meet our credit criteria. As such, we reserve the right to deny new patient requests for any reason.

Established Patients

White figures working together on jigsaw puzzle
Standard office visits for established patients are 30 minutes in length.

Standard office visits (POVs) for established patients are 30 minutes in length. These appointments are for diagnosis, gathering information and monitoring outcomes. Some chronic conditions that require frequent follow-up such as Diabetes and CIRs, or those where medications need to carefully monitored and/or modified also fall into this category. As with all medical office visits, POVs require forms to be filled out. If you'd like to complete the POV intake form before you arrive, you can download it here.

Established patients must maintain treatment compliance as well see that their account remains in good financial standing. Failure to meet either of these policies may result in being denied further appointments until they are satisfied or corrected.

Established patients must also notify us immediately of any changes in insurance coverage or home address. Insurance eligibility is checked prior to each visit and if the insurance we have on file is no longer valid, your visit may be cancelled with or without notice. Please know it's your responsibility to make sure we have your current information on file.

Follow-up Visits

Path in the woods
If a follow-up is necessary, schedule it before you leave.

If a follow-up appointment is necessary, it should be scheduled prior to leaving our office. Please stop at the front desk and make arrangements before leaving. If labs are required, those need to be scheduled, as well. Once scheduled, if you miss or need to reschedule labs, the follow-up appointment will be cancelled or rescheduled to allow for retrieval of lab results. Test results are used to monitor and measure therapeutic outcomes and are necessary for most office visits. Absence of results reduces or eliminates the benefit of a physician's visit. Because of this, in most cases, missed lab appointments will require your doctor's appointment to be rescheduled, as well.

GO Visits

Appointments after 5:00PM, Monday through Friday, are reserved for GO visits and scheduled on a first-come-first-served basis. These 15 minute appointments are for acute problems that do not require lab tests, such as colds, urinary tract infections, rashes, etc. They are also used for stable prescriptions that must be refilled every 30 days. See About -> Processes -> Prescriptions for details. Prescriptions that require labs or modifications do not qualify for "GO" visits. GO visits are for single problems only and can't be used as a substitute for standard office visits.

Surgical Procedures

Scissors in cleaning solution
Surgical procedures are scheduled on Friday afternoons.

Surgical procedures are performed on Friday afternoons. See Services -> Internal Medicine -> Minor Surgical Procedures for details.

pre-op clearance

Unlike minor surgeries we perform at our facility, more serious operations performed by surgeons and specialists usually require pre-op clearance from your primary care physician. The purpose of a pre-op clearance is to evaluate any risk the anesthesia or the surgery itself presents prior to undergoing invasive procedures. This typically pertains to a patient's cardiac and pulmonary condition associated with the particular type of surgery, as well as their infectious susceptibility and functional capacity.

it's critical that you schedule any pre-op clearance as soon as your surgery is scheduled. Depending on your condition, medications may need to be altered or tapered beforehand and, in some cases, instruction or preparatory treatment may be necessary.

Pre-op clearance is more than just a formality and not everyone will be automatically cleared for surgery. Failure to take pre-op clearance seriously may result in a delay or cancellation of your procedure.

ER follow-up

person taking someones blood pressure
When scheduling an ER follow, please state that your WERE in the ER, as well as WHERE, WHEN and WHY.

Unfortunately, from time to time people need go to a hospital emergency room. If you visit an ER, at discharge you are typically instructed to schedule an appointment with your primary care physician for a follow-up. In may cases, you are told to contact your doctor's office within a few days and that would be wrong. Recovery from an ER visit takes time and "a few days" rarely allows you to heal enough to where we can make an effective evaluation or provide useful recommendations. We encourage patients to wait two weeks before scheduling an ER follow up, especially if your trip to the ER was due to a traumatic injury. There are exceptions so if you are in doubt, please contact our office. IMPORTANT: When scheduling an ER follow-up you must let the scheduler know that you WERE in the ER, WHERE (which hospital) you were in the ER, WHEN you were in the ER and WHY you were in the ER.

Annual Wellness Visits

Blocks spelling out 'wellness'
Wellness is all about prevention

It's generally considered good health maintenance to visit your doctor annually for a "check-up." Many insurance companies now offer an annual wellness visit without co-pay, co-insurance or a fully paid deductible before covering 100% of the rendered service. These visits are for preventative purposes have very specific guidelines. They are not substitutes for a standard office visit. See Annual Wellness Visit in the Patients section for details.

Workman's Compensation

We are not obligated to accept Workman's Compensation cases. If your appointment is related to Workman's Compensation, we will consider it only if we are given the Workman's Compensation insurer and a valid case number. This information must be provided and confirmed before your appointment is scheduled. See About -> Policies -> Legal for further information.

Motor Vehicle Accidents

Figure showing back pain
It's important to let us know if you're making an appointment for a work-related injury or illness.

We do not accept cases related to Motor Vehicle Accidents without a police report and detailed auto insurance information from all involved parties. See About -> Policies -> Legal for further information.

Legal Testimony & Depositions

Scheduling for legal testimony, deposition or expert witness must be arranged as far in advance as possible and subject to time availability. See About -> Policies -> Legal for further information.


Drawing test tubes for blood work
Blood work is a critical part of diagnosing and monitoring health status.

Lab test are frequently referred to as "blood work" and help doctor's check for certain diseases and conditions. They also help monitor the function of organs such as the kidneys, liver, thyroid, and heart. In addition, they are used to identify risk factors for a variety of conditions and the presence of various minerals, enzymes and blood quality factors, as well as check the effect of medications. They are performed by venipuncture, also known as a blood draw, a minimally invasive procedure where a small needle is used to extract blood and plasma from a vein. Don't worry, our nurses are the best there are at drawing blood and we've made believers out of the most stubborn "hard sticks."

We require all lab tests to be performed by our preferred laboratory. This provides the consistency and reliability that is vital for effective care. We've seen significant variance in test results and feel that continuity of data is paramount to quality healthcare. Given that, this policy is strictly enforced. Unfortunately, those that cannot or will not subscribe to this policy are unable to be a Knight Center patient.

Fasting may be required for certain lab tests. We schedule appointments for these between 8AM and 10AM Tuesday through Friday. If you are scheduled for a fasting-lab, you can't consume anything but water or black coffee after 12:01AM on the day of your scheduled appointment until we've drawn blood samples.

healthlab

Abdominal x-ray
Sometimes we need to order tests from third-parties.

Our partner lab facility is HealthLab®, a division of Northwestern Medicine®. HealthLab is a full service CLIA approved, clinical laboratory combining 20 years of lab experience with today's most advanced technology to provide comprehensive testing services and general health screenings.

Third-Party Testing

Ct scanner
Computed Tomography (CT) Scanner

We often use third-party services for diagnostic tests we don't do in our facility. These include imaging such as X-rays, CT Scans, MRIs and NMIs, as well as various genetic tests, stool analysis and swab testing. We will schedule these tests for you but it's critical that you provide us with any insurance restrictions, pre-authorization requirements or network constraints. Although we do our best to screen for this information, you are responsible for understanding any limitations or covenants included in your health insurance plan. These services are billed directly by the testing facility and we do not act as a financial mediary or middle-man.

Third-party testing usually includes a follow-up visit to review the test results. We will schedule these based on when we expect to receive results but it's important to inform us if you miss or have to reschedule a third-party test as we will also need to reschedule your follow-up visit. Please note that we will schedule your initial third-party test, but any changes or re-scheduling is between you and the testing facility.


'Referral' written on glass
Let us know about any insurance limitations on specialists.

You may be referred to specialists or other providers from time to time. We will coordinate these referrals for you but it's critical that you provide us with any insurance restrictions, pre-authorization requirements or network constraints. Although we do our best to screen for this information, you are responsible for understanding any limitations or covenants included in your health insurance plan. These services are billed directly by the referred-to provider and we do not act as a financial mediary or middle-man.

Referrals usually include a follow-up visit to review the findings. We will schedule these based on when we expect to receive results but it's important to inform us if you miss or have to resechedule a referral appointment as we will also need to reschedule your follow-up visit. Please note that we will schedule your initial referral appointment but any changes or re-scheduling is between you and the referred-to provider.


Formulary

Pills and capsules
To be effective, it's important to follow instructions given with prescribed medications.

Although we do our best to prescribe the most economical medications, your insurance company may require you to try other drugs first, get pre-authorization before covering certain drugs or have prescription quantity limitations. Insurance plans typically have a drug formulary with categories or "tiers" that separate which drugs are covered, your cost and any coverage prerequisites. We will do our best to accommodate your insurance plan.

Compliance

Lucy in her doctor's booth
Follow your doctor's orders!

To be effective, it's important to follow instructions given with prescribed medications. Compliance, also known as adherence involves getting prescriptions filled, remembering to take medication on time and understanding the directions. Please contact us if you're unclear on how to take prescribed medications or if you get conflicting information or alternate suggestions from your pharmacist.

Common reasons for non-compliance include fear, cost, misunderstanding, number of medications or bad information. It's our goal to minimize patient medications so it's absolutely critical that you communicate any concerns that would make you non-compliant so we can discuss alternatives and consequences.

Controlled Substances

Handwritten prescription
Controlled substance can only be prescribed in 30 day increments

Controlled substances are drugs that can have a detrimental impact on your health if used improperly and are regulated by the US Drug Enforcement Agency under the Controlled Substances Act. It is illegal to be in possession of a controlled substance without a prescription. Controlled substances can only be prescribed in 30 day increments and are generally used for chronic conditions. Therefore, we allow patients being treated for a chronic disease to schedule refill visits in 15 minute GO slots if there is no change or modification to the prescription. Everyone on a controlled substance will need to schedule labs and a standard office visit at least once a year to make sure there are no complications or unwanted side effects. Prescriptions for Controlled Substances are paper prescriptions only.

Opiates

Drugs
Opiates include Dilaudid, hydrocodone, methadone, Demerol, OxyContin, Percocet, morphine, opium and Codeine. These drugs have a high potential for abuse, can lead to severe dependence and frequently lead to overdosing and death. Patients treated with opiates often turn to heroin, Fentynal or other illicit drugs when their prescription runs out. It's extremely difficult to compare tolerance and dosage levels of prescription drugs with street drugs, especially if there's been a time lapse since the last prescribed dose. This creates a high risk for overdose.

If you are on an opiate prescription, you will need to sign a pain agreement to attest to abstaining from all illicit narcotics. A quarterly office visit is required at minimum and you may be subjected to random drug testing. Non-compliance or a failed drug test will result in your immediate termination from the practice.

hand written script
Some prescriptions have a high risk of addiction and overdose.

Lost Prescriptions & Forgery

We monitor controlled substance prescriptions through the Illinois Prescription Monitoring Program database. Use of any unauthorized or fraudulent prescriptions will result in your immediate termination from our practice and local authorities will be notified. Illinois penalties for first time prescription forgery is up to 3 years in prison and fines up to $100,00. This may also be separate from additional drug charges related to sale and/or delivery of a Controlled Substance.

Lost prescriptions for opiates will not be refilled under any circumstances.


Cancel stamp
Cancellations require a 24-hour business day notice.

We require a 24-hour business day notice for cancelling an appointment. IMPORTANT: This means calling us on Sunday afternoon to cancel an appointment on Monday afternoon doesn't qualify as a 24 hour notice. Business days are Monday through Friday so a cancellation for a Monday appointment would require a notification on Friday prior to the time of your scheduled visit. We dedicate resources for each appointment. Unlike many medical practices, we don't double or triple book so we request you allow us a enough time to fill your vacated slot.

A $100 charge will be applied to your account for a cancellation notice less than a 24-hour business day. Frequent offenders may be dismissed from our practice at our discretion.


Medical Records

Vinyl LP record
Your medical records are protected by HIPAA.

Your healthcare information is protected under the Health Insurance Portability and Accountability Act. The purpose of HIPAA is to ensure that your Protected Health Information is "secured without prohibiting the flow of such information to the exclusion of quality health care". This is why we can share relative information with covered entities on your behalf or for the exclusive purpose of your health management. HIPAA covered entities include medical providers, insurance companies, insurance clearinghouses and business associates including electronic medical record and practice management software vendors, lab partners and other providers.

The transfer of this information to those who are not covered entities or not directly related to your care requires your permission in writing. For example, we can't give it to your employer, a financial organization or even a relative without your written consent. Exclusion to this include authorized government entities gathering data for oversight purposes.

Medical file and stethescope
Transfer of medical information requires the patient's written authorization except for covered entities.

You have the right see your medical records on request and dispute any entries or information you dispute. Although we are not required to alter your records if we disagree with your interpretation, we must still document the fact that you had issue with a statement or conclusion. We have 60 days to comply.

You may request a copy of your medical records under a signed written request and must pay for the copying and delivery. The price is calculated using criteria set annually by the Illinois Comptroller's Office under statute 735 ILCS 5/8-2001(d) . The per page price is reduced by 50% for transfer via electronic media. Life Insurance companies, attorneys requesting your records for civil litigation purposes or patients transferring out will be charged this fee and will also require a signed written authorization.

IMPORTANT: Maintaining, preparing and copying medical records is a timely and costly process. Record requests submitted by attorneys with an enclosed "$20 statutory fee" will be denied. The statute in question allows for the review of records, not a copy of records. Their check will be returned with an invoice for the necessary amount required to obtain a copy of your records. See Legal for further details.

Transfer of Care

Our New Patient Packet contains a Record Release form which needs to be completed and signed so we can obtain any medical records from your previous healthcare provider. If you have multiple providers, we'll need a completed form for each provider. Please note, they have 30 days to comply.

Patients transferring care to another facility will be invoiced for the copy and transfer of medical records in our possession, regardless of who initiated the transfer.

insurance

Policy on Health Insurance

Health insurance policy
Take the time to understand your health insurance plan.

Health insurance is a program or service used to assist in paying for medical expenses. It's acquired through a variety of means including privately purchased plans, employer provided plans and social plans provided by the government such as Medicare and Medicaid. Although we participate in several commercial insurance networks, we may not be included as a network provider for your specific plan even though we may be in-network for other plans offered by the same company. A partial list of insurance companies we have agreements with can be found at Patients -> Insurance -> Network Participation. There are also insurance companies whose networks we are not part of and social programs we do not participate in. For example, we do not accept plans offered by Medicaid, Medicaid Managed Plans or Medicaid contractors.

Services we provide to you comprise a legal agreement between you and our organization. The guarantor is ultimately responsible for any payments or liabilities for services rendered. It's important to understand that you are the customer of the insurance company. As such, understanding the coverage, terms, requirements, conditions and limitations of your plan is your sole responsibility exclusive to any contracts or agreements we might have with your insurance company.

Blocks with health icons stacked in pyramid
All patients need to make sure we have a copy of their valid insurance card on file.

We are familiar with the complexities (and frustrations) of health insurance plans. In fact, we dedicated an entire section to Insurance under Patients. New insurance "products" come out each year while others disappear and sometimes your co-pays or formularies change in the middle of a plan period. It's also becoming more and more difficult to understand just what is covered, what percentage is covered, under what circumstances is something covered and what your share of the cost will be. If you have any questions about these things or are unclear on items in your Summary of Benefits, contact your insurance broker, human resources department or the insurance company directly and have them explain it to you until you are confident you know the ins and outs of your policy. Health insurance is costly and you have the right and responsibility to understand your benefits. You'll be the one who will, ultimately, end up paying the price for any bad assumptions. Failure to do so may end up becoming quite costly in more ways than just monetarily. After all, we're talking about your health!

All patients need to make sure we have a copy of their valid insurance card on file. For new patients, we require copies of your card before your first appointment will be scheduled so we can verify coverage. We confirm eligibility one week and one day before each visit. We also verbally confirm your insurance company and current address with you on arrival. We're sorry if this seems excessive but errors or omissions on either of these can become difficult to resolve. If we find that your address is invalid or your insurance is inactive, your visit may be cancelled until we get updated information. Important: Please make sure you let us know immediately about any changes to your health insurance or mailing address.

Financial

Payment responsibility

Card reader, card being swiped
Co-payments are due at time of service.

Each patient is required to have a financial agreement on file signed by the patient or their legal guardian acting as financial guarantor for provided services. This includes treatment related to motor vehicle accidents (MVA), work related injuries (WC) or other third-party legal disputes.


Co-payments

Co-payments are due at the time of service. The obligation for co-payment collection is included in most provider/insurance company contracts. Failure to do so is a breach and insurance companies can take back payments if we are unable to prove the patient's share was collected. It can also be construed as insurance fraud.

Among other things, insurance companies set prices for the plans they offer based on the dollar amount physicians are willing to accept and the amount people are willing to pay. For example, say a physician is contracted with an insurance company in which the payment for a service is $100. Meanwhile, a patient is considering two policies offered by the insurance company. In one policy, the insurance company pays 100% of physician fees (no co-payment) at a monthly premium of $500. The second policy is only $400 a month but the patient has a $25 co-payment. If the patient takes the less expensive policy and the doctor waives the co-pay, the doctor is, effectively, defrauding the insurance by charging them $100 for the same service they charge the patient $75. In this scenario, the patient is getting a policy that was priced as though they would be responsible for some of the physicians fee, yet they didn't spend anything. They were getting the same service of a policy costing $500 a month ... at $400 a month. IMPORTANT: It is a felony to routinely waive co-pays, co-insurance, and deductibles for patients.

LOCATION

NOTICE: OUR ADDRESS HAS RECENTLY CHANGED!

The Knight Center for Integrated Health
4300 Brandywine Drive
Peoria, IL 61614

Business Hours

General information

Hour glass

Our office is open Monday through Friday, year-round although some services may be available only on certain days.  See the schedule below for details. We're closed on New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving, Black Friday and Christmas, but we're open on most government holidays.

IMPORTANT: We'll do our best to keep this page updated but please note that hours and schedules are subject to change without notice. In the event of any schedule changes, if you have an existing appointment that will be affected, someone from our staff will contact you to reschedule.

Appointments

Doctor appointment on calendar

Please note that appointments are subject to availability. We don't double and triple book so there are limited time slots available on a given day. Although we do our best to meet all of our patient's needs, we encourage you to schedule your appointments as far ahead of time as possible. Waiting until the last minute, may make it difficult to find an available slot that's convenient for you. This is especially true late in the year as many people rush to get in last minute visits or procedures before their insurance deductible resets.

reminder notice

Reminders

Don't worry about forgetting your appointment ... we can help! We'll send you an email, text or phone call reminder a few days prior to your scheduled visit. Just be sure to let the scheduler know how you'd like to be reminded.

Cancellation List

We keep a cancellation list in case anyone would like to move up their appointment if a slot becomes available. People on this list will be contacted in the order they were entered.

Schedule

Schedule by Appointment Type

Labs Established Patient New Patient Urgent Care* IVs Surgical Procedures
Mon 8AM - 10AM 9AM - 12PM
1PM - 4:30PM
None 4:30PM - 5:30PM None None
Tue 8AM - 10AM 9AM - 9:30PM
1PM - 2PM
10AM - 12PM
2:30PM - 4:30PM
4:30PM - 5:30PM None None
Wed 8AM - 10AM 9AM - 12PM None 4:30PM - 5:30PM 1PM - 4:30PM None
Thu 8AM - 10AM 9AM - 9:30PM
1PM - 2PM
10AM - 12PM
2:30PM - 4:30PM
4:30PM - 5:30PM None None
Fri 8AM - 10AM 9AM - 12PM None None None 1PM - 4:30PM

Map & Directions

GO!

Mailing Address

The Knight Center for Integrated Health
PO Box 3478
Peoria, IL 61612

Phone Directory

Main Phone Number: (309) 692-0123
Main Fax Number: (309) 692-0184

Active Hours

IMPORTANT: Our telephones come on at 9:00 AM Monday through Friday. They are off between the hours of 12PM and 1PM and resume normal activity from 1PM to 4PM. If you need to reach us during inactive times, please leave a message and someone will promptly return your call when business hours resume.

Voice Mail System

We know most people prefer to speak with a real person and we strive to make that happen. During active hours, though, there are times when we just can't get to your call before the automated voicemail system takes over. If you get the auto attendant, please leave a message.

Phone Etiquette

IMPORTANT: Repeated hang-ups and call backs WILL NOT get you to a person any sooner and may actually delay a reply. If you get an auto attendant, the person you are trying to reach is not available, they are NOT ignoring you. We understand that can be frustrating but imagine if you were with a provider or staff member and were constantly interrupted because incoming calls took priority. Please be courteous and leave a message!

Please note that we receive daily reports on all inbound and outbound call activity, including the caller name, phone number, time of day, if a message was left and the duration of each call. We become frustrated, too, when we have difficulties reaching others, but please be honest when voicing any complaints about failed attempts to reach us as we will compare your claims to our call logs. We sincerely want to provide the best service quality we can but exaggerations and fabrications will not tolerated.

Leaving a good Message

When you leave a message, providing accurate and thorough details will reduce a lot of the "phone tag" that often takes place when we need more information. This will get you an answer much quicker. A good message includes all the specific information we'll need to make a reccomendation or decision without needing to contact you further clarification.

Important: If you are calling about a medical condition, the following information is critcal:

Components of A Good Message

  • Who are you?
  • How should we contact you?
  • What are your symptoms?
  • When did they start (number of days or weeks)?
  • Are they constant or do they vary throughout the day?
  • If not constant, do they occur at the same time each day (i.e. in the morning, before bed, etc.)?
  • What were you doing when they began?
  • Have you tried anything to alleviate your problem (i.e. over-the-counter medication, rest, etc.) and, if so, what was it and what effect did it have on your condition?
  • Have you recently changed your routine or implemented any significant lifestyle changes (i.e. new work schedule, started an exercise program, life changing event, recent sleep problems, etc.)?
  • Include all related details (i.e. diet change, injury, new medications, travel, etc.)

Email Directory

General Email

Why Email?

@ sign in envelope
We like email!

Email is our preferred method of communications. It's not that we don't want to speak with you, email is just a much more efficient way to get your questions answered and will likely get you a quicker response. It's available 24/7 so you can reach out to us any time and we can work on your request without putting you on hold or having to "get back to you". Each department has its own email address as listed in the directory below.

IMPORTANT: Email abuse, including spam, phishing, mass-emails or any other inappropriate activity may result in your address being blocked. If you are a patient, you may be terminated from the practice. Attempts to override this through multiple email accounts will be reported to the Federal Communications Commission and/or the Department of Homeland Security.

Dept Email
General Mailbox info@theknightcenter.com
Administrative admin@theknightcenter.com
Scheduling scheduling@theknightcenter.com
Billing & Claims billing@theknightcenter.com
Nurse nurse@theknightcenter.com

Career Opportunities

We're Growing!

Road with arrow
Your career path starts here!

We're one of the last independent medical offices in Central Illinois. We like it that way because it allows us to focus on results without being encumbered by the standards, guidelines, and bureaucracy common to hospital-owned clinics. We're always interested in big-thinkers who can bring new perspectives and life experience to our team. We provide a supportive work environment, embrace diversity and offer a competitive salary and benefits package. If you want to be part of something unique, work in a place where your ideas are valued and, literally, help make a positive, life changing impact on people ... we'd like to hear from you!

Even if we have no open positions, we're always interested in getting to know motivated, qualified job candidates. If you are an Advanced Practice Registered Nurse, Certified Medical Assistant, Licensed Practical Nurse or a Receptionist/Front Desk person we'd love to review your qualifications and add you to our rèsumè bank.

IMPORTANT: Interested parties may email their rèsumè in confidence to admin@theknightcenter.com.   Those that are mailed, faxed, dropped-off or delivered by any other means will not be considered.

Sorry, we currently have no openings but feel free to submit your qualifications for future consideration.

Internship Opportunities

Learning on the job ...

Internship TIP
Put your skills into real word practice.

Periodically, we offer student internships. These are learning opportunities where students work under the direct supervision of a medical professional to gain real-world, practical experience in the medical field. Student interns must be computer-literate and willing to work in a fast-paced, dynamic environment. Although we have partnerships with various educational institutions, we also consider qualified prospects that submit their rèsumè directly. Interested parties should send their rèsumè with available dates and times to admin@theknightcenter.com. These are unpaid positions.

Sorry, we are not seeking any interns at this time but feel free to submit your qualifications for future consideration.

Leasing Opportunities

We Have Office Space Available!

Architectural model
Help us expand our services!

Our patients tell us they would like more health care services at our location. Are you a Dietitian, Clinical Psychologist, Nutritionist, Counselor or Social Worker looking for office space? If so, this may be the opportunity you've been waiting for! We are seeking like-minded tenants that practice these disciplines or provide other services complimentary to ours for referrals and consultation for common patients.

We have multiple units available that can be combined or rented individually, each with separate metering for gas and electric. Our building is in a high visibility location with easy access to and from Interstate 74. Ample parking is available and a bus stop is conveniently located a block away. We are on a frontage road with low traffic but are clearly visible to the high traffic of War Memorial Drive and the on and exit ramps from the expressway.

We offer competitive and flexible lease terms for qualified prospective tenants. Interested parties should email admin@theknightcenter.com for further details.

Primary Care

Primary Care is a broad term that covers a variety of "general medicine" areas that includes family practice, pediatrics, OB/GYN and internal medicine. We practice internal medicine. Internal Medicine is primary care for adults. The term is based on the study and knowledge of the internal organs of the adult body. Many internists use a specific minimum age, such as 14 or 16, when considering perspective patients, however, we make that determination based on biology and accept patients that have reached puberty.


What is Primary Care? Maybe a lot more than you think!

medical clinic syringe
In addition to general medical care, PCPs provide education, counseling services and manage most diseases.

People often think of primary care providers for treating colds and flu, moderate aches and pains or the doctor they see for annual exams or work physicals. The primary care provider is "their doctor" and they've often been seeing the same physician for years. In many cases, so have their parents, siblings and kids. In addition to the usual bumps, bruises, sore throats and stomach aches we all struggle with from time to time, the primary care provider also manages most diseases, provides counseling services, and develop coaching and support programs. They are also a valuable resource for health education and the latest medical research. They treat everything from depression and anxiety to high blood pressure and diabetes. Your primary care provider should be your first contact for all health-related issues regardless of the cause, affected area, anatomic system or symptoms.

We can take care of most health issues at our location. We also specialize in Women's Health issues such as hormones, menopause and osteoporosis. More complex conditions like coronary artery disease, stage 4+ kidney disease, asthmatics with frequent hospitalizations and various auto-immune and rheumtologic conditions may also require the oversight of a specialist. We examine and evaluate your condition and can determine if a specialist is required. If so, your primary care provider will coordinate and confer with the specialist on any further treatment or procedures. People that develop a relationship with their primary care provider and stick with them over the long haul can gain substantial health benefits.


7 Reasons to have a Primary Care Provider (PCP)

  1. A PCP maintains detailed records that include your personal health information, family history, test results, and allergies.
  2. A PCP knows what medications you're currently taking as well as effects and reaction to past medications.
  3. A PCP knows if you're prone to specific side effects and will be able to identify any potential contraindications.
  4. A PCP develops and updates a comprehensive health profile which improves diagnostic accuracy and timeliness. The better your doctor knows you, the more effective they will be in creating a treatment plan.
  5. A PCP understands your history, habits, environment and lifestyle which helps to better identify increased risks for certain diseases and make targeted preventative recommendations.
  6. A PCP has broad overview of your complete health and better understands how to optimize interaction between systems (i.e. cardiovascular, pulmonary, musculoskeletal, gastrointestinal, etc.)
  7. A PCP monitors your behavioral health and screens for anxiety and depression, conditions whose presence patients are often unaware of.

Complex Disease Management

Conditions We've Treated

A - B
C - D
E - H
I - N
O - R
S - Z


Abdominal Pain, acute
Abdominal Pain, chronic
Acne
Acute cholecystitis
Addison's disease
Adiposis dolorosa
Adrenal insufficiency
Allergic rhinitis
Alzheimer's disease
Anal Fissure
Anaphylaxis
Adropause
Anemia, macrocytic
Anemia, microcytic
Anemia, normocytic
Angioedema
Anxiety Disorders
Appendicitis
Arthritis, generalized
Arthritis, hands
Asthma
Attention deficit hyperactivity disorder (ADHD)
Babesiosis
Bacterial vaginosis
Bariatric nutrition
Bartonella
Benign prostate enlargement
Bladder infection
Breast cancer screening
Bronchiectasis
Bronchitis, acute
Bronchitis, chronic

Minor Surgical Procedures

Greco-roman surgical tool
Greco-roman surgical tools

There aren't many primary care medical offices that perform surgical procedures. In fact, most Internists learn very few outpatient surgical procedures in medical school. Our providers, however, have substantial training and experience with most minor surgeries. Dr. Knight studied plastic surgery and gynecologic investigations during her Women's Health Fellowship and received extensive training from Dr. David Anzulda when she took over his practice (see History). Dr. Anzaldua wanted to be sure she could provide the same quality he had for the previous twenty years, which included outpatient surgery.


Uhh...what exactly makes a surgical procedure "minor"?

Nole removal procedure
Minor surgery means we only cut into skin, mucus membranes and connective tissue.

Minor surgery means we only cut into skin, mucus membranes and connective tissue. Biopsies, the process of procuring tissues or body fluids using a needle or trocar, fall into this category, as well. Minor surgery can be performed in a lab or exam room setting with access to appropriate aseptic technique and work area. The risk for microbial contamination is very low.


...As Opposed to "major" ?

Major surgery is more invasive and risky. Any altering of normal anatomy, removal of organs or entering a body cavity would be major surgery. In general, if a mesenchymal barrier is opened (pleural cavity, peritoneum, meninges), the surgery is considered major. Major surgery must be conducted in an operating room equipped for survival surgery, which means it has the equipment and monitoring devices to put a patient completely out ... then bring them back. Because of what's exposed during major surgery, inadvertent microbial contamination can be a problem. As such, sanitation levels are more stringent.


Procedures we perform

Skin
Hemorrhoid
Uro/Gyne


Suspicious lesion biopsy
Changing moles
Actinic Keratosis
Basal Cell Cancer (less than 10 mmc)
Squamous Cell Cancer (greater than 10mm)
Biopsy for rash etiology
Cryotherapy for warts, keratosis
Earlobe repair
Laceration repair
Abscess incision and drainage
Small lipoma excision
Sebaceous cyst excision
Sebaceous cyst excision
Trigger Point Injections
Sebaceous cyst excision
Trigger Point Injections
Botox Cosmetic
Botox Medical
Mesotherapy
Juvéderm filler
Joint injections/aspirations
Sclerotherapy of Internal Hemorrhoids, Stage 1
Sclerotherapy of Internal Hemorrhoids, Stage 2
External hemorrhoidectomy
Anal fissure treatment
Urethral dilation
Urinary simple cystometry
Endometrial biopsy
Cervical cryotherapy
IUD placement
Vaginitis evaluation
Thin prep pap smear

Diseases & Syndromes

Vintage medication tins
Mainstream medicine has a history of initially scorning and later adopting some medical practices.

Environmental Medicine is an area of study that examines how the environment(s) in which we live, work and play affects our general health, as well as the role environmental toxins and pathogens play in sickness and disease. Physical, chemical, biological and genetic factors all contribute to environmental illness. The resulting condition or reaction typically manifests as an overactive immune system and is triggered by one or more substances often found in our everyday lives ... and often taken for granted. Triggers include exposure to mold or water-damaged buildings, tick-borne infections, household and/or workplace chemicals, food sensitivities and a host of other microbial infections and biotoxins. Although mainstream medical experts are at odds on the validity of environmental illness, the feelings and symptoms are very real as anyone with Lyme Disease or Mold Toxicity will testify.


fungus and mushrooms in forest
Environmental medicine examines the role of natural toxins in disease.

What's wrong with me?

So how do we diagnose environmental illness? It starts with listening to the patient and encouraging them to tell their story. When did it start? Where were you living at the time? Were there water intrusions, rashes, tick bites? When did you last feel normal? We get to know our patients. We gain a comprehensive understanding of the patient's environment and symptomatic history, systematically and sequentially identify and eliminate common causes using mainstream medical standards of care and continue gathering relative data through testing. We ensure that our conclusions are driven by real data and outcomes can be statistically correlated to the treatment deployed.

Mainstream medicine has a long history of initially scorning, then later endorsing certain medical practices. Practitioners of treatment methods acknowledged and embraced by today's healthcare experts such as osteopathy, psychiatry and physical therapy were once considered quacks. Prior to 1982, the medical community steadfastly agreed that peptic ulcers resulted from stress or spicy foods and were treated with bed rest and milk. Anyone suggesting that the they were caused by a bacterial infection would have been considered crazy. In similar fashion, probiotics are still not accepted as valid treatment by many gastroenterologists despite clear connections between disease and the microbiome. The same holds true for many physicians that consider environmental toxins a probable cause of presented symptoms and they are often required to defend their conclusions to industry "experts." This skepticism dates back to the 1960s and is tied to commercial and government interests that are biased by the money those interests are protected to uphold. It is also related to the movement toward less time spent by the physician gathering the patient history and delegating much of this to their staff. Innovation is always stifled by strivinge to maintain the status quo, even if they can't provide a valid diagnosis within the principles they fight to enforce. They argue that the patient is psychosomatic or malingering and any improved outcomes are simply a "placebo effect." Despite this resistance, we adhere to scienfic principles held forth in epidemiology, clinical research and statistical analysis as demonstrated in this excerpt from an actual deposition.

silouhette of head
People are often wrongly labeled psychosomatic

As such, patients with conditions like Fibromyalgia Syndrome, Chronic Fatigue Syndrome or Seronegative Rheumatoid Arthritis are often wrongly labeled as psychosomatic, however further investigation frequently reveals that many were exposed to mold, Lyme disease or both. These conditions also overlap often and some patients have ALL of them.

The good news is that we can now test for potentially underlying conditions like Chronic Inflammatory Response Syndrome (CIRS) and Mast Cell Activation Disease (MCAD), both caused by an impaired immunodeficiency. If unrecognized or left untreated, many patients with CIRS and/or MCAD will eventually develop Multiple Chemical Sensitivity (MCS). Fortunately, all of this can be diagnosed and is treatable.


Chronic Inflammatory Response System (CIRS)

Slime mold
CIRS is caused by mold, bacteria, fungi and viruses.

CIRS is often referred to as Biotoxin Illness or Mold Illness. Although we now understand that the source of CIRS is often mold, it can also be caused by other pathogens including various bacteria, fungi and viruses. CIRS is especially difficult to diagnose as the symptoms resulting from CIRS mirror symptoms of other illness including Lyme Disease, Ehrlichiosis and multiple Auto Immune Disorders. Patients suffering from CIRS may experience fatigue, weakness, sensitivity to light and/or smell as well as flu-like symptoms such as nausea, diarrhea, achiness, headaches and abdominal pain. It can affect the entire body or individual systems/regions and is often characterized by blurred vision, tinnitis, nose bleeds, laryngitis, sharp joint pain, cramps, shortness of breath, heart palpitations, metallic taste, tingling in the extremities, skin sores, itchiness, numbness discoloration in extremities, extreme thirst, confusion, disorientation, cognitive difficulties, depression, anxiety, irritability and poor recall. 80% of CIRS patients acquired the disease wholly or in part from water damaged buildings, usually their residence or place of employment.


Chronic Inflammatory Response System -Water Damaged Buildings (CIRS-WDB)

Leaky drain pipe
CIRS-WDB comes from water damaged buildings

CIRS-WDB is commonly traced to water-damaged structures in which the interior contains molds, fungi, bacteria, actinomycetes and mycobacteria as well as a broad variety of inflammagens and other volatile compounds.

Did the '73 oil embargo make my basement moldy?

Theories on the rapid increase of sickness in the late 20th century, now believed to be related to the presence of mold, point to the energy crisis of the 1970's. A decline in global oil production created a demand for energy efficient houses. New homes were designed to be air-tight and water-tight in response to rising heating and cooling costs. Building codes for new construction were also updated to include requirements for insulating interior walls and pipes, and many existing homeowners took similar steps to reduce household energy consumption. Although this significantly improved energy efficiency, it also made it difficult to spot plumbing leaks. Water in sealed wall/attic enclosures evaporated much slower and was often "trapped". This caused some molds to flourish, often without the residents' knowledge.

It was also during this era that drywall became more commonly used on walls and ceilings. Drywall is made from gypsum and blended with starch and paper pulp mixed with water and elmusisifier to create a paste, which is then spread, compressed and dried between two sheets of paper. Paper pulp (and, eventually, paper) typically comes from forestry products which have been known to retain dormant Wallemia spores. Wallemia may survive the drywall fabrication process and remain in a dormant state until "awakened" when indoor humidity exceeds 55%.

"Black Mold" isn't always black

Black mold in corner
Black mold is the most toxic of molds

The “toxic black mold”, or simply "black mold" that many of us are familiar with, stachybotrys chartarum, requires 95% saturation to grow. Catalysts range from dripping faucets, water seepage through foundation cracks, water pipe leaks or any area that is consistantly wet or damp. It's frequently referred to as "mildew" and mistakenly believed to be harmless. In fact, Stachybotrys is recognized as the most toxic of molds and is generally the product of areas with considerable water damage, usually because the affected areas have been ignored or were unnoticed. This type of mold is common to drywall, carpets, drip pans, ceiling tiles and wall paper or other materials rich in cellulose.

Aspergillus penicillium and Aspergillus versicolor both belong to the "black mold" group (although can also be pinkish or gray) and, in addition to the same environments inhabited by stachybotrys chartarum, is frequently found in ductwork and on joists. Aspergillus is of particular concern because it produces the potent carcinogen mycotoxin aflatoxin and, in many cases, looks like dust.

Important: Don’t be fooled into thinking color equals toxicity, however. Chaetonium does not even look like mold. It can be purple or yellow and still make people very sick.


Why Me?

That’s a common question. Well, you can’t pick your parents. An area of genes on chromosome 6 are called the HLA genes. These genes are involved in determining self vs non-self. For instance, if Joe needs a kidney and Eddie wants to give him one, they need to match genetically so Joe’s body will accept and not reject Eddie's kidney. Antigens are tags on cells that act like name badges. The antigens most responsible for donated organ rejection are HLA-DR (first six months), HLA-B (first two years), and HLA-A (long-term survival). These same regions on chromosome 6 are associated with susceptibility to many diseases. According to Dr. Ritchie Shoemaker, 95% of his cohort that fit the profile for environmental illness have HLA DR haplotypes (genes) that make up 35% of the 54 possible types. He further found associations between specific types with CIRS, mold susceptibility, Lyme Disease, or Multiple susceptibility. He refers to these as the dreaded haplotypes.

DNA strand
24% of the population carries at least one susceptible halotype

Dr. Shoemaker estimates that 24% of the population carries at least one susceptible halotype and is thus more susceptible to CIRS. Many practitioners, after they start looking for CIRS, find it in so many patients that they don’t believe it’s only 24%. it'as likely they aren't considering selection bias and its role in funneling certain patients their direction. There are many people that are not getting answers from our current medical system and they eventually find doctors that are open minded and willing to look outside the box. If you are one of those doctors, then your patient population will have a much higher incidence of these findings then the general population. Don’t let it skew you into thinking this science is wrong, it’s simply a reflection of how perspective can influence conclusions. Because of finding it in most of their patient, many practitioners stopped testing for it because they don’t want to waste the money. We've made it optional but find it helpful because, in addition to Celica and CIRS, these HLA halotypes are also associated with other diseases such as Multiple Sclerosis and Narcolepsy.

As we learn more from the Human Genome project and the rapidly evolving knowledge about genetics, we suspect that we’ll find that many “rare” conditions are not as rare as we think, they just don’t always fit the textbook definition. We also may be able to prevent certain diseases (like Multiple Sclerosis) if we can identify the triggers. In fact, that’s exactly how diseases often occur, you start with a genetic susceptibility and which is triggered by a certain exposure. The saying is, “Genetics load the gun, but the environment pulls the trigger.”


Chronic Inflammatory Response Syndrome-Borreliosis Burgdorferi (CIRS-BB or Chronic Lyme Disease)

Deer tick on leaf
Testing for Lyme Diseasetoo early may result in false-negative results.

Suppose it's the middle of summer, say July, and a patient comes to our clinic complaining of flu-like symptoms and has a large (> 5cm) red circle on their thigh. Further discussion reveals they had just returned from a long weekend in a park located at the Illinois/Wisconsin border near Lake Michigan where they had been camping and hiking. It's likely acute lyme disease. Some say "until proven otherwise", but that would be wrong. Current testing for Lyme Disease returns a positive result when the presence of antibodies are detected. Our immune system creates antibodies to fight the infection but it may take several weeks for the antibodies to develop. Testing too early, then, results in false-negatives. Obtaining an accurate diagnosis requires multiple tests and may take months to confirm. Meanwhile, the patient continues to suffer. This is a huge problem in the US and is also why many who contract Lyme disease go on to develop chronic lyme disease or CIRS-BB.

Antibodies often remain in the blood for an extended period (sveral months, even years) after the infection is gone so the same test used to detect antibodies can't reliably indicate that the condition is "cured." The assumption that Lyme disease can be cured using a 2-4 week course of antibiotics did little to explain the continued pain, fatigue and cognitive impairment that many patients experience after treatment ushered in a new condition they called Post-Treatment Lyme Disease Syndrome (PTLS). PTLS is used to describe Chronic Lyme Disease by those that believe that Lyme Disease can’t persist. They would be wrong, too.

The amount of basic bench science that shows that B. burgdorferi can persist after being “adequately” treated is enormous. By way of comparison with the behavior of other species in the genus Borreliasuch as their role related to Tick-borne Relapsing Fever, there is no reason to believe it wouldn't. Unfortunately, given the limitation of existing test methods, we must defer to alternative tests such as the detection of B. burgdorferiDNA through urine specimens and the enumeration of CD57-positive lymphocytes that show suppression due to a chronic bacterial infection.

Gloved hand holding petri dish containing anthrax culture
Microbial cultures are considered the gold standard of diagnostic tools for infectious disease.

A microbial culture is a common diagnostic tool used in test labs to identify the source of infectious disease and is considered the gold standard. If the blood from a patient is plated on petri dishes of different agars and one grows Borrelia then you’ve proven they still have the infection.

In 1985, Dr. Alan MacDonald, in collaboration with Dr. Joseph Burrascan, successfully created a culture from samples taken from patients with persisting symptoms of Lyme Disease. He was able to replicate the culture over 7000 times, along with Dr. Burrascan's research, made great strides towards proving the existence of Chronic Lymes Disease. Dr. MacDonald's culture was later acquired by IgeniX Incorporated a commercial laboratory that specializes in the research and development of tests for Lyme Disease where it's, allegedly, undergoing further validation. To hear an interesting podcast from Dr. Burrascano on the history of Lyme Disease, click here.

Biotoxin Pathway and the Mother of Invention

How does a water-damaged building or tick bite lead to CIRS? Our best understanding so far is called the Biotoxin pathway. This model was designed by Dr. Shoemaker and correlates with the pattern of abnormal labs seen in CIRS. Dr. Shoemaker looked for biomarkers (levels of chemicals made in our body) in patients that came to him for help recovering from CIRS. He didn’t start out knowing this pathway or which biomarker tests to run.

In Pokomoke, MD, where his practice was located, people that fished, skied, or swam in the Pokomoke River were coming down with an illness that caused memory problems, widespread pain, fatigue, visual changes and diarrhea. In the past, he’d successfully treated Pfeisteria with a drug called cholestyramine and initially selected it to stop the diarrhea in patients suffering from this new mysterious illness. Cholestyramine was a drug for lowering cholesterol and didn’t work that well, but it was very effective in stopping the diarrhea that often accompanied gallbladder removal. What came as a shock was when Shoemaker discovered that, not only did it stop diarrhea, but fatigue, brain fog, pain, and visual problems as well. That lead to him to use it for other illness that presented with similar symptoms with success. That’s also why doctors should never lose their right to prescribe drugs off label. “Necessity” is the mother of invention in medicine, just like everything else.

Pokomoke River wetlands
Pokomoke River wetlands

From the realization that cholestyramine eradicated the symptoms, Dr. Shoemaker knew it had to be a lipophilic toxin. Cholestyramine is not absorbed into the body but passes through the intestines where it binds bile salts and carries them out. Bile salts are rich in cholesterol and fat and the ability of cholestyramine to remove these was supposed to lower cholesterol. The fact that it worked for typical CIRS symptoms meant that the toxin causing the symptoms was negatively charged and liked fat. From studying the process over 20 years aided by advances in immunology, Dr. Shoemaker was able to piece together a to explain how this happens.

It starts with an exposure to toxins that, in most people, will be “tagged” by their immune system, then broken down and eliminated. The HLA-DR genes that he found prevalent in those susceptible to certain triggers are involved in our immune system’s recognition of self vs. non-self. For example, to donate a kidney to someone, the donor and recipient would have to match across their HLA-DR genes. These genes code for antigens (proteins that stick out of cells surfaces). Foreign antigens on cells that don’t belong in our body are how we recognize them as foreigners. If the donor and recipient don’t match, the recipient’s immune system will reject the donor kidney as “foreign.”

So, the proteins involved with toxins from water-damaged buildings, Borreliosis, and ciguatera toxin must affect susceptible people similar to the immune system’s self-identification system. Think about that for a while. The person’s system with the wrong HLA DR type doesn’t see an invasion by these toxins as “foreign” and they are welcomed into the system of the person with matching HLA DR. However, further down the line there is a backup system called “the innate immune system”. This is our factory-installed immune system present from birth. It is less sophisticated, not as specific and is heavy-handed and hard to shut off. But it does see these toxins as unwelcome invaders and that’s when the problems start.

Silhouette of women thinking
The immune system is a relatively new area of understanding.

That leads to the biotoxin pathway or the innate immune system cascade of problems. The names of the players in the immune system are foreign to most of us, even in medicine. The immune system is a relatively new area of understanding and probably the least understood of neurological problems. The biotoxins bind to surface receptors called toll receptors. This binding increases the production of cytokines. Some cytokines seen rising are TGF beta-1 or Human Transforming Growth Factor Beta-1 (TGF Beta-1), complement split products, C4a, C3a (in Lyme Disease only), Matrix metallopeptidase-9 (MMP9) and elevated vascular endothelial growth factor (VEGF) which will deplete to deficiency.

The immune system also changes neuropeptides in our brain or central nervous system (CMS) . This causes a decrease in melanocyte stimulating hormone (MSH) which normally handles anti-inflammatory and neurohormonal regulatory functions. The lower MSH gets the more the system can run amok and lead to poor sleep, mood swings, fatigue, pain, and hormonal abnormalities. Antidiuretic hormone (ADH) is often low as a result and leads to unquenchable thirst and inability to concentrate urine.

Adrenocorticotrophic Hormone (ACTH) is also often dysregulated. It may initially be higher than normal and provide some symptomatic relief but when it falls, the patient will be severely fatigued, a condition that worsens when cortisol also falls.

Leptin is produced by fat cells and is supposed to tell the brain when we’re full by sending a signal to reduce our appetite. However, the receptor for leptin is also part of the feedback loop for MSH. As stored toxins in fat cells increase leptin levels, the MSH receptor becomes resistant to leptin. This can cause tremendous weight gain in a very short period. We’ve frequently seen this in cases of mold exposure (but not Lyme or other toxins). As such, when someone says, “I don’t understand Doc, how could I gain 20 pounds in two weeks without a change in my diet?” we ask, “Did your roof recently start leaking or did your water heater break (or some similar reason for pooling of water)?” Often, the reply is something like, “What? How did you know? A couple of months ago we had to replace a leaky water pipe." Yep, you’ve got mold.

These levels can all be checked with blood tests:

  • MSH
  • ACTH/Cortisol
  • ADH/Osmolality
  • MMP9
  • VEGF
  • TGF Beta-1
  • C4a
  • C3a
  • Leptin
Biotoxin pathway diagram

Mast Cell Activation Disease (MCAD)

Guards at Buckingham palace
Think of mast cells as members of an infantry contingent similar to those that guard the Buckingham Palace.

MCAD is another condition triggered by our foes Mold and Lyme (in addition to several other chemical substances) and have been linked to certain genetic predispositions. Mast cells are part of the immune system. Although T-Cells are largely responsible for surveilling and protecting us from foreign invaders, mast cells are employed as "Surface Sentinels." Think of mast cells as members of an infantry contingent similar to those that guard the Buckingham Palace. Just like the Queen's Guard regiment standing at attention at Palace entrance and exits, mast cells line bodily surfaces in contact with the outside world including our respiratory, digestive, genital and urinary tracts, as well as our skin. You may think, "Wait a minute, how are all these "tracts" on my inside in contact with the outside?" Think of them as hallways passing through our body with doors to the outside world on each end where mast cells are standing guard. They're also guarding along the hallways, too, just in case someone tries to leave the tour group and sneak into a room they shouldn't.

Microscopic view of Mast Cells
Mast cells release mediators which play a vital role in our defense against pathogens and hostile microorganisms.

Mast cells or "Mastzellen", which means "well-fed cells," were named so because they contain large granules. The cells originate in bone marrow and migrate to skin and mucus tissues when they reach maturity. When triggered, they release substances called mediators. Mediators play a vital role in our defense against pathogens and hostile microorganisms. The most well-known mediators is histamine and we now recognize that most of the histamine in our body comes from in mast cell granules. Anyone with allergies is familiar with histamine. Histamine is what causes itching and sneezing and, if the releases is significant, it can lead to throat swelling and hives. Other mediators include trayptase and cytokines both components of inflammation and leukocytes, or "white blood cells." Several mediators have been identified but there is still a prevailing misconception on the shear volumer of mediators that mast cells can release. Medical text books and research material usually limit the number to 20 or less, however, we now know there are, at least, 3000 different mediators. There are mediators that dilate blood vessels, increase blood pressure, elevated the production of red blood cells and boost the output of norepinephrine (adrenaline). Conversely, other mediators constrict blood vessels, lower blood pressure, reduce red blood cell count ... well, you get the idea.

Mast cells are regulated by a KIT gene. So far, 35 different KIT gene mutations have been discovered and 17% of the population has at least one mutation with many people having multiple mutations. KIT mutations can interfere with the stability of mast cells and sometimes cause mast cells to go "rogue." At first, researchers found a single mutation leading to a type of cancer called Systemic Mastocytosis but as additional mutations were identified, many could be linked to a host of other undesirable consequences but few were found to cause cancer.

Below is a list of diseases that Dr.Lawrence Afrin, author of Never Bet Against Occam” and national expert on Mast Cell Activation Syndrome felt may be linked to mast cells.


diseases linked to mast cell dysfunction

A - B
C - D
E - H
I - N
O - R
S - Z


Acute lymphoid leukemia
Acute myeloid leukemia
Adenomyosis
Allergic Rhinitis
Anemia of chronic disease
Anti-phospholipid antibody syndrome
Aplastic anemia
Asthma
AD/HD
Atypical angina
Atypical nephrolithiasis
Autism spectrum disorders
Benign ethnic leukopenia
Bipolar disorder
Blurry vision, episodic
Budd-Chiari Syndrome
Burning mouth syndrome
Burning scalp syndrome

Dr. Afrin argues that the approach for problem-solving should not begin by making the problem more difficult. He explains that it's more likely that someone with an array of bizarre, typically unrelated symptoms could be explained by a single underlying condition rather than two or more separate diseases. We find that multiple triggers are not uncommon but the root cause is still an innate immune system dysfunction. Environmental pathogens can trigger a genetically susceptible person's innate immune system to go awry. When it does, on average it presents with twenty-five different symptoms that would otherwise seem impossible to connect!

Issues Related to MCAS:

  • Syncope/Pre-syncope (passing out)
  • Pseudo allergic reactions
  • Urticaria (hives)
  • Dermatographia (write on skin with fingernail and welts up)
  • Dysautonomia (abnormal heart rate or blood pressure regulation)
  • Strange reactions to medications, often resulting from inactive ingredients
  • Episodic or intermittent flares with increased frequency and duration with age
  • Similar to CIRS, multiple symptoms over multiple systems without diagnosis

Mold or water-damaged building exposure is the most common and ubiquitous source for MCAD. When patients are told they have told Lyme Disease or Cigaterra toxin, they are often pleased to finally get answer. When hearing that their problems are possibly related to mold exposure, they stick their head in the proverbial sand. In fact, it happens so frequently that we're beginning to suspect that mycotoxins or anything else from the evil soup that exists in water-damaged buildings must also be capable of mind control. When given instructions on tackling the problem, they frequently do the exact opposite! According to Dr. Neil Nathan from his book Toxic: Heal Your Body, this is mold-induced “cognitive dissonance.” In psychology, cognitive dissonance is when someone holding two or more contradictory beliefs and behaves in a manner that conflicts with at least one belief and it causes them great distress. This issue is two-fold. First off, people frequently have problems reconciling the concept that their illness may be the result of their residence. Secondly, MCAS literally creates confusion and trouble with logical functions in it's vicitims. These problems can be further compounded by an unsupporting spouse or employer denial. No one wants to hear that their house could be killing them or causing dementia. It's much easier to blame a tick.

Inflamed brain cell cause by Alzheimer's
Inflamed cells in brain of an Alzheimer's patient

Researchers and physicians are beginning to realize that dealing with complexity like this will be ever more critical when diagnosing future diseases. As we learn more about the human genome, we're beginning to understand why "Drug X" only works on 30% of patients or "Drug Y" may work as expected in 40% but fails in different ways for three other "groups." The biggest challenge is mainstream medicine's unwillingness to relaize that we’re not all the same and we can’t apply a cookie cutter approach to everyone. Dr. Dale Bredesen has demonstrated this in his protocol that has reversed early Alzheimer’s disease in over 100 patients. Shouldn’t this be all over the medias? Why didn't we see this on the front page of Internal Medicine News or in the American Family Practitioner Journal? Turns out it's because it was never published in either of those two mainstay journals. Why? Probably because his findings won't lead to one drug for fixing 36 potential problems that causes Alzheimer’s. Most of his approach is about eating right and optimizing our vitamin, mineral and hormone levels. After all, that might be kind of hard to patent!

What does this have to do with MCAS? Glad you asked! In his book, The End of Alzhiemer's Disease, Bredesen discusses three types of Alzheimer’s. The first two types are related to each other and associated with the ApoE 4 gene. The third type, however, is from toxic exposure and shows findings similar to CIRS. Mold exposure is not a problem to be taken lightly. Once identified, it's best to work on correcting and restoring your environment as soon as possible. The longer the exposure, the higher the probability of developing autoimmune diseases. It’s a process..but it's doable.



Multiple Chemical Sensitivity (MCS)

Common household sprays and cleaners
MCS is suspected to come from substances in plastics, paints,synthetics, pesticides and other organic chemicals.

Symptoms of Multiple Chemical Sensitivity are much like those presented in CIRS and MCAD (headaches, fatigue, nausea, depression, confusion) but are suspected to come from interaction with substances found in plastics, paints, synthetic fabrics, pesticides and other organic chemicals. Those with MCS are known to be intolerant of a wide range of chemicals and frequently have a negative reaction to certain foods, as well.

In our practice, patients that have presented with MCS have been found to have CIRS, MCAD or both.Some practitioners theorize that there is a "syndrome hierarchy" that flows from CIRS to MCAD to MCS. We disagree with that hypothesis considering we have patients with CIRS that do not develop MCAD, as well as MCAD patients with no evidence of having CIRS. Other doctors claim they have never encountered an MCS patient that did not have a problem traced back to mold exposure but we are reluctant to subscribe "all or none" conclusions. Although we would agree that MCS may be an eventual outcome for those suffering from CIRS and/or MCAD if those conditions are left untreated, however, we've found that patients that have had MCS for an extended period have often developed complex coping systems and tend to be very fragile. They are often reticent and adverse to unfamiliar treatment although we have found that MCS patients can benefit from elimination diet trials and have found that, combined with the removal of any disruptors present in their environment(s), can produce successful outcomes.

Genetic Susceptibility

Genes call the shots!

DNA
Deoxyribonucleic acid (DNA) is a molecule we inherit from our parents that contains all of our genetic information.

Why does one person acquire a specific disease or disorder and others having the same demographic profile are spared? Is it bad choices, bad experience, bad location or just bad luck? Simply put...yes. We touched on this briefly when we discussed how some environmental illnesses align with certain genetic charactersitics, but this this ection is more of a genetic primer.

Although humans share most of the same genes (99.5%), the variations in the differences (0.5%) of the unshared genes are what makes us unique. We're all familiar with the phrase "runs in the family." It describes the genetic traits passed to us through our ancestry, literally. Therefore, just as we inherit characteristics that contribute to our physical appearance, we also inherit health risk factors, susceptibility to certain illnesses and resistance to others. Perhaps you've noticed that people from the same family, besides looking similar, often share (and avoid) the same health problems.


It's all in the DNA - A crash course in Genetics

Most of us have seen Jurrasic Park so we know about deoxyribonucleic acid (DNA) and it's "twisted-ladder" or "double helix" shape. The nucleus of each cell in our body contains an identical, tightly wound DNA strand inside our chromosomes (more on those later). DNA ladder "rungs" are base pairs of the chemical building blocks adenine (A), guanine (G), cytosine (C), and thymine (T). Joined by hydrogen bonds, A is always paired with T, G is always paired to C and the rungs are attached to "rails" made of phosphate and sugar. The rungs are arranged, or "coded", in groups of three in a precise order called sequences. DNA strands are quite long (about 6 feet) and are separated into different regions of sequences that combine to represent detailed instructions for the function, management and structure of cells. These regions aregenes.


Genetic contractors and the protein factory

genes with dna
Genes use sequences, or "codes," to iniate the production of proteins.

Genes use these sequences, or "codes," to iniate the production of proteins by reading and storing the codes in messenger ribonucleic acid (mRNA) molecules through a process called transcription. During transcription, a portion of DNA is unwound and copied creating an identical strand (mRNA). The mRNA migrates to the cell cytoplasm, the cell area outside the nucleus, where it attaches to ribosome. Ribosome is a "factory" that enlists amino acids, also known as the "building blocks of life," to produce proteins per the specification of the expressed gene, the gene that initiated this cycle and encoded by our DNA to act as the catalyst for the production of specialized cells. This is necessary because heart cells have different requirements than brain cells or skin cells and, therefore, require different proteins. Ribosome uses mRNA as a blueprint to determine which amino acids to recruit and the assembly details necessary for building the correct protein. This is called translation.

To reproduce, cells split in two. Regardless of the cell type, new cells must include a complete DNA strand. During the replication process, DNA unwinds as it does during the transition process, however, instead of only the portion required to synthesize a specific cell type, the entire DNA strand unwinds and splits in two. The two strands then bind to complimentary bases (A, G, C or T) already in the cell to form two full, double-strand (remember our "twisted-ladder") DNA molecules. Cells can correct errors that occur during replication through validation and repair functions indigenous to all cells, but there are billions of base pairs making it probable that, given the right circumstances, errors will persist. The majority of the time, this isn't a problem as slight DNA variations are common and rarely duplicated in subsequent cells. Mistakes that are copied into subsequent cells, however, are known as "mutations" and can be passed to offspring.


We're all mutants (or at least a little "abnormal")

Influenza virus
Inherited mutations are often noticeably apparent in families and, depending on the amount of DNA affected, can be a problem.

Cells mutate for many reasons including the use of certain drugs, viruses, chemical exposure or for reasons we've yet to discover. Inherited mutations, those passed from parent to child, however, only occur if a mutation is present in the male sperm or the female egg. Inherited mutations are often noticeably apparent in families and, depending on the amount of DNA affected, can be a problem. For example, the re-ordering of a protein's amino acid sequence could modify or disrupt the function of the protein which could be very harmful, even fatal. In cases of Phenylketonuria (PKU), a disorder of amino acid metabolism, is an inherited mutation that prevents infants from breaking down the amino acid phenylalanine. A build up of phenylalanine in the blood stream can interfere with brain development and lead to brain damage or intellectual disability.


Why the difference between men and women has nothing to do with planets

As previously mentioned, each cell contains copies of the DNA strand, regardless of the cell type. The 6-foot long (and about .0000008" wide) strands contain over 20,000 genes and are "super-coiled" to fit into chromosomes as part of a cell nucleus. Except for reproductive cells and red blood cells, human cell nuclei contain 23 pairs (46 total) of chromosomes, with each pair consisting of a chromosome from each parent. There is one pair used for gender selection, the sex chromosome, may have different chromosome types (XX or XY), whereas the other 22, for all intents and purposes, are identical. Males have one X and one Y chromosome and females have two X chromosomes. As such, males acquire a Y chromosome from the father, X chromosome from the mother and females acquire an X chromosome from each parent. X chromosomes have more genes than the Y chromosome, therefore, in males, the unpaired X chromosome will express most or all of its genes. The genes of the other 22 pairs can all be fully expressed. In females, however, genes from one of the X hormones, father or mother, is disabled early in development through a process called X Inactivation. This can result in one cell containing genes from the father's X and another containing genes from the mother's X and leads to minor abnormalities. In rare cases where females have more than two X chromosomes, the additional X tends to be inactive and has little impact on developmental abnormalities. Males with two Y chromosomes, however, are much more likely to have physical and/or mental problems. Irregular numbers or translocation of the other 22 non-sex pairs typically lead to severe abnormalities like Down's Syndrome or leukemia and, in some cases, can be fatal to a fetus.


Genetic Disorders

ultrasound image of baby in womb
Genetic disorders are caused by abnormal genes which are often inherited.

Genetic Disorders are caused by abnormal genes which are often inherited but may also arise from new mutations. Although genetic abnormalities are fairly common (most of us have anywhere from 100 to 400 abnormal genes) the corresponding genes from the other paired chromosome eliminates most detrimental effect as the probability of any person having two copies of an abnormal gene is minimal. None-the-less, research shows that certain inherited gene mutations increase the risk of some diseases. For example, we know that mutations in BRCA1 and BRCA2 genes can increase the risk for breast and ovarian cancer and that an abnormal Rb1 gene is found in 40% of children that develop retinoblastoma, a cancer of the eye. Known single-gene disorders include cystic fibrosis, sickle cell anemia and Marfan Syndrome and muti-factorial inheritance disorders, disease caused by a combination of environmental factors and mutlple gene mutations, include heart disease, high blood pressure, Alzheimer's disease, arthritis, diabetes, cancer and obesity.


OK, but what does this have to do with mold?

Certain gene types are susceptible to one or multiple environmental illnesses that are triggered in the presence of molds or other environmental toxins.

triggers

Currently known environmental illness triggers

  • Water-damaged buildings, commonly referred to as Mold Toxicity
  • Lyme Disease or Borreliosis, possibly Babesiosis, Bartonellosis, Rocky Mountain Spotted Fever
  • Pfeisteria exposure (protozoa)
  • Ciguatera toxin (from eating Caribbean reef fish such as Barracuda, Grouper, Snapper)
  • Blue green algae blooms
  • Brown recluse or Mediterranean recluse spider bite
  • Metals, either high doses or presence of heavy metals
  • Chronic microbial infections
  • Pesticides
  • Volatile organic compounds
  • Electromagnetic Force (EMF)

Treatment

Taking (and Giving) a good history

Figuring out patients with previously undiagnosed complex problems starts with ensuring the patient knows they are in a place where they are safe from ridicule or disbelief and taking a very thorough history. Patients or physicians who read this and think that it makes gullible are mistaken ... we can spot a drug seeker a mile away! In most cases, these patients are NOT drug seekers and many are actually scared of medications from prior bad experiences. Much of the history may still have to be asked directly about because in the past they were told that a symptom was nothing or that nothing can be done about it so they have ignored it or filed it away. If you keep telling someone that there is a hole in the dyke and the water is escaping and they just shrug and say sorry I wish I could help but I don’t know what to do, they eventually decide that the hole is supposed to be there. You must always ask WHY? Why do they not respond to medications like everyone else? A common symptom that's often minimized is fainting or nearly passing out. We had a patient with episodes of not being able to move for hours that had MOG antibodies, a condition similar to Multiple Sclerosis. You would think that she would realize something is terribly wrong but it typically resolved in a few hours. It didn’t make any sense to her, so she ignored it. She also didn’t realize how bad she was until she was treated with something that worked and most of her symptoms were relieved for the first time in a long time. It can happen in many different diseases. It’s not normal to pass out frequently, a vasovagal response to the sight of blood or something scary not withstanding.

Medical history form on clipboard
Figuring out patients with complex problems starts with taking a very thorough history.

As varied and crazy as many of the MCAD symptoms are, there are some that are more common than others. Urticaria or hives are common, as well as dermatographia or skin writing, a condition in which a light scratch causes the skin to welt up so much you can actually write on it without a marker or pen. It lasts anywhere from 5 to 30 minutes. There are more skin findings with long names that come and go and, with MCAD, are slow to heal. Chronic eye irritation is common, as well as having trouble focusing. Blepharospasm or twitching of the upper or lower eyelid is also common. There are frequent findings of “sterile” inflammation which means inflammation without an infectious cause. A big clue is a list of allergies to medications that is very long and some of the reactions very bizarre. An example might be someone that claims to be allergic to prednisone. I understand if they say their aalergic reaction is hyperactivity, insomnia, paranoia, weight gain, etc., but if they say rash or hives, then I would be flummoxed. When this happens, it's usually due to medication fillers not the active ingredient itself. Idiopathic epistaxis (nose bleeds) can also be MCAD but hint at mold exposure, too. Gastroesophageal reflux is common but often doesn’t respond to the usual medications. A history of frequent respiratory infections is not uncommon. Neuropsychiatric issues are also common and of course, don’t help the patient in terms of credibility. Shortness of breath is also a common finding and complaint. Interstitial cystitis is likely related or caused by MCAD. The list goes on ... but the point is that someone with a lot of complaints and maladies may have a mast cell problem.

Diagnosis is made by collecting blood and urine sample and looking for elevated mediators. We don’t always find them the first time but will try again, especially if the person is having a symptom flare-up. The findings are usually a modest elevation of one or more of the following but not so high as to suggest systemic Mastocytosis or Hereditary Alpha-Tryptasemia (although we have encountered the latter, too).

Mast Cell Mediators we test for

  • Tryptase
  • Chromogranin A
  • Heparin
  • Histamine
  • Prostaglandin D2
  • Urine Prostaglandin D2
  • Urine N-methylhistamine (histamine metabolite)
  • Norepinephrine
  • Dopamine
  • Epinephrine
  • Factor VIII
  • Protime
  • PTT

overview & history

Women's Health

Women’s Health is the foundation of The Knight Center and Dr. Knight’s specialty. The inspiration to specialize in women’s health came from her realization that most medical research was done on men. Despite having distinctly different physiological characteristics than men in addition to a host of reproductive related health needs that do not apply to men, research and education on women’s health was very sparse. Let’s be honest, though, the women’s health movement didn’t really begin until the women started fighting for reproductive rights in the 1960s during the second wave of feminism (the first occurring in the mid-19th through the early-20th century as women began fighting for, among other legal issues, the right to vote.)

Pink women's health icon
The Women's Health Movement has advanced significant changes in medicine to address the unique needs of women.

During the 1960s, abortion was illegal in every state unless required to save the mother’s life. Although, there were 8,000 therapeutic abortions done annually, it is estimated that over 1 million illegal abortions were performed each year as well. Approximately one-third of those undergoing illegal abortions had complications that leading to hospitalization and 500 to 1,000 died. In a stand to “end sexism in the health system”, the demand for reproductive rights sparked what became the Women’s Health Movement (WHM). Through the efforts of WHM activists, in addition to other feminist groups, abortion was legalized in the 1973 Roe v. Wade Supreme Court decision. The WHM was becoming a powerful political force and soon after the Roe v. Wade ruling developed a comprehensive approach to women’s health that covered all areas, not just reproductive, that is still use today.

The WHM has since advanced significant changes in medicine to address the unique needs of women. This includes such personal victories as taking an active voice in their healthcare by standing up to condescending male physicians to radically changing childbirth practices by providing alternative birthing methods in which the partner could participate and less medical intervention was required. Midwives, once again, became an option and childbirth organizations like Lamaze International and the International Childbirth Educational Associations were formed as specialized birthing centers began appearing to meet the rising demand for a more humanistic approach to childbirth.

Women's Health & Genomics

Despite today's political and racial tension, the overall DNA differences in men of different races is insignificant. However, the difference in DNA between men and women is considerable! When the DNA activity (and subsequent downstream impact) of two men are compared, we see they, pretty much, do the exact same thing in both. But ... when making the same comparison between a man and a woman, the behavior is very different.

dna and chromosomes in a cell
The overall DNA differences in men of different races is insignificant, however, the differences in DNA between men and women is considerable!

Remember from "genetic susceptibility" in the Environmental Medicine section that men (XY) get an X chromosome from Mom and a Y chromosome from Dad. Every cell in their body is expressing genetic traits contained in the dominant X chromosome. In women (XX), one of their two X chromosomes (one from each parent) is expressed and the other kept silent, however, which one is silenced varies from cell to cell and tissue to tissue. This means either X chromosome may express in any cell and, therefore, express differently for the same trait in every cell. In humans, the decision for which X is expressed is random. The paternal X has the same chance as the maternal X. This is called mosaicism and is a characteristic common to all women.

Mosaicism is often explained using the Calico Cat analogy. Ever notice that calico cats are usually girls? Both chromosomes the male recieves from its parents contain genetic information on the color of his coat, but the weaker Y chromosome from Dad is dominated by the X chromosome from Mom so only the coat colors encoded in the maternal X chromosome will express. This means the color of his coat is determined by only the X chromosome and it will be the same in each cell. In female cats, however, there are two X chromosomes and either can express at any time. That means each cell can express more than one color. This is what gives calico cats their "mosaic-like" patterns and why they are almost always female.

Some women express their maternal X 62% of the time and the paternal X 38% of the time. Men don’t do that. This begs the favorite Dr. Knight expression, "With greater sophistication, comes more complication!”

Life Stages

A Woman's Lifetime Journey

Puberty

Men in a boat fishing at sunset
"Puberty" is defined as the beginning of the ability to reproduce.

"Puberty" is defined as the beginning of the ability to reproduce. Typical puberty includes breast bud development between the ages of 8 to 13 but most commonly between 10 ½ to 11 years of age. It’s the first sign of sexual development, however, underarm and pubic hair can occur quite earlier. This doesn't necessarily indicate puberty will happen sooner. Breast development before age 8 is considered "precocious puberty" and none by age 13 is considered "delayed puberty."

To describe where one is at in the stages of development pediatricians refer to the Tanner Scale. There is a scale for breast development, male genital development and female pubic hair development. Pubic hair usually lags breast development but as already stated that’s a more variable presentation. The peak of the growth spurt in girls is usually around 9 to 12 years of age. Girls hitting puberty later will often have a later growth spurt. With the start of menses, the growth typically slows down a lot, but they can still grow 2 to 3 inches following menarche.

MENSTRUAL CYCLES

Women's hygiene products
Although the average menstrual cycle is 28 days long, it can last from 21 to 45 days.

Welcome to womanhood and monthly bleeding. If your cycle is every 28 days and you only bleed a few days and never heavy, congratulations! The average woman’s cycle is 28 days long. That means some months it occurs twice ... which is still normal. Although calendar months are longer than 28 days, they are roughly based on lunary cycles, which occurs every 28 days, same as menses. Dividing 365, the number of days in a year, by 28 give us 13 cycles annually.

During the menstrual cycle, luteinizing hormone (LH) and follicle stimulating hormone (FSH) are released from the pituitary gland in our brain and control the cycle. The pituitary sits behind the eyes and controls everything hormonal. From this area of the brain is the control of our “rhythms”.

Although the average menstrual cycle is 28 days long, it can last from 21 to 45 days. In general, the closer to 28 days the better the fertility. Although gynecology considers a cycle regular if it’s coming every 24 to 38 days, that's not quite accurate. The length of the cycle is actually counted from "day 1" of menses to the next "day 1" of menses. When asked about your last menstrual cycle, the correct answer starts at the first day of the last period, not the last day. Now there are apps available to track your cycle, a huge improvement, especially those that can predict the start of menses for those who are irregular.

The hilarious comic below by Jorge Munoz, a cardiac electrophysiology PA as well as author and illustrator at medcomic.com skillfully depicts what happens during the menstrual cycle. You should check out his work!

Menstrual cycle process comic

The purple guy is the oocyte gradually increasing and making more estrogen from FSH stimulation initially, then an LH surge slaps the oocyte and knocks the egg right out, that’s also called mittelschmerz ... the pain of ovulation. Not everyone feels it but many do. Then the corpus luteum (former home of the egg) now makes progesterone to prepare the uterus for implantation if the egg gets fertilized by sperm. If the egg isn’t fertilized the corpus luteum shrinks and disappears and the lining is shed. This is called menstruation. The days between ovulation and start of menstruation are fixed at 14 days. If a woman’s cycle is typically 21 days, she ovulates on day 7 and should NOT use birth control that has a 7-day break or 7 days of blanks. She is fertile on birth control and needs a 24-day approach.

A longer cycle especially when it’s around 35 days or longer is more often associated with anovulatory cycling, meaning no ovulation. This is often a sign of Polycystic Ovarian Syndrome.

Reproductive Years

Pregnant woman
Ideally, women plan their pregnancies.

Ideally, women plan their pregnancies. Birth control was championed by Margaret Sanger, an obstetrical nurse, she had seen the plight of factory women at the turn of the century in the poorest boroughs of New York City and it inspired her work towards women haven’t the right to decide whether or not to have a child and the right of a child to be wanted. She also published pamphlets, called Family Limitation in 1914, and it was illegal. She started the first birth control clinic, it was raided and shut down in 1916 and she was jailed. But the publicity her trials generated only furthered her cause. She was likely inspired even more so by losing her own mother at 40 years of age after 18 pregnancies that produced 11 children. But it was the story of Sadie Sachs that was the turning point. The 28-year-old wife of a truck driver and mother of three, was near death from blood poisoning following a self-induced abortion. Sanger attended her for two weeks before the crisis was past and three weeks before she could leave the apartment. When the doctor was there, Sadie asked, “Another baby will finish me, I suppose?” The doctor strongly agreed, “Any more capers, young woman, and there’ll be no need to send for me.” “I know doctor, but… what can I do to prevent it?” The doctor retorted, “You want your cake and to eat it too, do you? … Tell Jake to sleep on the roof.” Sanger would be forever haunted by the look of desolation on Mrs. Sach’s face. Not long afterward, the telephone rang, and Jake’s agitated voice begged her to come at once, but Sadie died within minutes of her arrival and Sanger made her decision that day. She would not go back to merely keeping people alive.

The wealthier women back then used condoms and withdrawal methods. Many poor women complained that they couldn’t get men to use them and wanted a method they could use themselves. Women and children routinely worked 60 hours a week at this time and poor women suspected they were kept in the dark to produce more workers. The lower a man’s earning potential back then the higher risk for his children to die and the bigger the family size the more infant deaths.v

Opposing women’s rights to birth control was Anthony Comstock. “Comstockery” was a type of thinking about sexuality and way of using the law that held the US from moving forward from 1873 to 1936 but Sanger would triumph over Comstock. Comstock lobbied through Congress a law banning pornography and included information and devices for the prevention of conception, which he characterized as lewd, filthy, obscene, and disgusting. He got himself named as a special agent of the U. S. Post Office, with the power to arrest and confiscate material. He declined a salary and instead worked for a percentage of the fines he imposed. He boasted that he convicted 3,760 people, destroyed 160 tons of material, and drove 15 people to suicide. He tricked a doctor and jailed him for six years after the doctor answered an ad that was a plea for contraceptive advice but really Comstock. He arrested a shop owner that left a mannequin undressed in the window.v

George Bernard Shaw, who called birth control “the most revolutionary idea of the century,” quipped that Comstockery is the world’s standing joke at the expense of the United States.” v Comstock not knowing who Shaw was called him a smut dealer and tried to suppress his plays. Sanger tried to get help from Suffragists and Union leaders but neither group helped. Doctors were of no help either, she suspected they knew as little as her and it was illegal to discuss what they did know.

Sanger felt the matter was of utmost importance, at the time women were dying where two million illegal abortions occurred annual and many were fatal. 25,000 women died during childbirth as well, many succumbing to a weak condition after several children conceived and birthed in succession. She went to France to learn how they were declining their birth rate over the past three generations. She was there only a month and learned of the solutions, suppositories, and tampons that women used and passed down to their daughters, a family prized recipe, and returned to publish it in 1914.

Maragaret Sanger
Margaret Sanger, pioneer in Woman's Rights and birth control

She started a monthly newsletter called The Woman Rebel. It urged women to rebel against all forms of slavery, especially biological. She was against child labor, having too many babies, and the Comstock law. She had not disclosed how yet, but just talked about why birth control was so needed. Comstock still sought her out and arrested her. She had little time to think and decided to write everything she learned down in a pamphlet she called Family Limitation. She had 100,000 printed and found temporary homes for her three children. She fled to England and cabled her friends to mail the copies of Family Limitation, deliberately sending one to the judge that was appointed for her trial and hostile towards her. Now in England she studied everything she could find on the subject. She visited the world’s first birth control clinics in the Netherlands. The Netherlands had the lowest maternal death rate and the US had the highest at that time. The Netherlands also had the lowest urban death rate for babies. They also had the lowest level of prostitution, venereal disease, and illegitimacy. She wrote her heart-broken husband and divorced stating she required freedom to pursue her cause. Ironically, William Sanger was the first martyr of the cause. He was tricked by Comstock into giving her pamphlet to a man posing as an old friend wanting birth control information and gave him one of his wife’s pamphlets. He was arrested and jailed by Comstock for 30 days when he wouldn’t disclose his wife’s whereabouts.

The pamphlet and her year of exile achieved great publicity about censorship of family planning information. Her oldest daughter fell sick with pneumonia right before her trial and died. Margaret had cared for her constantly to no avail and was numb with grief when her trial commenced. The public and social registers rallied to her side with 97% favoring the availability of birth control. Clarence Darrow volunteered his services but Sanger refused his help as well as his advice to plead guilty for a lighter sentence. She appeared as her own defense and the government finally dropped the case to avoid making her a "martyr".

She didn’t feel victorious, though, because the right to birth control was still not everyone’s right. She went on a a nationwide lecture tour and organized affiliates for her birth control league that eventually became Planned Parenthood. Lecture fees and royalties from her many books and pamphlets provided what little income she had. She also opened the first clinic in 1916. She couldn’t find a willing doctor to staff it so she and her sister, Ethel Byrne, also a nurse, did the work. Women from New Jersey, Pennsylvania, and Massachusetts came to her clinic in New York. At the clinic, female patients atteneded educational workshops and were fitted for diaphragms. Statistics compiled from patient data became the first research on women and pregnancy and helped substantiate her case. Of course, the clinic was illegal. Ten days after it opened it was raided and closed by the NYC Vice Squad. Sanger was arrested and spent the night in a rat-infested cell but posted bail and resume business the next day.

She looked forward to her trial but her sister’s trial came first where she was sentenced to 30 days in a workhouse. While incarcerated, Byrne refused to eat or drink, announcing she would die for the cause. After 185 hours of fasting, it was ordered that she be force fed. Ethyl was released under the conditiion that she would not continue to operate the clinic and Sanger nursed her back to health. The newspapers speculated that “the youth of 1967 will not believe a woman was imprisoned for this in 1917.”

Sanger than faced her own trial. She was also sentenced to the workhouse, but they didn’t want another situation like Byrne, so she was sent to jail instead. In 1918, the court of appeals provided what Sanger had long sought, an interpretation that applied the words “prevention or cure of disease” to women and pregnancy where it had previously only covered men and venereal disease.

Mainstream medicine, the behemoth, still didn’t want to take on birth control. Undeterred, Sanger hired a doctor to travel the country and teach contraception to interested physicians. She kept a list of these physicians and referred women that reached out to her to the nearest one. She also reopened her own clinic in 1923 where it was staffed by a woman doctor willing to work without pay since there were no available funds. Dr. Hannah Stone’s competent care and eloquent statistics helped reverse the public attitude about contraception. Dr. Stone noted that her patient population mirrored the community where her clinic resided, 38% Protestant, 32% Jewish and 29% Catholic. Of her 1,655 patients, 1,434 had aborted themselves regularly, one woman had done it 40 times.

In 1929, Sanger's clinic was raided again and Dr. Stone’s records were confiscated. This time, however, the medical establishment saw the confiscation of records as a violation of privacy between patient and physician and stood behind Dr. Stone. The charges were eventually dropped.

In 1922, Sanger married a millionaire. He was 13 years older than her and held a conservative ideology but they had an agreement in which she would maintain her independence personally and professionally, perhaps he soon realized that he may have signed up for more than he bargained for when he became her partner in crime. Diaphragms weren't manufactured in the US and he helped her smuggle them in from Germany. They were shipped from Germany to Canada and hidden in boxes of 3-in-1 oil. He eventually funded a company to make diaphragms in the US. In 1936, Sanger established the rights of doctors and other qualified professionals to use the mail and common carriers for health education literature, her final victory. Interestingly, the word "contraceptive" wasn’t removed from US obscenity statutes until 1971. Sanger lived her final years in Tucson, Arizona, dying at the age of 86 in 1966. Her two sons both became doctors.

We should recognize that it was not that long ago that women had neither the right nor the means to control contraception. Without these rights , women would not be able to have careers, pursue education past high school, have a healthy number of children and live to enjoy them. We all benefit when women have equal rights.

Childbirth may be a natural thing, but it can often go wrong as well. It’s an area that we would advise you carefully choose your path. As far as contraception goes, we can implant IUDs and remove them. We no longer implant Implanon®, however, because very few women liked them and we removed as many as we put in. We also can prescribe birth control pills, patches, and rings, but the beloved diaphragm is a lost art.

Menopause

Woman relaxing

Menopause is preceded by “perimenopause” which is when changes in the monthly cycle become apparent but they still continue. For some women this will be brief and for others it will last years. During perimenopause it's not uncommon for flow to be heavier or lighter and cycles to come closer together or farther apart. PMS symptoms may get worse, sleep suffers, moods swing and hot flushes can begin. Although this is expected, it's also important to consider seeing your doctor to make sure it’s not a sign of thyroid problems. Many women have had hysterectomies for heavy bleeding and later learned they were simply hypothyroid. Signs of thyroid dysfunction include changes in menstrual cycles, hot and cold intolerance, changes in mood, plus additional symptoms similar to menopausal symptoms. T

Disease Affects on Women

Our DNA makes about 20,000 different genes. To see how active they are, scientists measured the RNA made by 18,670 genes (a very good representation) in 53 different tissues from 544 adults, postmortem. The donors consisted of 357 men and 187 women. Over 6,500 of the same genes differed in expression and activity based on gender. These distinctions represent about 1/3 of all genes and it, therefore, can be argued that women are "33%" different than men. As such, it can be concluded that diseases also affect men and women differently ... and they often do.

Heart Disease

As recent as the early 2000s, it was well recognized that women were often underdiagnosed with heart disease until it was too late. This was especially problematic since cardiovascular disease (CVD) was and still is the leading cause of death among women in the United States. About 1 in every 3 to 1 in every 5 women die each year from heart disease. Heart disease often presents differently in women and it occurs later in life.

Most women don't consider cardiovascular problems during their reproductive years but advances in technology over the last 30 years has had very little impact on the number of women in that age group that die each year from heart disease while every other age group has seen a significant decline. As of 2012, however, almost half of women surveyed had no idea that heart disease is the number one killer of women.

Although men have more heart attacks then women, women are more likely to die fecause of smaller blood vessels and less collateral formation. Women also have higher bleeding complications from angioplasty and are more susceptible to drug-induced arrythmias.

Torsade de Pointes (TdP) is a type of arrythmia that affects women more than men and is usually fatal but, thankfully, rare. TdP describes an abnormal timing interval between the moment the heart ventricle contracts and relaxes and refills (QT interval). Several drugs have a side effect of potentially prolonging the QT interval and 70% of drug induced TdP occurs in women. Many present with atypical symptoms or no symptoms at all. Others have dull and heavy or sharp chest pain which can radiate to the jaw, neck, throat, upper abdomen or upper back. This condition is considered angina and is often accompanied by nausea, vomiting, and/or fatigue. Angina symptoms often initially only appear during activity but is considered unstable angina when symptoms begin to occur at rest. This is a very dangerous sequence of events and should be considered heart disease until proven otherwise.

Women are more likely then men to have a coronary spasm without having coronary artery disease. Although medical specialists frequently recommend a low-dose aspirin regiment for men over 50 (for those not susceptive to gastrointestinal bleeding), it's not as much as a no-brainer for women. The Women’s Health Study (WHS) involved 40,000 women over the age of 45. Each participant was randomly assigned a daily 100mg dose of aspirin (ASA) or a placebo. The decade-long study found that ASA significantly lowered the risk of total stroke by 17% (CI, 0.01-0.31) and the risk of ischemic stroke by 24% (CI, 0.07-0.37) in women, however, showed no reduction in deaths from heart attacks (myocardial infarctions [MI]) or coronary artery disease. This contrasts to men, where aspirin significantly reduces the risk of MI but neutral with respect to stroke. Although some recommend an aspirin regiment for both genders beginning at 50, we recommend women only start if their risk for heart disease on the Framingham Risk Score exceeds 10% or are 65 or older. Men should start at 50 but only if they don’t have an elevated risk of bleeding.

cancer

Cancer is the number one cause of death worldwide. Gender plays a crucial role in the incidence, prognosis, and mortality in a variety of cancers, some of which only occur in one gender or the other (breast cancer is not one of these ... 5% of breast cancer cases occurs in men.) Although men are excluded from uterine or cervical cancers (just as women are from prostate and testicular cancer), from 2009 to 2013 the incidence of cancer was 20% higher and the mortality (death) 40% higher in men.

Lung, stomach, liver, bladder, leukemia, and colorectal cancers occur more in males, however, women tend to develop more right sided colorectal cancer which is associated with a higher severity. Thyroid cancer also occurs more in females.

Early on, clinical trials for some cancer treatment only studied males (such as chemotherapy). As a result, women experience more adverse drug reactions to a lot of anticancer drugs. Women are typically less tolerant of chemotherapy then their male counterparts.

Anti-cancer drugs that affect genders differently

  • 5-Fluorouracil - Females experience higher toxicity
  • Paclitaxel - Females more likely to experience leukopenia (reduction in white blood cells)
  • Cisplatin - Females more likely to experience nausea
  • Bevacizumab - Females experience higher rates of abdominal pain, severe hypertension, and neutropenia
  • Rituximab - Female has better survival rates in certain types of lymphoma

Alcohol Abuse

Millions of women in the United States abuse alcohol, putting their health, safety, and general well-being at risk. While men are more likely to become dependent on or addicted to alcohol than women are throughout their lifetime, the health effects of alcohol abuse and alcoholism (when someone shows signs of addiction to alcohol) are more serious in women. These health effects include an increased risk for breast cancer, heart disease, and fetal alcohol syndrome, in which infants born to mothers who drank during pregnancy suffer brain damage and learning difficulties.

Depression

Women are more likely to show signs of depression and anxiety than men are. Depression is the most common women's mental health problem, and more women than men are diagnosed with depression each year.

Osteoarthritis

Osteoarthritis is the most common form of arthritis. It causes joint pain, stiffness, and swelling. Arthritis is the leading cause of physical disability in the United States. The condition affects millions of people in the United States and seems to effect more women than men.7

Sexually Transmitted Diseases

The effect of STDs/STIs on women can be more serious than on men. Leaving STDs/STIs untreated can cause infertility in women. STDs/STIs often go untreated in women because symptoms are less obvious than in men or are more likely to be confused with another less serious condition, such as a yeast infection.

Stress

According to a recent survey by the American Psychological Association, stress is on the rise for women. According to a survey by the American Psychological Association (APA), stress is on the rise for women. For example, almost 50% of all women in the APA survey reported that their stress had increased over the past 5 years, compared to 39% of the men.9 Stress also has unique effects on women. A recent NICHD study found that stress might reduce a woman's chance of becoming pregnant.10

Stroke

More women than men suffer a stroke each year. Although many of the risk factors for stroke are the same for men and women, including a family history of stroke, high blood pressure, and high cholesterol, some risk factors are unique to women.

Causes of women's increased risk for stroke

  • Taking birth control
  • Being pregnant
  • Using hormone replacement therapy
  • Having frequent migraine headaches
  • Having a thick waist (larger than 35.2 inches), particularly if post-menopausal, and high triglyceride (blood fat) levels

Endocrinology

Control of our body systems is largely achieved through two systems the nervous system and the endocrine system. The nervous system makes lightning fast or faster changes. The endocrine system releases hormones that work more slowly but also affect the entire system. The endocrine system includes the glands that make the hormones as well as their interconnection through feedback loops and distant target organs. The master gland or hypothalamus-pituitary gland controls them all and is connected to our central nervous system and is located right behind our eyes. From this very important location, it drives all our hormonal processes and is influences by the nervous system as well. The organs of the endocrine system secrete their hormones into the blood stream rather than into a duct system. The glands of the endocrine system are therefore ductless, unlike for instance, the pancreas head which has ducts that carry digestive enzymes to the gut. But the tail of the pancreas is part of the endocrine system and secretes Insulin and Glucagon into the blood stream.

The endocrine system is almost completely controlled by feedback loops. Feedback loops work toward homeostasis. Homeostasis is where the body attempts to keep everything in status quo or in balance.

The hormone messengers fall into three categories based on their chemical structure:

Amines

Amines are derived from single amino acids. Amino acids are the protein building blocks that contain carbon, hydrogen, oxygen and an amine group or NH3. Norepinephrine, epinephrine, and dopamine are all examples of catecholamines. Thyroid hormones are unique amines that also contain iodine molecules.

Peptide and proteins

Peptide hormones and proteins consist of 3-200 amino acid residues and can be very large. All pituitary hormones such as Thyroid Stimulating Hormone and Follicular Stimulating Hormone are peptide hormones. Leptin from fat cells, ghrelin from the stomach, and insulin from the pancreas are also peptide hormones.

Steroids

Steroid hormones all are formed from cholesterol. Our steroid hormones are grouped into five categories based on the receptors they bind: glucocorticoids, mineralcorticoids, androgens, estrogens, and progestogens. Vitamin D3, cholecalciferol, and Vitamin D2, ergocalciferol, are fat-soluble secosteroids and are therefore pseudo-steroids but act as hormones as well.

Pituitary Hormones

pituitary gland image
The pituitary gland has two parts, the anterior pituitary or adenohypophysis and the posterior pituitary or neurohypophysis.

The pituitary gland has two parts, the anterior pituitary or adenohypophysis and the posterior pituitary or neurohypophysis. Those fancy names are never used but from their root you can hopefully guess that the anterior pituitary received signal from the hypothalamus that either stimulate or suppress release of hormones. The posterior pituitary is not glandular, meaning not stimulated by hormones, instead it’s stimulated by neurons from the hypothalamus that secrete neurophyseal hormones, oxycotin and vasopressin. That sounds very similar, but the difference is the anterior part is largely regulated by feedback loops. The posterior part is controlled by the nervous system. If you could see them under a microscope they differ a lot in tissue structure.

Anterior Pituitary Hormones

ACTH Adrenocorticotrophic hormone stimulates the adrenal gland production of cortisol, aldosterone and DHEA (glucocorticoids, mineralcorticoids, and androgens).

TSH Thyroid stimulating hormone stimulates the thyroid gland production of thyroid hormones, 90% of that being T4 or levothyroxine and much less T3 or liothyronine.

FSH Follicular stimulating hormone and LH Luteinizing hormone together control the menstrual cycle in females and the production of sperm in males. They also influence the reproductive system's maturation.

GH Growth hormone guess what? Promotes growth. It also affects lipid and carbohydrate metabolism and is released primarily during sleep.

PRL Prolactinsecretion is involved in milk production, but also plays a role in spermatogenesis, prostate hyperplasia, and secretion of estrogens and progesterone. Prolactin levels when raised also negatively affect TSH and ACTH.

Hypopituitarism

Hypopituitarism is characterized by reduced secretion of some or all the hormones. It can be congenital or occur from trauma or blood loss associated with childbirth. It can also occur from tuberculosis and syphilis which makes us wonder about Borreliosis as well. Dr. Knight did research in early 2000 looking at a connection between growth hormone deficiency and Fibromyalgia and identified a subset that was attributed to GH deficiency with incredible improvement with GH replacement. Politics of medicine interfered when the Endocrinology Societies feared misuse of growth hormone treatment could happen when used by non-Endocrinologists and passed guidelines that promoted only Endocrinologists could diagnose GH deficiency which led to the end of that program.

This did nothing to stop the misuse of growth hormone in the anti-aging clinics but stopped non-endocrinologists from legitimate use in patients with proven growth hormone deficiency which for some reason most adult endocrinologists are not interested in pursuing or treating! Another paradox in medicine.

Other forms of hypopituitarism include pan-hypopituitary which means absence of all the hormones and usually is a result of trauma, brain surgery, stroke, hemochromatosis (condition of too much iron in the blood), sarcoidosis, infections, or pituitary resection of a tumor. Fortunately, a rare condition despite so many causes.

Hyperpituitarism

Hyperpituitarism or over secretion is most often associated with a benign tumor of the pituitary gland called a pituitary adenoma that typically over secretes prolactin. This condition is referred to as hyperprolactinemia and the tumor is called a prolactinoma. But tumors can secrete more than just prolactin, as is found in Cushing’s disease where ACTH is also secreted in abundance. It can be oversecreted continuously or intermittently. The latter being much harder to diagnose. Acromegaly is the result of excess growth hormone secretion and Andre the giant is a well-known person that had this condition. He showed the features of gigantism, due to GH secretion in excess as a child, and acromegaly, from continued excess secretion in adulthood. He stood 6’ 0” at 14 years of age and was 6’ 7” just a year later! His final height was said to be 7’ 4”. Acromegaly is best appreciated by seeing pictures of person overtime and observing the broadening of the jaw and their teeth moving farther apart. Their hands and feet also continue to grow.

If you want to learn more about Acromegaly and how it's treated, follow this link Acromegaly Treatment.

Cushing’s disease vs. Cushing’s syndrome

Cushing’s syndrome is a disorder due to excess cortisol. It can be caused by taking too much cortisol or steroids, but it can also result from our body producing too much cortisol, a condition known as Cushing’s disease. The symptoms of Cushing’s syndrome include “moon facies” or rounding and fattening of the face, upper body obesity, a hump like protrusion called a buffalo hump at the top of the thoracic spine, thin arms and legs, severe fatigue and muscle weakness, high blood pressure and high blood sugar, easy bruising, and purple colored stretch marks called striae.

This does not cover all the possible problems with pituitary gland function but, thankfully, other conditions are relatively rare. Next up are thyroid disorders and they are not only not rare, but in the midwest "goiter belt", where we're located, thyroid disease is prevalent. This is because 2.6 million years ago, glaciers covering much of the Midwest ground their way north carrying layers of idione-rich soil along for the ride. Iodine is an important element in the production of thyroid hormones. The flat landscape left behind is great for farming but was severely depleted of Iodine. Glacial activity, literally, paved the way for much of the thyroid trouble commonly found in North America's heartland.

Thyroid Hormones

Thyroid gland

The butterfly or bowtie shaped thyroid gland is located where the neck meets the chest just above the sternum. Thyroid problems In the 1920s, 30% of school children in the lower Midwest had goiters or enlarged thyroid glands. Public health officials found this was likely caused due to low levels of Iodine in the soil, the result of glacial activity transporting Iodine-containing top soil northward as it created the broad plains of the lower Midwest during the Pleistocen epoch, a period that began 2.6 millinon years ago. In other words, flattened areas of the Midwest have low iodine. To remedy this, researchers looked at ways to add Iodine to our diet. Scientists looked at ways to add Iodine to our diet. They compared adding iodine to salt, as well as using it as a bread preservative. Although the latter worked better, the former won on price and led to the "Iodized Salt" currently found in most kitchen cabinets and dining room tables. Unfortunately, the "low-salt" or "sea-salt" diet wasn't a consideration when salt became the de facto iodine supplement in the early 20th century. Consequently, thyroid disease is on the rise ... again. It’s also more common to develop thyroid problems when moving from an iodine sufficient area (coastal or northern geographies) to the "Midwest Goiter Belt" so we also see more thyroid problems in transplants than salt-eating natives. If you prefer sea salt, be sure to buy iodized sea salt rather than "natural" sea salt. Only a trace amount of Iodine is contained in natural sea salt and it's not enough to meet our needs, especially if you live in the "goiter belt."


Hypothyroidism

Thyroid gland

Typically, endocrine diseases are a result of over or under production of a hormone. Like hypopituitary and hyperpituitary, we have hypothyroidism and hyperthyroidism. The under active form, hypothyroidism, is much more common and easier to treat. Hypothyroidism in the United States is mostly a result of an autoimmune disease called Hashimoto’s thyroiditis. But in the goiter belt, it is as much if not more so from iodine deficiency or a combination of both. Symptoms of hypothyroidism include fatigue, cold sensitivity, constipation, dry skin, weight gain, joint swelling, achiness, depression, anxiety and goiter.

To understand how the thyroid gland is controlled and where things go wrong, consider the adjacent diagram. TSH is sent from the pituitary gland through our blood stream and it interacts with the TSH receptor of the thyroid gland. There it stimulates the thyroid cells to make and release thyroid hormones. Typically, the gland makes 90% T4 and 9% T3 and 0.9% Reverse T3. These percentages are estimates and you will see different numbers in different sources. No matter, it mostly makes T4, also called levothyroxine. Levothyroxine’s activity is limited as it is mostly a prehormone that is activated by conversion to liothyronine by removal of an Iodine molecule. Liothyronine (T3) is the active thyroid hormone. This conversion is done by enzymes called iodinases. Through a similar reaction but by removing a different one of the four Iodine molecules, levothyroxine (T4) can also be converted to Reverse T3, an inactive thyroid hormone. Typically, 40% goes to T3, 40% goes to Reverse T3, and 20% is excreted as T4. This system is thus controlled by both the pituitary gland feedback loop and the activity of these iodinases for the outcome.

Historically, the first thyroid hormone used was T3 or liothyronine before there were labs to monitor levels and once labs were developed it was discovered that it was typically overdosed and caused serious side effects, such as osteoporosis and atrial fibrillation. Then T4 replacement was introduced and found to be much safer and most patients were able to adequately convert the T4 to T3 or so it seemed. We also only had the ability to measure TSH and Free T4 accurately before Free T3, Total T3 and Reverse T3 were available. Another issue is that T4 to T3 conversion happens mainly intracellularly. We can’t truly measure how adequate it is but we can guess. Like so many areas of mainstream medicine, what works for the majority does NOT work for everyone. Experts estimate that at least 30% of thyroid patients on only T4 are being under-replaced and their metabolism is typically running 10% slower on just T4 then before they had hypothyroidism. Most of us feel that losing 10% of our metabolism is a huge disservice.

Janie A. Bowthorpe, a medical educator, had hypothyroidism. She never felt well or resolved her hypothyroid symptoms after being treated with just levothyroxine for 20 years. While applying for social security disability and she began researching hypothyroidism extensively and convinced her doctor to start testing her T3 levels. She also began using dessicated thyroid, an extract created from dried thyroid glands that contain both T4 and T3, and it changed her life. After 20 years of misery using levothyroxine only, Janie made it her life’s mission to educate the public about the madness surrounding thyroid treatment. When patients complained about limited or no improvement in their condition when prescribed only T4, they were often ignored or made to believe that their problems were in their head. She felt that people needed to be made aware of the therapeutic benefits of adding T3 to their treatment regimen. Her books and website continue to be a valuable resource on thyroid and other endocrine illnesses and even teach you how to approach a doctor that still doesn’t know there is more to thyroid than TSH and Free T4. She is a pioneer and deserves credit for awakening us to the important thyroid hormone, liothyronine(T3).

Another reason that TSH and Free T4 fail to adequately explain our current thyroid metabolism level is that the processing of T4 is different in the pituitary gland than in the rest of our system. Only in the pituitary gland does T4 not get converted to Reverse T3. The pituitary gland converts everything to T3 and releases TSH as if all T4 is converted to T3. But wait! Why would our system have what looks like a design flaw? Survival! We are programmed to survive, not necessarily thrive. Hyperthyroidism is much more dangerous than hypothyroidism, therefore our systems evolved to avoid that at all costs if possible. The reverse T3 mitigates hyperthyroidism and does a good job of protecting us. Without, most people would die instantly from hyperthyroidism.

Janie felt better when combining Free T3 and Reverse T3 if the ratio was kept 20:1 or greater. Considering that Reverse T3 is measured as a total, an ENT doctor thought it would be even better to compare the Total T3 to the Reverse T3 and began successfully using ratios for Total T3 to Reverse T3 of 8 - 10 for patients NOT previously being treated with thyroid hormone. We follow a similar track but have found that effective ratios tend to fall between 7 and 14 depending on the patient’s level of anxiety. Currently, we start with 7:10 for those with anxiety or over the age of 80. For anyone that still has fatigue, ratios up to 14:10 can usually be tolerated without any hyperthyroid symptoms or adverse effects on heart rate or bone density as long as the T3’s and Free T4 are within the normal limits.

In endocrinology, everything has a Goldilocks point where thyroid ratios are "just right." Too much or too little of anything can affect outcomes. For example, T3 and T4 both cause fatigue, anxiety and cold intolerance and when either is too high, often leaving patients "wired and tired". Symptoms such as fatigue and hair loss may indicate that thyroid levels are too high or too low. Each person has his or her own Goldilocks point and finding it sometimes requires a lot of testing, measuring and monitoring, however, there is an optimal level for each of us. We were surprised to recently discover that Janie no longer advocates the use of thyroid ratios as we have found them to be far more helpful than the TSH and Free T4. Perhaps, because ratios alone cannot provide the complete picture. Is the T4, possibly, below the lower limit of normal? If so, does it matter for that person? If they feel great, probably not but it still needs to be evaluated on anyone reporting hypothyroid symptoms. Sometimes a doctor needs to be a detective, too.

In addition to thyroid rations, we also look at glucose and lipids for evidence of high or low thyroid levels. When thyroid levels are low, blood sugar rises and so does LDL and triglycerides. Although Janie now says the “normal” range of T4 should be higher than previously suggested, this is contrary to our findings. In most (but not all) patients, when the T4 is in the upper half of the normal range, the reverse T3 is also high so it backfires. None-the-less, everyone is unique. Some patients clearly feel worse when their T4 is low. Remember, we are trying to figure out what is happening inside cells based on blood levels.

Janie now considers a normal Reverse T3 as 8 - 10. If that were true, however, almost no one would have normal thyroid metabolism. In addition, if you push the T4 into the upper half of normal, the reverse T3 will rarely be that low ... it will be in the 20s. Although the consensus for “normal” Reverse T3 is 8 - 25 it's probably closer to 8-14. Most doctors don’t bother with Reverse T3 anyway because it can be skewed by other events and usually requires a little time-consuming prying to appropriately evaluate. For example, two days after the death of her spouse, a patient still came in for her thyroid labs (she was from that generation that keeps their appointments no matter what.) Thanks to her, though, we know that a Reverse T3 of 50 is “normal” for new widows. In 2 months, she returned to the normal “normal.”

Along with traumatic life events, other circumstances can lead to a high Reverse T3, too. Patients within a month after being hospitalized with a serious illness often present with Reverse T3 in the 30s. A recheck in 2 months finds that most have returned to normal. Reverse T3 can also be affected by diet (not eating enough or only eating once a day) and lack of sleep_ and increased by eating too little or not often enough as well as not getting enough sleep. In fact, the Reverse T3 is why the HCG diet (process of injecting human chorionic gonadotropin, a hormone identical to TSH that is present at high levels in early pregnancy, to “fake” the body into making thyroid hormones on 500 calories a day.) Although this may help with quick weight loss, it will eventually cause the Reverse T3 to skyrocket and slow the metabolism to a grinding halt. You may “lose” at first but you really lose when you gain it all back and then some. You can’t cheat the system when it comes to weight loss.

Do cats actually have nine lives? Anyone living on a farm will agree that they do. When a cat is struck by a car, it may go into hiding while it recovers. After being gone for a week or two, it suddenly emerges. Maybe it limps, maybe it used up another life and looks fine ... but either way, its back. In that week in hiding, the cat’s Reverse T3 was through the roof which allowed it to subsist with little regard for food or water and just heal. That is what the Reverse T3 is doing, trying to minimize the need for energy resources for other uses so they can be dedicated to healing and recovery. It does this by slowing everything down. Ever notice that time seems to slow down in during traumatic events, like a car accident, that really only lasted a few seconds? Could that be a sudden spike in Reverse T3?

Despite advances in research and technology and regardless of a lifetime of experience, people are complicated and things occasionally don't respond as expected. Dr. Knight says this happens to keep doctors humble and remind them they are not in charge. We must always judge by unbiased evaluation of symptoms, look at markers for thyroid effectiveness (glucose levels, lipid levels, and gonadal hormones), check adrenal hormones and test Vitamin D. This provides the "big picture." We've found that thyroid levels tend to be easier to manage and replacement doses more effective when the vitamin D level is over 30, the AM cortisol is in the range of 8-16 with acceptable Adrenocorticotropic hormone (ACTH) levels and a mid-range normal dehydroepiandrosterone hormone (DHEA, hormone that helps produce estrogen and testosterone) at age-appropriate levels or over 150. If ACTH and cortisol are above or below our expected range a biotoxin illness (Lyme disease, mold toxicity, cigaterra toxin, etc.) should be ruled out and any potential root causes need to be looked into first or it will be impossible to get the hormones properly balanced. Furthermore, "mismatched" ACTH and cortisol levels may also indicate a possible biotoxin illness. As a rule of thumb, we consider them matched if results comply with the following metrics:

If cortisol is less than 7, ACTH should be greater than 10.

If cortisol is greater than 16, ACTH should be less than 15.

Because of our background in hormonal research, we've always used blood levels for evaluating thyroid levels and they've proven effective. Serum levels are considered the gold standard, however, they are generally cost prohibitive. Saliva levels are helpful for detecting problems with sleep, circadian rhythms, and especially useful in identifying intermittent Cushing’s Syndrome but, overall, are not as reliable as blood levels for most testing.

Hyperthyroidism

Hyperthyroidism is very dangerous. Hyperthyroidism is overactive thyroid hormone production that can result in an elevated heart rate, weight loss, hair loss, diarrhea, oily skin, perspiration, irritability, tremors, eyelid lag, muscle weakness, irregular menses, usually light menstrual flow and bulging eyes. Left untreated, it will lead to death, even in a young, otherwise healthy person. It has been said (and we wish we knew who to credit) that the thyroid system is bridled to the adrenal system, but the thyroid is two racehorses, and the adrenal system is two plow horses. If the racehorses run full throttle, it won’t take long before the plow horses drop. In similar fashion, hyperthyroidism will soon kill the adrenal system.

A few years ago, our community experienced a tragedy when a well-known gymnast died. She mentored many aspiring young gymnasts and was loved and respected by all. She was also soon to be married and it was later learned that she had stopped taking her anti-thyroid medications. They were causing her hair-loss and she wanted to look her very best on her wedding day. Although she was not our patient and we had no personal relationship with her, she was active in our city and, clearly, a very intelligent young woman. This is troubling because, surely, she would not have jeopardized her life had she been warned. If any of our patients have or develop hyperthyroidism, they will have to endure a long lecture on the potential consequences of taking it too lightly just in case the endocrinologist did not. No one is happy when they lose their hair, and some become quite desperate ... but no one should risk death!

Hyperthyroidism often results from another autoimmune disease called Grave’s disease. In fact, Grave’s disease, and Hashimoto’s disease (also an autoimmune disease that causes hypothyroidism) are two ends of a spectrum. Patients can start in the middle and, early in their disease course, vacillate between hypothyroid and hyperthyroid states but eventually will become one or the other. This also occurs when the thyroid is enlarged and nodular (goiter) and one or more nodules are excreting thyroid hormone without regards for the TSH hormone.

Thyroiditis, inflammation of the thyroid, can also cause hyperthyroidism. This is common after having a baby, recovering from a virus or, in rare cases, from painless sporadic thyroiditis a transient variant of Hashimoto’s disease. Postpartum and painless thyroiditis typically have high thyroperoxidase antibodies which are thought to be significantly involved in thyroid dysfunction and the pathogenesis of hypothyroidism, whereas post-viral is usually painful but does produce antibodies. A few even rarer causes of thyrotoxicosis include a TSH secreting pituitary adenoma, gestational thyrotoxicosis (because Beta-HCG and TSH are identical), molar pregnancy, struma ovarii, and widely metastatic functional follicular thyroid carcinoma. Recently, we saw a case of post-viral thyroiditis just 2 weeks after the patient’s ccovid-19 infection resolved.

Hyperthyroidism is treated with thionamides (propylthiouracil and methimazole). These compounds decrease hormone synthesis and, over several weeks, will be effective at controlling hyperthyroidism in 90% of hyperthyroid patients. In Grave’s patients, they also decrease serum TSI and have shown to induce remission. Based on four different randomized controlled trials, 12-18 months was optimal and resulted in long-term remission in 40-60% of Grave’s patients. Toxic nodular goiter, rarely goes into remission, so thionamides are used then for short term management before definitive treatment with radioactive iodine or surgery. Although we send our hyperthyroidism patients to an endocrinologist, we sometimes manage cases if there is a long waiting period. If it's too long, however, we start dialing and complaining.

Adrenal Hormones

Adrenal glands produce hormones that help regulate your metabolism, immune system, blood pressure, response to stress and other essential functions. We have two adrenal glands, one on top of each kidney. It is primarily known for producing adrenaline (also known as epinephrine) to prepare us for "fight or flight" during stressful situations, there are many other hormones released by the adrenal gland adrenal unrelated to stress but critical to our survival.

Adrenal gland

The adrenal gland is made up of two distinct parts, the adrenal medulla and the adrenal cortex each serving a specific function. Although the adrenal system has a feedback loop just as the thyroid, the two regions respond to different nerve centers. The inner part, the medulla, is influenced by the sympathetic nervous system, our "stress response" network (think "s" for "stress"). The parametric nervous system affects the cortex, the 3-layered outer part of the adrenal gland. Each layer is named for the hormones produced within that layer. The outermost layer is the mineralcorticoid or aldosterone production site. Alsdesterone maintains sodium levels in the kidney, salivary glands, sweat glands and colon and plays an important role in managing blood pressure, plasma sodium (Na+), and potassium (K+) levels. Beneath the mineralcorticoid lies the glucocorticoid layer or cortisol production site. In addition to helping with "fight or flight", cortisol manages how your body uses carbohydrates, fats, and proteins as well as controlling the sleep cycle and regulating blood sugar (glucose). The inside layer is the androgen layer which is responsible for producing sex hormones.

Yeah, that got complicated really fast. For our purpose, let’s just focus on the Adrenocorticotropic hormone (ACTH) and cortisol loop. ACTH stimulates the release of cortisol from the adrenal cortex but be aware that ACTH, the dehydroepiandrosterone hormone (DHEA, steroid that converts to estradiol and testosterone), and cortisol are all produced from the same precursor, pregnenolone. Again, this is an oversimplification of a very complex process and the pathway from cholesterol (the basic hormonal building blocks) to hormones has many more steps, however, it's important to understand that cortisol, DHEA and aldosterone are made in the same gland from the same substrate (pregnenolone).

ACTH - Cortisol loop

In stressful situations, the adrenal gland gets "emergency" signals from the brain (specifically, from the hypothalamus and pituitary gland) to produce more cortisol, which also requires more ACTH, as well as more pregnenolone. When the stress is resolved, the adrenal gland gets an "all clear" signal and returns to normal production levels. If the stress does not go away, however, the adrenal gland will continue to make cortisol and, eventually, the pregnenolone supplies will run low. When pregnenolone levels get too low to keep up with the demand, other adrenal hormone production will stop so the pregnenolone needed for their construction can be diverted to producing more cortisol. The brain is broadcasting a "fight or flight" message that demands immediate action. Once the emergency has passed, the adrenal gland can go back to making other hormones. Until then, it's "all hands on deck." This is the "pregnenolone steal phenomenon."

Pregnenolone steal diagram

Since cortisol production takes priority and requires ACTH to stimulate the building process, DHEA pregnenolone gets hijacked and sex hormones (testosterone, estrogen, progesterone) get booted off the assembly line. This creates a hormonal imbalance that can cause PMS, infertility, menopause transition problems, PCOS and a host of other symptoms. Unfortunately, some people stay in "fight or flight" mode all the time, a condition that often accompanies autoimmune and chronic inflammatory disorders.

We usually associate stress with the pressure and anxiety felt when we face such things as money issues, family strife, job pressure, etc., but a lot of stress is health related. Food sensitivities, systemic inflammation, viral infections, digestive problems, autoimmunity and insomnia are all sources of chronic stress and lead to the pregnenolone steal. Many researchers claim there is a limit to the amount of pregnenolone we can produce in a given day and the extremely low levels of cortisol and DHEA create the "adrenal fatigue," a general term used to describe the previously mentioned symptoms.

Recent studies, however, indicate that stress-related health conditions are, literally, in our head (not including specific adrenal-related illness such as Addison's disease or adrenal insufficiency) ! In fact, adrenal glands get larger when dealing with chronic stress situations, implying that they adapt to manage an increased demand for cortisol. Does that mean the pregnenolone steal is a myth?

HPA-axis disfunction diagram

We now know that stress symptoms start in the brain rather than being the unfavorable result of the adrenal gland's inability to keep up with the demand for cortisol New research shows that, outside of adrenal-spacific diseases, hypothalamic and pituitary changes are more responsible for symptoms than the adrenal gland itself. It turns out that our brain determines what is stressful and releases chemical mediators in response through a process called allostasis. Allostasis means the process of maintaining stability by active means," which usually describes increased output of stress hormones as well as other mediators. Allostatic load, expresses the wear and tear on the body caused by allostasis, particulary if allostatsis continues after the stress producing event has ended. In fact, we now know higher cognitive brain areas are targeted by stress hormones and acute and chronic effects can also differ based on things like previous experience with stress, genetic make-up and age. While reduced DHEA and increased cortisol levels often coincide with stress-related symptoms, the cause is comes from regulatory processes in the brain (e.g., feedback inhibitions, receptor signaling, genomic regulation of enzymes, etc.), not a pregnenolone deficiency. Since we now understand that adrenal glands don't fail or become fatigued when the demand for cortisol increases, HPA(hypothalamus-pituitary-adrenal)axis disfunction/disregulation has replaced the term adrenal fatigue.

The Cortisol/DHEA ratio is a recognized and well-studied marker for diagnosing chronic stress. Cortisol is measured through saliva or serum tests and DHEA is a blood test. When checking the overall status of the HPA-axis, in addition to the cortisol/DHEA ratio, we also look at total cortisol output, cortisol awaking response, cortisol diurnal rhythm and total DHEA-sulfate. We find that saliva tests work best when measuring the diurnal and awakening response as some may be "stressed" by the 7-8 lab draws required when using blood tests to acquire the same data. The "artificial" stress will negatively skew outcomes and provide unreliable data.

gonadal hormones

Sex Hormones

The gonadal hormones, also known as sex hormones, are steroid hormones produced in the male testes or female ovaries. They stimulate reproductive organs, germ cell maturation, and secondary sex characteristics in the males and the females. They include estrogens, progesterone, and testosterone. Did you know that men and women make all three? The differences in hormone levels and receptors are what makes us appear male or female.

    most common Gonadal hormone issues at our clinic

  • Delayed puberty or primary amenorrhea
  • Secondary amenorrhea
  • Polycystic ovarian syndrome
  • Menorrhagia
  • Dysmenorrhea
  • Other menstrual issues
  • Premenstrual Dysphoric Disorder
  • Perimenopause
  • Menopause
  • Andropause or Low Testosterone
  • Hypogonadism

The Gonadal System and Puberty

Understanding the gonadal system begins with understanding puberty. Puberty progresses through five stages defined by Professor James M. Tanner. So, of course, they are called the Tanner stages.

Tanner Stage 1

The hypothalamus begins to release gonadotrophin-releasing hormone (GnRH). GnRH travels to the pituitary gland and triggers the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in both boys and girls. Typically, after a girl’s 8th birthday and after a boy’s 9th or 10th birthday. There are no noticeable changes at first.

Tanner Stage 2

GIRLS: The signals increase and girls develop breast buds which are small swellings below each nipple. They may complain of them being itchy or tender, which is considered normal. The areola around the nipple will expand and they are often different sizes. The uterus begins to get larger and pubic hair starts growing on the labia. Pubic hair and maxillary hair can start sooner than breast development and that is a normal variant. Higher body mass index often leads to an earlier onset of puberty. There are also racial differences.

BOYS: The signals increase and the testicles and skin around the testicles (scrotum) begin to enlarge. Pubic hair starts growing at the base of the penis.

Tanner Stage 3

GIRLS: The breast buds grow and expand. Pubic hair thickens and gets curlier. Maxillary hair starts growing. The first pimples erupt on the face or upper trunk. Girls height begins to surge at 3.2 inches per year. Fat starts to deposit on hips and thighs. Average age is 12 years old during this stage .

BOYS: Around 13 years of age, the penis and testicles get larger. Some may begin to form breast tissue under their nipples but it will go away in a couple of years. Boys begin to have nocturnal ejaculation (wet dreams). Their voice may crack as it lowers in pitch. Muscles get larger. Their height increases 2 to 3.2 inches annually.

Tanner Stage 4

GIRLS: At around 13 years old, the breasts take on a fuller shape, passing the bud stage. Many start their first period between 12 and 14 years old, but some start sooner. Height growth slows down to 2 to 3 inches per year. Pubic hair gets even thicker.

BOYS: Now around 14 years old, the testicles and penis continue to enlarge and the scrotum gets darker. Armpit hair starts to grow. A deeper voice becomes permanent. Acne may appear.

Tanner Stage 5

GIRLS: : Breasts reach an adult size and shape, though they may continue to change through the age of 18. Periods become regular after six months to two years. They reach their adult height one to two years after their first period. Pubic hair spreads out to reach inner thighs. Reproductive organs are fully developed. Hips, thighs, and buttocks fill out in shape.

BOYS: Usually they reach this stage around the age of 15. The genitals have reached their adult size, pubic hair has spread and filled in to the inner thighs, facial hair is coming in and they may need to begin shaving, height growth is slowing down, but muscles may still be growing. By 18 most boys have reached their full growth. There are boys that are late bloomers and usually their dad was as well. They start later and grow very fast to make up for lost time.


Understanding Gonadal Hormonal issues

Primary Amenhorrhea

Primary amenorrhea means that a girl has not had any bleeding vaginally, has reached 15 years of age and has developed the normal growth and secondary sexual characteristics described above.

causes of amenhorrea

A girl's menstrual cycle begins between 10 and 15 years of age but, about 180 years ago, puberty used to come later. In the 1840s, the first menses usually occurred between 14 and 17 years of age. One cause for today's earlier puberty is obesity. In recent years, obesity has doubled in children and quadrupled among adolescents. High body mass index leads to earlier puberty. Increased consumption of soda, sweetened fruit drinks, and sweet tea has also been linked to earlier menses in girls independent of their body mass index (BMI).

Secondary Amenorrhea, Athleticism and Anorexia

Initially, menses are irregular for most girls, but they should be regular after 6-24 months. "Regular" is every 24-35 days. Girls that are athletic and have low body fat can develop secondary amenorrhea or absence of menses due to their physical make up. If a girl doesn’t have her menses at least 4 times a year she is at a higher risk of osteoporosis. Functional hypothalamic amenorrhea (FHA) is a type of amenorrhea found in athletes and people with anorexia nervosa. The profile of FHA (with secondary amenorrhea) is a woman with normal cycles became irregular, then stopped altogether after she lost weight, increased physical activity or experienced significant stress. If it happens on multiple occasions and improves with reduced activity, it usually points to a calorie deficit. Comparing BMI at the start of menses to current BMI would be useful when diagnosing amenorrhea but it is important to exclude other causes of amenorrhea, however, this is diagnosed by exclusion. We would, therefore, rule out thyroid disorders, inflammatory bowel disease, Celiac disease, or other disorders detailed separately.

We bring this up here because secondary amenorrhea requires a higher index of suspicion as it can point to potential future health problems. For example, stress fractures in female athletes often indicate the presence of amenorrhea or oligomenorrhea that are reflecting low hormones and a higher risk of low bone density.

Polycystic Ovarian Syndrome (PCOS)

Polycystic ovarian syndrome (PCOS) also causes fewer periods. PCOS is often viewed as a fertility problem but we view it as much more than just a fertility issues since it also raises the risk of Type 2 diabetes, makes weight loss difficult, increases the risk of uterine cancer and is associated with several other women's issues. Women with PCOS are more likely to have irregular periods, acne, unwanted hair growth, heavier menese and obesity. Our approach to PCOS is a little different than gynecologists. We see PCOS as being diagnosed one of four ways:

  1. High fasting insulin (over 17)
  2. High testosterone or DHEA (androgens)
  3. High LH:FSH ratio which is also a sign of insulin resistance
  4. Many small cysts covering the ovary seen on ultrasound or laparoscopy (by a gynecologist)

In adolescents, diagnosing PCOS is more complicated but we usually see this on people in their 20s. Our approach depends on which of the four findings are present. For someone with elevated insulin levels, often the LH:FSH ratio will also be elevated and the androgens will be normal. We would start with metformin which lowers the insulin level and helps with weight loss. Many patients reverse their PCOS when they return to more normal weight.

Not all women with PCOS are overweight, though. If we find androgens are high, we rule out causes of androgen excess that can be reversed such as medications or an adrenal tumor. Testosterone levels are highest in the morning around 8 am so blood should be drawn as close to then as possible. Because oral contraceptives suppress testosterone, PCOS is often overlooked on women using birth control if the cause is high testosterone. For that very reason, oral contraceptives are often used to treat PECOS.

Pregnancy is the most common cause of amenorrhea and always the first test. Other conditions that must be considered and ruled out are thyroid dysfunction, hyperprolactinemia, and chronic disease panel (CBC, CMP, ESR, CRP) checked to screen for other conditions. As mentioned before LH, FSH, estradiol, progesterone, and testosterone are usually tested, if possible, as close to the 19th day of the cycle as we can get but, due to fewer , irregular menses, it's often impossible to time.

Other Considerations:

17-hydroxyprogesterone is a good screening test for nonclassic congenital adrenal hyperplasia secondary to 21-hydroxylase deficiency. This needs to be tested if not amenorrheic during the first 10 days of the cycle. Testing the progesterone at the same time to be certain we’re not testing in luteal phase is helpful.

DHEA Sulfate is included to rule out adrenal tumors. DHEA S levels can be over 700 mcg/dL in girls with virilizing tumors, certainly a level over 400 mcg/dL would bear repeating.

Cortisol should be tested if the patient has centralized obesity as Cushing’s syndrome can mimic PCOS. Growth hormone excess and acromegaly can present like PCOS in the beginning, as well.

Ultrasonography is not routinely used for diagnosis by non-gynecologists and can be a false positive in adolescents. But the reason for doing one is to rule out an ovarian tumor, a rare cause of virilization. Most of our patients are presenting with insulin resistance types and not hirsutism so this is not often required in our work up.

Whenever findings don’t make sense or there is evidence pointing to the possibility of a virilizing tumor, referral to an endocrinologist is in short order. However, we still end up pursuing this from time to time when we can't find a receptive endocrinologist who is willing to do the work up. Stranger things happen all the time.

Dysmenorrhea, menorrhagia, and other menstrual disorders

Our approach to heavy bleeding is to evaluate the thyroid function first. This is a common cause especially if they’ve already seen their gynecologist and didn’t get any answers. For someone not under the care of a gynecologist, we also consider estrogen dominance, looming menopause, fibroids, uterine hyperplasia and malignancy, coagulopathy, "progestin only" pills and intrauterine devices. We rule out causes we can treat, then refer patients to gynecology for further work up and management. We have seen women that were treated with ablation, a procedure to disrupt the path of incorrect electrical signals causing an abnormal heart rhythm by scarring or destroy the path tissue in the heart, without ever having had a thyroid assessment. Turns out they were hyperthyroid, a treatable condition which, if properly managed, may have prevented the need for surgery.

Premenstrual Dysphoric Disorder or PMS

Have you ever noticed how some conditions get a "fancier" name when a drug company comes up with a new medication to treat it? That was certainly the case with premenstrual dysphoric disorder (PMDD) which we used to call premenstrual syndrome or PMS. No matter what you call it, for some women PMS/PMDD can pose severe symptoms that occur every cycle, usually the week before the start of menses. Symptoms include notable depression on awakening, agarophobia, lack of motivation and irritability. An interesting study found that emotional symptoms are relieved on some woman with fluoxetine (genetic Prozac) or sertraline (generic Zoloft) for just that day. Many women experience bloating, constipation, breast enlargement, and tenderness. Headaches and migraines are also common right before the start of the menses due to decreasing estrogen levels and can be avoided by using a topical estrogen gel on those days only.The somatic complaints of bloating, constipation, and water retention make sense with the luteal peak of progesterone. They are helped by the one-time dose of antidepressants.

Screening

Health Screening Recommendations

Preventive health is primarily about screening for illnesses.The US Preventive Services Task Force annually updates their recommendations. These are the most common screenings for adolescents and adults, excluding pregnancy and postpartum recommendations.

Cervical Cancer

Screening is recommended for 21 to 65-year-old women and is done by doing a “pap smear” now called the Thin Prep. This is the main purpose for doing a gynecological exam. Cervical cancer is very slow growing and when caught early very treatable. It’s a shame for any woman to have cervical cancer when it’s so easy to avoid. Past 65 years it’s only continued in those with history of abnormal paps but should be considered if a woman were to have a new partner.

Breast Cancer

Screening is largely done through mammography but there is also a special service for women at higher risk now that incorporates MRI. Unfortunately, they won’t do MRI for patients refusing mammography even if they had breast cancer. It probably is due to an insurance stipulation but how stupid. My patient refuses it because her sister had thyroid cancer felt in part due to mammography.

Prostate Cancer

Screening for this is controversial. We feel the PSA is still helpful as long as you know the normal progression with age and watch for the rate of change. A single PSA is not helpful but over time they can help.

Colon Cancer

Screening either through colonoscopy or Cologuard is recommended for everyone over 50 years of age. Cologuard is a great option for those that are low risk and want to avoid the prep. Recommended ages 50 to 75.

Heart Disease

Screening is done through everyone getting an EKG at 65 yo. But we also encourage people to consider doing a Coronary Artery Calcium score. It’s $100 and a great way to know if you have any plaque in your arteries. Men should consider doing at 50 yo and women at 60 yo.

Lung Cancer

In former and current smokers screening for this started about 5-7 years ago. It’s recommended any time at or after 55 years of age for smokers or ex-smokers with a pack year history of 30 pack-years or more and have smoked within the past 15 years. To calculate your pack years, see this example:

Sally smoked 2 packs per day for 10 years and then cut down to 1 pack a day for five years and then quit. She started at 35 years old (it's not common but we’ve seen it.)

  • 10 yrs x 2 pack/day
  • 5 yrs x 1 pack/day
  • 25 pack years

She technically would not qualify. However, if she smoked 2 packs per day for all 15 years then she would. Now if she also had a spouse that smoked, she would qualify even with a 20-pack year history per the American Association for Thoracic Surgery.

Hepatitis C

Screening is now recommended for 18 to 79 years old as of 2020. At first it was recommended mainly for baby boomers because they have the highest rates, but younger people aren’t that far behind so it’s universal screening now.

Osteoporosis

Screening of all women at age 65 years and men at 75 years. Dr. Knight added the men, but current policies are overlooking them like they used to do for women and heart disease. Screening in women under 65 is also available based on risk assessment.

Abdominal Aortic Aneurysm

Screening in men aged 65 to 75 years who have ever smoked. This was just added December of 2019.

Diabetes Mellitus

screening in adults 40 to 70 that are overweight. Not sure why it would stop at 70? Plus considering there are adolescents now with Type 2 Diabetes Mellitus I start at 25 years of age and anyone younger with a BMI over 30.

Daily Low Dose Aspirin

We recommend an aspirin regiment for men over 50 yo and women over 65. These are different than USTF suggestions but follows scientific research.

Depression

screening for adolescents and adults is recommended. They don’t make any suggestions for how that should be done. Same goes for Domestic Violence, but Dr. Knight did her master’s thesis on this topic so that’s not a problem.

HIV and syphilis

screening should be done for higher risk individuals.

Gonorrhea and Chlamydia

are routinely tested in women under 30 years of age that are sexually active and also higher risk individuals. HIV preexposure prophylaxis should also be offered to those at higher risk.

Smoking Cessation

in adults and education to prevent initiation in adolescents is the newest addition as of April 2020 (the preinitiation part).

Alcohol and Drug Abuse

Screening for unhealthy Alcohol use and drug use is recommended. The latter added June 2020.

High Blood Pressure and Lipids

Screening is recommended for those over 18 years of age for blood pressure and 40 to 75 for lipids.

care for chronic conditions

Managing chronic conditions

medical clinic syringe
In addition to general medical care, PCPs provide education, counseling services and manage most diseases.

Patients with chronic health conditions such as hypertension, hypothyroidism, Type 1 or 2 Diabetes Mellitus, depression, anxiety, fatigue, Fibromyalgia, migraines, chronic pain, and many more need to periodically have lab tests to monitor the disease status and treatment efficacy. The patient will need to schedule an appointment to review the results and discuss any neccessary changes in status or treatment. The time between appointments will depend on the condition and level of control but, generally speaking, these are the rules:

Diabetes Mellitus, Type 1 or 2

Diabetic patients should have labs and follow up every 3 months. Tests should include hemoglobin A1c which reflects blood sugar levels over past 3 months, a complete metabolic profile (liver, kidney, electrolytes, and glucose level), a lipid profile (cholesterol levels), and aurine spot check for protein. The urine is only checked yearly unless it’s abnormal, then it’s repeated every time until it’s normal again.

Hypothyroidism

medical clinic syringe
In addition to general medical care, PCPs provide education, counseling services and manage most diseases.

Initially, treating Hypothyroidism requires frequent lab tests to titrate dosages. Once they're set and we don't need to make further adjustments, we recommend checkups go from every 3 months to every 6 months. If they remain stable over a year, hypothyroid patients can follow up once a year. But, we always tell patients they shouldn't wait if something feels "off". if something isn't quite right, they should move up their checkup appointment. Hypothyroid labs usually include a full thyroid panel (TSH, Free T4, Free T3, Total T3, and Reverse T3) but some patients just don’t need all of that. Why keep checking everything if they're always normal and the patient feels fine? In fact, hypothyroid issues and how a patient feels is usually reflected in the TSH and Free T4 levels.

Starting at midlife and beyond, we still recommend yearly thyroid screening because we live in the Goiter Belt (upper Midwest). This part of the country was flattened by glaciers 20,000 years ago, aprocess that carried off our Iodine-rich topsoil. Because of Iodine depletion, in the 1920's, 30% of school children had goiters ("goiter" just means enlarged thyroid.) The lack of Iodine is what led to the iodination of table salt. Today, manufacturers are using Himalayan salt, Kosher salt, and bottled sea salt without iodine, so the prevalence of thyroid issues here is still much higher than the rest of the US.

Hypertension, Hyperlipidemia and Impaired Fasting Glucose

medical clinic syringe
In addition to general medical care, PCPs provide education, counseling services and manage most diseases.

These conditions are risk factors for leading to diabetes so we recommend patients diagnosed with either have labs, including an impaired fasting glucose test, and check up every 6 months.

Prescription Monitoring

Patients on any prescription medications and/or over the counter medications taken daily should have annual labs and follow up. For those that show a history of stable results (3 years or more) we relax checkups to every other years, however, if they suddenly gain or lose weight or just don’t feel right, they should come in. Age also plays a role in the recommended time between checkups and is considered based on the medication and disease.

Specialized Prevention

Specialized Preventative Exams

medical clinic syringe
In addition to general medical care, PCPs provide education, counseling services and manage most diseases.

Specialized Preventative Exams are employer requested annual visits, report of cholesterol or glucose, school physicals, sports physicals, adoption physicals, life insurance exams and others that are requested for administrative purposes. This can often conflict with insurance regulations or other "wellness visits," especially since most insurance plans only cover one preventive exam a year. This can be an issue if someone did a “annual visit” for work and later told they need an adoption physical. We can usually figure a way to achieve what everyone wants and needs as long as the patient provides us with detailed information about the purpose for the visit ahead of time. If we find out that your insurance will not cover it after a visit has been documented and billed, changing it would be an act of fraud and we simply won't do that. In this case, the patient will be responsible for the bill.

We will never consider a New Patient visit as a "wellness" visit. To be a wellness visit, the patient must have nothing wrong. If anything, and we mean ANYTHING, is prescribed or a diagnosis listed, the encounter will not qualify as "wellness." For example, we once saw a young woman that was generally well but wanted to start oral contraceptives as well as get a refill for her acne medication. Despite the birth control prescription being part of preventative health as defined in the Affordable Care Act, her claim for a wellness visit was denied by her insurance company because of the acne prescription. Conventional wisdom would suggest it would be much more efficient if a patient could get a medication refill and a preventative exam at a single appointment and save a return trip but combining multiple issues but insurance companies see them as separate reasons and, therefore, usually reject the claim in whole or apply a co-pay or deductible to the claim. Insurance companies want to make sure no one gets their quarterly diabetes follow-up for free by booking it as a preventative or annual wellness visit.

Immunization

Immunization recommendations

Shots aren't always a popular topic but vaccinations qualify as preventive health and are an important part of what's discussed during a preventative exam. As most people opt for pharmacies or their employer (for those that work at large companies) for these, we don't keep many on hand as it's difficult to be cost-competitve with large firms like Walgreens or CVS (although we do purchase flu shots at the beginning of each influenza season.) Regardless of where you go for immunizations or vaccinations, they need to be included in the patient chart. Important: Let us know if you were immunized or vaccinated elsewhere so we may keep your records updated.


Vaccine Age 19 - 26 Age 27 - 49 Age 50 - 64 Age 65 or more
Influenza inactivated or recombinant (IIV, RIV) 1 Dose annually 1 Dose annually 1 Dose annually 1 Dose annually
Influenza live attenuated 1 Dose annually 1 Dose annually
Tetanus, Diptheria, Pertussis (Tdap or Td) 1 Dose Tdap, then Td or Tdap booster every 10 years 1 Dose Tdap, then Td or Tdap booster every 10 years 1 Dose Tdap, then Td or Tdap booster every 10 years 1 Dose Tdap, then Td or Tdap booster every 10 years
Measles, Mumps, Rubella (MMR) 1 or 2 doses depending on indication (if born after 1956) 1 or 2 doses depending on indication (if born after 1956) 1 or 2 doses depending on indication (if born after 1956) up to age 60
Varicella (VAR) 2 doses (if born after 1979) 2 doses (if born after 1979) 2 doses starting at age 47 2 doses
Zoster recombinant (RZV)(preferred) 2 doses starting at age 56 2 doses
Zoster live (ZVL) 1 doses if over age 59 2 doses
Human papillomavirus (HPV) 2 or 3 doses depending initial vaccination age or condition 1 dose up to age 45
Pnuemococcal conjugate (PCV 13) 1 dose 1 dose 1 dose 1 dose
Pnuemococcal polysaccharide (PPSV23) 1 or 2 doses depending on indication 1 or 2 doses depending on indication 1 or 2 doses depending on indication 1 dose
Hepatitis A (HepA) 2 or 3 doses depending on vaccine 2 or 3 doses depending on vaccine 2 or 3 doses depending on vaccine 2 or 3 doses depending on vaccine
Hepatitis B (HepB) 2 or 3 doses depending on vaccine 2 or 3 doses depending on vaccine 2 or 3 doses depending on vaccine 2 or 3 doses depending on vaccine
Meningococcal A, C, W, Y (MenACWY) 1 or 2 doses depending on vaccine and indication, booster 1 or 2 doses depending on vaccine and indication, booster 1 or 2 doses depending on vaccine and indication, booster 1 or 2 doses depending on vaccine and indication, booster
Meningococcal B (MenB) 2 or 3 doses depending on vaccine and indication, booster 2 or 3 doses depending on vaccine and indication, booster 2 or 3 doses depending on vaccine and indication, booster 2 or 3 doses depending on vaccine and indication, booster
Haemophilus influenzae type b 1 or 3 doses depending on indication 1 or 3 doses depending on indication 1 or 3 doses depending on indication 1 or 3 doses depending on indication

Notes

Haemophilus influenzae type b vaccination

Special situations

  • Anatomical or functional asplenia (including sickle cell disease): 1 dose if previously did not receive Hib; if elective splenectomy, 1 dose, preferably at least 14 days before splenectomy
  • Hematopoietic stem cell transplant (HSCT): 3-dose series 4 weeks apart starting 6–12 months after successful transplant, regardless of Hib vaccination history

Hepatitis A vaccination

Routine Vaccination

  • Not at risk but want protection from hepatitis A (identification of risk factor not required): 2-dose series HepA (Havrix 6–12 months apart or Vaqta 6–18 months apart [minimum interval: 6 months]) or 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months [minimum intervals: 4 weeks between doses 1 and 2, 5 months between doses 2 and 3])

Special situations

  • At risk for hepatitis A virus infection: 2-dose series HepA or 3-dose series HepA-HepB as above
  • Chronic liver disease (e.g., persons with hepatitis B, hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal)
  • HIV infection
  • Men who have sex with men
  • Injection or noninjection drug use
  • Persons experiencing homelessness
  • Work with hepatitis A virus in research laboratory or with nonhuman primates with hepatitis A virus infection
  • Travel in countries with high or intermediate endemic hepatitis A
  • Close, personal contact with international adoptee (e.g., household or regular babysitting) in first 60 days after arrival from country with high or intermediate endemic hepatitis A (administer dose 1 as soon as adoption is planned, at least 2 weeks before adoptee’s arrival)
  • Pregnancy if at risk for infection or severe outcome from infection during pregnancy
  • Settings for exposure, including health care settings targeting services to injection or noninjection drug users or group homes and nonresidential day care facilities for developmentally d isabled persons (individual risk factor screening not required)

Hepatitis B vaccination

Routine Vaccinations

  • Not at risk but want protection from hepatitis B (identification of risk factor not required): 2- or 3-dose series (2-dose series Heplisav-B at least 4 weeks apart [2-dose series HepB only applies when 2 doses of Heplisav-B are used at least 4 weeks apart] or 3-dose series Engerix-B or Recombivax HB at 0, 1, 6 months [minimum intervals: 4 weeks between doses 1 and 2, 8 weeks between doses 2 and 3, 16 weeks between doses 1 and 3]) or 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months [minimum intervals: 4 weeks between doses 1 and 2, 5 months between doses 2 and 3])

Special situations

  • At risk for hepatitis B virus infection: 2-dose (Heplisav-B) or 3-dose (Engerix-B, Recombivax HB) series or 3-dose series HepA-HepB (Twinrix) as above
  • Chronic liver disease (e.g., persons with hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice upper limit of normal)
  • HIV infection
  • Sexual exposure risk (e.g., sex partners of hepatitis B surface antigen [HBsAg]-positive persons; sexually active persons not in mutually monogamous relationships; persons seeking evaluation or treatment for a sexually transmitted infection; men who have sex with men)
  • Current or recent injection drug use
  • Percutaneous or mucosal risk for exposure to blood (e.g., household contacts of HBsAg-positive persons; residents and staff of facilities for developmentally disabled persons; health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids; hemodialysis, peritoneal dialysis, home dialysis, and predialysis patients; persons with diabetes mellitus age younger than 60 years and, at discretion of treating clinician, those age 60 years or older)
  • Incarcerated persons
  • Travel in countries with high or intermediate endemic hepatitis B
  • Pregnancy if at risk for infection or severe outcome from infection during pregnancy. Heplisav-B not currently recommended due to lack of safety data in pregnant women

Human papillomavirus vaccination

Routine Vaccinations

  • HPV vaccination recommended for all adults through age 26 years: 2- or 3-dose series depending on age at initial vaccination or condition:
  • Age 15 years or older at initial vaccination: 3-dose series at 0, 1–2, 6 months (minimum intervals: 4 weeks between doses 1 and 2/12 weeks between doses 2 and 3/5 months between doses 1 and 3; repeat dose if administered too soon)
  • Age 9 through 14 years at initial vaccination and received 1 dose or 2 doses less than 5 months apart: 1 dose
  • Age 9 through 14 years at initial vaccination and received 2 doses at least 5 months apart: HPV vaccination complete, no additional dose needed.
  • If completed valid vaccination series with any HPV vaccine, no additional doses needed

Shared clinical decision-making

  • Age 27 through 45 years based on shared clinical decision-making:
  • 2- or 3-dose series as above

Special situations

  • Pregnancy through age 26 years: HPV vaccination not recommended until after pregnancy; no intervention needed if vaccinated while pregnant; pregnancy testing not needed before vaccination

Influenza vaccination

Routine Vaccination

  • Persons age 6 months or older: 1 dose any influenza vaccine appropriate for age and health status annually
  • For additional guidance, see

Special situations

  • Egg allergy, hives only: 1 dose any influenza vaccine appropriate for age and health status annually
  • Egg allergy more severe than hives (e.g., angioedema, respiratory distress): 1 dose any influenza vaccine appropriate for age and health status annually in medical setting under supervision of health care provider who can recognize and manage severe allergic reactions
  • LAIV should not be used in persons with the following conditions or situations:
  • History of severe allergic reaction to any vaccine component (excluding egg) or to a previous dose of any influenza vaccine
  • Immunocompromised due to any cause (including medications and HIV infection)
  • Anatomic or functional asplenia
  • Cochlear implant
  • Cerebrospinal fluid-oropharyngeal communication
  • Close contacts or caregivers of severely immunosuppressed persons who require a protected environment
  • Pregnancy
  • Received influenza antiviral medications within the previous 48 hours
  • History of Guillain-Barré syndrome within 6 weeks of previous dose of influenza vaccine: Generally should not be vaccinated unless vaccination benefits outweigh risks for those at higher risk for severe complications from influenza

Measles, mumps, and rubella vaccination

Routine Vaccinations

  • No evidence of immunity to measles, mumps, or rubella: 1 dose
  • Evidence of immunity: Born before 1957 (health care personnel, see below), documentation of receipt of MMR vaccine, laboratory, laboratory evidence of immunity or disease (diagnosis of disease without laboratory confirmation is not evidence of immunity)

Special situations

  • Pregnancy with no evidence of immunity to rubella: MMR contraindicated during pregnancy; after pregnancy (before discharge from health care facility), 1 dose
  • Nonpregnant women of childbearing age with no evidence of immunity to rubella: 1 dose
  • HIV infection with CD4 count ≥200 cells/μL for at least 6 months and no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart; MMR contraindicated in HIV infection with CD4 count <200 cells/μL
  • Severe immunocompromising conditions: MMR contraindicated
  • Students in postsecondary educational institutions, international travelers, and household or close, personal contacts of immunocompromised persons, with no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart if previously did not receive any MMR or 1 dose if previously received 1 dose MMR

health professionals

  • Born in 1957 or later with no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart for measles or mumps or at least 1 dose MMR for rubella
  • Born before 1957 with no evidence of immunity to measles, mumps, or rubella: Consider 2-dose series at least 4 weeks apart for measles or mumps or 1 dose for rubella

Meningococcal vaccination

Special situations for MenACWY

  • Anatomical or functional asplenia (including sickle cell disease), HIV infection, persistent complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use: 2-dose series MenACWY (Menactra, Menveo) at least 8 weeks apart and revaccinate every 5 years if risk remains
  • Travel in countries with hyperendemic or epidemic meningococcal disease, microbiologists routinely exposed to Neisseria meningitidis: 1 dose MenACWY (Menactra, Menveo) and revaccinate every 5 years if risk remains
  • First-year college students who live in residential housing (if not previously vaccinated at age 16 years or older) and military recruits: 1 dose MenACWY (Menactra, Menveo)

Shared clinical decision-making for MenB

  • Adolescents and young adults age 16 through 23 years (age 16 through 18 years preferred) not at increased risk for meningococcal disease: Based on shared clinical decision-making, 2-dose series MenB-4C at least 1 month apart, or 2-dose series MenB-FHbp at 0, 6 months (if dose 2 was administered less than 6 months after dose 1, administer dose 3 at least 4 months after dose 2); MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series)

Special situations for MenB

  • Anatomical or functional asplenia (including sickle cell disease), persistent complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use, microbiologists routinely exposed to Neisseria meningitidis: 2-dose primary series MenB-4C (Bexsero) at least 1 month apart, or 3-dose primary series MenB-FHbp (Trumenba) at 0, 1–2, 6 months (if dose 2 was administered at least 6 months after dose 1, dose 3 not needed); MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series); 1 dose MenB booster 1 year after primary series and revaccinate every 2–3 years if risk remains
  • Pregnancy: Delay MenB until after pregnancy unless at increased risk and vaccination benefits outweighs potential risks

Pneumococcal vaccination

Routine Vaccinations

  • Age 65 years or older (immunocompetent):– see [New Pneumococcal Vaccine Recommendations for Adults Aged ≥65 Years Old]: 1 dose PPSV23
  • If PPSV23 was administered prior to age 65 years, adminster 1 dose PPSV23 at least 5 years after previous dose

Shared clinical decision-making

  • Age 65 years and older (immunocompetent): 1 dose PCV13 based on shared clinical decision-making
  • If both PCV13 and PPSV23 are to be administered, PCV13 should be administered first
  • PCV13 and PPSV23 should be administered at least 1 year apart.
  • PCV13 and PPSV23 should not be administered during the same visit

Special situations

  • Age 19 through 64 years with chronic medical conditions (chronic heart [excluding hypertension], lung, or liver disease, diabetes), alcoholism, or cigarette smoking: 1 dose PPSV23
  • Age 19 years or older with immunocompromising conditions (congenital or acquired immunodeficiency [including B- and T-lymphocyte deficiency, complement deficiencies, phagocytic disorders, HIV infection], chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenic immunosuppression [e.g., drug or radiation therapy], solid organ transplant, multiple myeloma) or anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies): 1 dose PCV13 followed by 1 dose PPSV23 at least 8 weeks later, then another dose PPSV23 at least 5 years after previous PPSV23; at age 65 years or older, administer 1 dose PPSV23 at least 5 years after most recent PPSV23 (note: only 1 dose PPSV23 recommended at age 65 years or older)
  • Age 19 years or older with cerebrospinal fluid leak or cochlear implant: 1 dose PCV13 followed by 1 dose PPSV23 at least 8 weeks later; at age 65 years or older, administer another dose PPSV23 at least 5 years after PPSV23 (note: only 1 dose PPSV23 recommended at age 65 years or older)

Special situations for adults aged 65 and older

  • PPSV23 for adults aged ≥65 years. ACIP continues to recommend that all adults aged ≥65 years receive 1 dose of PPSV23. A single dose of PPSV23 is recommended for routine use among all adults aged ≥65 years (1). PPSV23 contains 12 serotypes in common with PCV13 and an additional 11 serotypes for which there are no indirect effects from PCV13 use in children. The additional 11 serotypes account for 32%–37% of IPD among adults aged ≥65 years (22). Adults aged ≥65 years who received ≥1 dose of PPSV23 before age 65 years should receive 1 additional dose of PPSV23 at age ≥65 years (2), at least 5 years after the previous PPSV23 dose (Table 1) (5).

Tetanus, diphtheria, and pertussis vaccination

Routine Vaccination

  • Previously did not receive Tdap at or after age 11 years: 1 dose Tdap, then Td or Tdap every 10 years

Special situations

  • Previously did not receive primary vaccination series for tetanus, diphtheria, or pertussis: At least 1 dose Tdap followed by 1 dose Td or Tdap at least 4 weeks after Tdap and another dose Td or Tdap 6–12 months after last Td or Tdap (Tdap can be substituted for any Td dose, but preferred as first dose); Td or Tdap every 10 years thereafter
  • Pregnancy: 1 dose Tdap during each pregnancy, preferably in early part of gestational weeks 27–36

Varicella vaccination

Routine Vaccination

  • No evidence of immunity to varicella: 2-dose series 4–8 weeks apart if previously did not receive varicella-containing vaccine (VAR or MMRV [measles-mumps-rubella-varicella vaccine] for children); if previously received 1 dose varicella-containing vaccine, 1 dose at least 4 weeks after first dose
  • Evidence of immunity: U.S.-born before 1980 (except for pregnant women and health care personnel [see below]), documentation of 2 doses varicella-containing vaccine at least 4 weeks apart, diagnosis or verification of history of varicella or herpes zoster by a health care provider, laboratory evidence of immunity or disease

Special situations

  • Pregnancy with no evidence of immunity to varicella: VAR contraindicated during pregnancy; after pregnancy (before discharge from health care facility), 1 dose if previously received 1 dose varicella-containing vaccine or dose 1 of 2-dose series (dose 2: 4–8 weeks later) if previously did not receive any varicella-containing vaccine, regardless of whether U.S.-born before 1980
  • Health care personnel with no evidence of immunity to varicella: 1 dose if previously received 1 dose varicella-containing vaccine; 2‑dose series 4–8 weeks apart if previously did not receive any varicella-containing vaccine, regardless of whether U.S.-born before 1980
  • HIV infection with CD4 count ≥200 cells/μL with no evidence of immunity: Vaccination may be considered (2 doses, administered 3 months apart); VAR contraindicated in HIV infection with CD4 count <200 cells/μL
  • Severe immunocompromising conditions: VAR contraindicated

Zoster vaccination

Routine Vaccination

  • Age 50 years or older: 2-dose series RZV (Shingrix) 2–6 months apart (minimum interval: 4 weeks; repeat dose if administered too soon) regardless of previous herpes zoster or history of ZVL (Zostavax) vaccination (administer RZV at least 2 months after ZVL)
  • Age 60 years or older: 2-dose series RZV 2–6 months apart (minimum interval: 4 weeks; repeat if administered too soon) or 1 dose ZVL if not previously vaccinated. RZV preferred over ZVL (if previously received ZVL, administer RZV at least 2 months after ZVL)

Special situations

  • Pregnancy: ZVL contraindicated; consider delaying RZV until after pregnancy if RZV is otherwise indicated
  • Severe immunocompromising conditions (including HIV infection with CD4 count of less than 200 cells/μL): ZVL contraindicated; recommended use of RZV under review less than 200 cells/μL): ZVL contraindicated; recommended use of RZV under review

If you have concerns about mercury, then you should request preservative free vaccinations. Almost all vaccinations can be given without thimerosal but be sure to get it early in the flu season because they run out quickly. Measles, mumps, and rubella as well as varicella and rotavirus vaccines do not contain thimerosal.

Vaccines may contain very small amounts of aluminum for instance but reports show the total amount is less than what's contained in breast milk or formula. Wait? Why is there aluminum in breast milk? Apparently, aluminum is the third most common element on earth and is abundant in our food and water. Some people may have unhealthy levels of aluminum in their system (this is determined by hair or urine analysis) but it is unlikely that it came from vaccines. Aluminum is ubiquitous, but most aluminum toxicity is from occupational exposure.

Vaccines often raise concerns about is autism. According to research done by Dr. Amy Yasko, however, almost all children with autism show signs of exposure to high levels of toxic heavy metals. None-the-less, many children exposed to similar amounts are not autisitic. It appears that children susceptible to autism are unable to normally detoxify heavy metals and soon become overwhelmed. There is an abundance of processed food and food containing additives that are excitotoxins. This plays a big part in ASD as well. The heavy metals are everywhere and unavoidable, for the most part, but they need help with detoxifying and we’re learning how that can be done safely in ways that are both amazing and fascinating. It involves first understanding a persons genome with respect to the methylation cycle. Using dietary modifications and supplements to and then dietary changes and supplements to reroute around ineffective enzymes or enzymes blocked by heavy metals. Done slowly and carefully, it will detoxify the same metals in addition to improving the overall immune system, especially functions that address chronic infections and other immunodeficiencies. In fact, some argue that increases in autism in the US is related to a greater toxic load in today's environment. Perhaps many of us would be autistic had we been born within the last 5 years where the high level of environmental toxins may have a more detrimental impact on younger, more vulnerable brains. Although we don't treat children, this area of research is of particular interest to us because anything that helps autism would likely benefit patients suffering from chronic fatigue, Alzheimer’s disease, and many illness that are linked by chronic neural inflammation, toxicity from infections, metals, chemicals, and food (mostly food additives).

Picture of boy with small pox and a boy without
Can you guess which boy received a smallpox vaccination?

From training in public health and epidemiology, we are pro-vaccine because, in addition to personal protection, it protects the entire community, as well. Whenever someone says they are against vaccination, we think of this picture and wonder if they grew up in the early part of the last century if they'd feel differently. The picture shows two boys, one who was vaccinated for smallpox and one who was not. Can you guess which one was immunized?

Just like we feel wearing a mask is the considerate thing to do, getting a vaccine is not just about you but also about everyone else because it significantly reduces the odds of spreading an infection to others. There are exceptions, of course, but most people can and should get vaccinated.

Root Cause & Disease reversal

What is Functional Health?

Functional Medicine (FM) believes that by addressing the root cause, rather than the symptoms, practitioners may find one condition has many different causes. Likewise, one cause can lead to many different conditions. This often translates to food allergies and/or immune triggering. As such, rather than waiting for other "known" symptoms to develop or continuing to "band-aid" patients, digging a little deeper to find a source or trigger may yields life-changing outcomes for the better. For example, always looking for root causes of Fibromyalgia Syndrome symptoms, Dr. Knight identified a group that shared common growth hormone deficiencies that appeared be linked. Unfortunately, growth hotmone research has since been politically "quaffed" as a result of oversue in the "anti-aging" space.

Working with patients suffering from Lyme Disease and the associated research in treating these patients led Dr. Knight to the American Academy of Environmental Medicine (AAEM) where she learned about methods used by founder and Functional Medicine pioneer, Dr. Theron Randolph. Randloph took a very detailed patient history and asked many questions rarely asked by doctors such as, "when did you first not feel well? Did this occur after moving to a new house? Starting a new job? Going to a new school? Can you associate the start of feeling poorly with any other occurrence?" By thoroughly approaching each patient as an unique puzzle to solve (and working tirelesly to do so) as opposed to following a med school flow chart, in many cases, he found the root cause of his patient's illness. He proved this by noting the immediate patient improvement when the trigger was removed and watching the illness return when the item was re-introduced, often with flourish. His findings are extensively documented, filmed and frequently shocking. Despite using actual patients and not actors, the patient reaction to being re-exposed to a trigger extensively were so strange they were often accused of "faking" it. The founders and members of the AAEM are recognized as the first to describe or the first to acknowledge this ocondition.

  • Serial Dilution
  • Endpoint Titration
  • Sublingual Immunotherapy
  • Optimal Dose Immunotherapy
  • Food Allergy/Addiction
  • Provocation/Neutralization
  • Avoidance/Reintroduction Challenge Testing
  • Rotary Diversified Diet
  • Chemical Sensitivity (MCS)
  • Total Load Phenomenon
  • Environmental Control in the Home, Workplace, and Hospital
  • Chemically Less-Contaminated Foods
  • Sauna Depuration
  • Hepatic Detoxication Enhancement
  • Gulf War Syndrome
  • Endocrine Mimicry Disorders
  • The Role of Mold in the Development of Systemic Illness
  • Yeast Syndrome
  • CFID/FMS

The name is somewhat of an oxymoron because physicians practicing Environmental Medicine are not only concerned with the environment, they consider the whole person, however few other disciplines acknowledge the environmental impact on disease except when discussing acute toxicity. The environmental effect can be slow and due to an increasing load or burden on an individual that leads then to an illness but was brewing all along. Functional Medicine and Environmental Medicine subscribe to the understanding that. To help someone, you must learn all you can about the whole person … including their environment.

Therefore, there is much overlap between Environmental Medicine and Functional Medicine. In fact there are often events and seminars that are joint ventures between AAEM and other groups that are Alternative or Functional Medicine in nature. For instance, the American Academy of Anti-Aging Medicine (A4M), and the American College for Advancement in Medicine are groups that have co-sponsored meeting with AAEM.

Most (if not all) of the members of the AAEM, are also practicing members of more mainstream medical societies and practice integrative medicine, that is we use both mainstream medicine and alternative medicine when it is a better fit or combination. Functional medicine practitioners often discard mainstream medicine and require their patients to seek out a mainstream doctor for primary care but, to us holistic practitioners, that does not make sense.

Tell us your story

Learning from the past

Functional Health emphasizes getting a detailed history with a detailed timeline of symptoms relative to other life changes. Whether using mainstream or alternative medicine, this is a principle we use every day to help our patients. We encourage patients to write their story of how their symptoms developed in chronological order.

To truly get to the bottom of any problem, you must start at the beginning. When did you last feel well? Were you a happy and healthy child or were you sickly from the start? Ask your parents, you may be surprised at 40 to learn that you were a colicky baby or was hospitalized for other reasons. Not every parent tells their kids about their health problems as toddlers or keeps good records. Just do your best and think back to a time you felt good. If you can’t remember ever feeling good it’s alright, that’s a clue as well.

Canary in a coal mine?

One patient recalled that, as a child, when they were searching for a new home, her mom would send her into the prospective house first. If she came out with a nosebleed, they took it off the list of possibilities. Clearly this person was very sensitive to mold and mold hits early on may have started a problem long ago. Did you grow up eating a diverse diet or only liked a few things and ate nothing else? Did you have pets at any time from a young age on? Do you have any animal allergies? When people are around an irritant every day the effect can become “masked.” If you have difficulties around your friend’s cat but not your own, if you were away for a few months, you’d likely have similar problems with your cat when you returned. That’s an example of masking.

Knowing what you're going through

One reason Functional Medicine (and many other alternative medicine styles) evolved came from doctor’s personal health problems that mainstream medicine failed to solve. For example, many doctors treating Lyme Disease or mold toxicity had it themselves. Most start as mainstream physicians but found that mainstream medicine didn’t provide solution for some of their sickest patients. To help them, they had to keep searching for more answers, more approaches, and be willing to think outside of the box.

Nutrigenomics & Personalized Medicine

Personalized Medicine

Herbs & Supplements

Herbs & Supplements Have a Place

oils, flowers, morter and pestle
Some supplements work for conditions where mainstream medicine offers nothing.

We use supplements and herbs that provide known benefits or "supplement" mainstream medications. There are many conditions that can be helped with certain supplements for which mainstream medicine has nothing to offer. For instance, there is no drug to reduce venous insufficiency, but it's well-studied that supplements made from the plants Horse Chestnut and Butcher’s Broom are effective in doing so. In another example, if a women in her twenties wants to lower her cholesterol naturally, we would recommend exercise, high fiber diet, fish oil and other supplements. By contrast, for a women with diabetes and a high LDL (bad cholesterol) level, we would support a trial of those changes and add Red Rice Yeast for 6 months. After 6 months, if her cholesterol is still high, we would look to a statin medication. We need to harness the power of both systems.

None-the-less, supplements aren't regulated by the FDA so they should be used with caution. We subscribe to consumerlabs.com, a service that provides test data and research information about supplements and the different brands they're sold under, in evaluating any supplements we recommend to patients. We uses this service regularly and can vouch for certain brands that are available from physician's offices only to those on the shelf at the grocery store.

Working with us

We're committed to providing quality care in a safe setting free from bias and prejudice. We believe people deserve to be treated with courtesy and respect and hold ourselves accountable to those standards. Despite the overwhelming opinion that health care services are often delivered in a non-caring "factory-like" manner, we feel that a person's health is their most personal and precious concern, regardless of race, background, social status or belief system. Therefore, each person deserves to be treated with dignity and has certain inherent rights. We expect visitors, patients and guests to adhere to this belief and refrain from behavior that is disruptive or poses a threat to the rights and safety of others.

On occasion, people interact with staff members based on where they assume an employee falls within a hierarchy. That would be a mistake here. We strive to maintain a "flat" organization and have structured operations to avoid redundancy as much as possible. This means each employee is empowered to make decisions based on policy guidelines within their area of responsibility. Because we value continuous process improvement, we welcome constructive criticism, however, it's important to understand that everyone here is responsible for managing their "piece" in the delivery of our overall service. Therefore, in most cases, if you think you're going over someone's head, you're probably not. As such, treating any staff member in a disrespectful, condescending or demeaning manner is the same as treating us all that way.

If you plan on working with us or visiting our facility, please familiarize yourself with the following:

Patient Rights

  • Recieve considerate and compassionate health care
  • Be treated with courtesy and respect
  • Be given complete and current information about your diagnosis, treatment and prognosis
  • Be provided with information that allows you to make informed decisions about your treatment plan including the risks and benefits, alternatives and outcome probabilities.
  • Privacy and confidentiality about your care and condition.
  • Be confident that any advanced directives you've prepared will be followed to the limits of the law.
  • Approach us with any questions or concerns about your treatment
  • Refuse treatment

Code of Conduct

  • Please be courteous when using a cell phone or other electronic devices in the waiting room.
  • Cell phones or other electronic devices must be turned off or in silenced when interacting with staff members.
  • Please supervise your children.
  • Aggressive or intimidating behavior directed towards staff or other visitors will not be tolerated.
  • Menacing or derogatory gestures are prohibited
  • Racial or cultural slurs are prohibited.
  • Threats to damage or destroy property is prohibited
  • Posession of firearms or other weapons is prohibited.

Being A Good Patient 101

Most people don't waste anyone's time on purpose. We're certain that you probably work in an industry that requires applied concepts like logic and foresight at the entry level.. We're also pretty sure you'd rather be in some other place than a doctor's office. We have no doubt that you'd do everything you could to help us streamline your visits here because you surely have better things to do. So, we're confident that when you finish reading this little diatribe, you'll understand that the difficulties these steps attempt to reconcile, come from your justified assumption that processes work like they're supposed to in the medical, just as they would in the real world. Unfortunately, unless you're a healthcare insider with, at leaset, a little exposure to real world expectations, you'd wouldn't know just how illogical and inefficient things are in the world of healthcare. Why would you? You'd also never know that many of the brilliant men and women who regularly perform medical miracles with about as much effort that most of use in tying our shoes ... can't tie their shoes! Therefore, being the hearty educators that we are, consider the drivel that follows as higher learning. Although some of the things we touch on here are similar to items in the policies section, those are more like a "rules and regulations" manual, hence the use of more "direct" language. Instead, think of this as valuable advice from a friend. Rather than Being a Good Patient 101, perhaps, this should be more aptly titled A Medical Insustry Survival Guide: From the Inside. Whatever the title, even if it's not your fault, it would be in everyone's best interest to keep that green fella on the left out of the the exam rooms. It's easy enough to make that happen, as long as you follow these simple steps....

#1 Tell us ahead of time if you want to discuss something you had done by another doctor.

Despite every effort to prevent this from happening, at least one or two times a week a patient comes in to follow up on something related to an encounter with another doctor or a test they had done somewhere else which we didn't schedule and we're completely unaware of. It wasn't mentioned when they made the appointment with us and they didn't even fess up to the CMA during the pre-visit interview. In fact, they didn't even write it on the visit sheet!Uh oh...

Soon enough, Doc enters the exam room and the patient says "Hi Doc! I’m here to discuss what 'Dr. So-and-so' said about my 'whatcha-ma-call-it'!" Doc looks down at the visit sheet and sees one line about their 'thing-a-ma-jig,' but not a single word on their 'whatcha-ma-call-it'. Doc grits her teeth and calmly asks, "Did you tell the CMA you were here to follow up on what 'Dr. So-and-so' said about your 'whatcha-ma-call-it'?” as a wisp of smoke from her ears. When the patient replies, "Uh...no???", a another puff of smoke comes out of her nostrils as she thingks "How can we possibly discuss this matter without a copy of 'Dr. So-and-so’s' note or the results from your 'whatcha-ma-call-it' test?"

A view from the inside...

We are an independant facility. We are not owned by a hospital, insurance company or any other red-tape infested bureaucracy. Therefore, we don't use their systems for records, we have our own. Although we can access to hospital systems, it's much more involved than a quick login, a mouse click or two and voilaè your report magically appears. Even if that were the case, it would be helpful to review these things ahead of time. You wouldn't really want to sit there watching us read would you?

To further complicate things, most specialists are also independent so their records aren't on the hospital systems either. So... Doc sends the CMA off to try tracking down the missing report as the smoke gets a little thicker.

Eventually, the CMA returns. Having spent 20 minutes on the phone with 'Dr. So-and-so's' office, he was told that they'd have to get back to him. By then the room has filled with smoke and, although he and Doc were communicating electronically, the smoke wafting down the hall caught his attentione and he noticed it was coming out form under an exam room door. Quickly he grabs a fire extigusher and timidly knocks on the door, asking "Is everything OK in there?" He recognizes the low gutteral growl he gets in reply and opens the door to reveal the patient he'd roomed 35 minutes ago and the fella in the picture. Keep in mind, the transformation from Doc to Monster and the smoke in the room is only visible to him and a few other select employees but, just in case, he opens a window before he leaves. Meanwhile, 45 minutes have gone by. The Monster...er, Doc looks her watch and realizes that she'll have to skip lunch if she expects to stay on schedule. She tells the patient to re-schedule for some time next week and thinks to herself that the patient was starting to look tasty.

The Take Away...

The days of getting a copy of every physician visit note, test results, x-ray, etc. are Long gone. It seems that most doctors employed by a hospital system assume that every other doctor works in the same system, too, and assume that we'll see their report when we log in the next day! We're quite aware that they may ASK you where to send a copy of your mammogram but do they send a copy? Nope! If we don't know what you're having done AND you don't tell us about it before you come in, you've likely just wasted a visit, the cost of your co-payment or co-insurance and will have to be re-scheduled.

Tell us about it when you book the appointment OR email our CMA (see our Email Directory) when you have your procedure done and write "Hey Ian, I’m coming in two weeks from Thursday to talk to Dr. Knight about 'Dr. So-and-so's' recommendation that I have my 'doo-hickey' removed and I just wanted to give you a heads up. By the way, I also had an MRI done on my 'doo-hickey' last week at 'blah-blah-blah' in 'Yadda-yadda-yadda'. FYI...".

That way, we can be prepared. The outcome? You save an extra visit and some moola, we stay on time, the Doc gets lunch and we keep the green fella in the dungeon where he belongs. It's a win-win!

Annual Wellness Visit

What is an "Annual Wellness Visit"?

An Annual Wellness Visit (AWV) is for the sole purpose of meeting with your primary care provider once each year to create, update and maintain a personal prevention plan based on your current health and risk factors. Importnat: An AWV is not a head-to-toe physical and does not include visits for treating acute or chronic illness, visits part of an exisitng treatment plan or any purpose not listed in the US Preventative Task Force recommendations at the bottom of this section. In those cases, co-payment, co-insurance and/or deductible waivers may not apply if your visit includes non-prevantive services.

What is included in an "Annual Wellness Visit"?

  • Establishment or update of an individual’s medical/family history.
  • Establishment or update of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
  • Measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.
  • Detection of any cognitive impairment that the individual may have as defined in this section.
  • Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations.
  • Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.
  • Establishment or update of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
  • Establishment or update of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
  • Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote selfmanagement and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.

us preventative task force recommendations

Topic Description Grade Release Date of Current Recommendation
Abdominal Aortic Aneurysm: Screening: men aged 65 to 75 years who have ever smoked The USPSTF recommends 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked. B December 2019 *
Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening: adults aged 40 to 70 years who are overweight or obese The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. B October 2015 *
Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication: adults aged 50 to 59 years with a ≥10% 10-year cvd risk The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. B April 2016 *
Asymptomatic Bacteriuria in Adults: Screening: pregnant persons The USPSTF recommends screening for asymptomatic bacteriuria using urine culture in pregnant persons. B September 2019 *
BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing: women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or an ancestry associated with brca1/2 gene mutation The USPSTF recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. B August 2019 *
Breast Cancer: Medication Use to Reduce Risk: women at increased risk for breast cancer The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects. B September 2019 *
Breast Cancer: Screening: women aged 50 to 74 years The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. B January 2016 *
Breastfeeding: Primary Care Interventions: pregnant women, new mothers, and their children The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding. B October 2016 *
Cervical Cancer: Screening: women aged 21 to 65 years The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting). See the Clinical Considerations section for the relative benefits and harms of alternative screening strategies for women 21 years or older. A August 2018 *
Colorectal Cancer: Screening: adults aged 50 to 75 years The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. The risks and benefits of different screening methods vary. See the Clinical Considerations section and the Table for details about screening strategies. A June 2016 *
Dental Caries in Children from Birth Through Age 5 Years: Screening: children from birth through age 5 years The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. B September 2014 *
Dental Caries in Children from Birth Through Age 5 Years: Screening: children from birth through age 5 years The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. B September 2014 *
Depression in Adults: Screening: general adult population, including pregnant and postpartum women The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. B January 2016 *
Depression in Children and Adolescents: Screening: adolescents aged 12 to 18 years The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. B February 2016 *
Falls Prevention in Community-Dwelling Older Adults: Interventions: adults 65 years or older The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. B April 2018 *
Folic Acid for the Prevention of Neural Tube Defects: Preventive Medication: women who are planning or capable of pregnancy The USPSTF recommends that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. A January 2017 *
Gestational Diabetes Mellitus, Screening: asymptomatic pregnant women, after 24 weeks of gestation The USPSTF recommends screening for gestational diabetes mellitus (GDM) in asymptomatic pregnant women after 24 weeks of gestation. B Sep-14
Chlamydia and Gonorrhea: Screening: sexually active women The USPSTF recommends screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection. B September 2014 *
Chlamydia and Gonorrhea: Screening: sexually active women The USPSTF recommends screening for chlamydia in sexually active women age 24 years and younger and in older women who are at increased risk for infection. B September 2014 *
Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling: adults who are overweight or obese and have additional cvd risk factors The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. B Sep-14
Hepatitis B Virus Infection in Pregnant Women: Screening: pregnant women The USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit A July 2019 *
Hepatitis B Virus Infection: Screening, 2014: persons at high risk for infection The USPSTF recommends screening for hepatitis B virus (HBV) infection in persons at high risk for infection. B Sep-14
Hepatitis C Virus Infection in Adolescents and Adults: Screening: adults aged 18 to 79 years The USPSTF recommends screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years. B March 2020 *
Human Immunodeficiency Virus (HIV) Infection: Screening: pregnant persons The USPSTF recommends that clinicians screen for HIV infection in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown. A June 2019 *
Human Immunodeficiency Virus (HIV) Infection: Screening: adolescents and adults aged 15 to 65 years The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk of infection should also be screened. See the Clinical Considerations section for more information about assessment of risk, screening intervals, and rescreening in pregnancy. A June 2019 *
High Blood Pressure in Adults: Screening: adults aged 18 years or older The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment (see the Clinical Considerations section). A October 2015 *
Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening: women of reproductive age The USPSTF recommends that clinicians screen for intimate partner violence (IPV) in women of reproductive age and provide or refer women who screen positive to ongoing support services. See the Clinical Considerations section for more information on effective ongoing support services for IPV and for information on IPV in men. B October 2018 *
Latent Tuberculosis Infection: Screening: asymptomatic adults at increased risk for infection The USPSTF recommends screening for latent tuberculosis infection (LTBI) in populations at increased risk. B September 2016 *
Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: Preventive Medication : pregnant women who are at high risk for preeclampsia The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. B Sep-14
Lung Cancer: Screening: adults aged 55-80, with a history of smoking The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. B Sep-14
Obesity in Children and Adolescents: Screening: children and adolescents 6 years and older The USPSTF recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status. B June 2017 *
Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: Preventive Medication: newborns The USPSTF recommends prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum. A January 2019 *
Osteoporosis to Prevent Fractures: Screening: postmenopausal women younger than 65 years at increased risk of osteoporosis The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. See the Clinical Considerations section for information on risk assessment. B June 2018 *
Osteoporosis to Prevent Fractures: Screening: women 65 years and older The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older. B June 2018 *
Perinatal Depression: Preventive Interventions: pregnant and postpartum persons The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. B Feb-19
Preeclampsia: Screening: pregnant woman The USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy. B April 2017 *
Prevention of Human Immunodeficiency Virus (HIV) Infection: Preexposure Prophylaxis: persons at high risk of hiv acquisition The USPSTF recommends that clinicians offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition. See the Clinical Considerations section for information about identification of persons at high risk and selection of effective antiretroviral therapy. A Jun-19
Prevention and Cessation of Tobacco Use in Children and Adolescents: Primary Care Interventions: school-aged children and adolescents who have not started to use tobacco The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. B April 2020 *
Rh(D) Incompatibility: Screening: unsensitized rh(d)-negative pregnant women The USPSTF recommends repeated Rh(D) antibody testing for all unsensitized Rh(D)-negative women at 24 to 28 weeks' gestation, unless the biological father is known to be Rh(D)-negative. B Feb-04
Rh(D) Incompatibility: Screening: pregnant women, during the first pregnancy-related care visit The USPSTF strongly recommends Rh(D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. A Feb-04
Sexually Transmitted Infections: Behavioral Counseling: sexually active adolescents and adults The USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs). B September 2014 *
Skin Cancer Prevention: Behavioral Counseling: young adults, adolescents, children, and parents of young children The USPSTF recommends counseling young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet (UV) radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer. B March 2018 *
Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication: adults aged 40 to 75 years with no history of cvd, 1 or more cvd risk factors, and a calculated 10-year cvd event risk of 10% or greater The USPSTF recommends that adults without a history of cardiovascular disease (CVD) (ie, symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater. Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults aged 40 to 75 years. See the "Clinical Considerations" section for more information on lipids screening and the assessment of cardiovascular risk. B November 2016 *
Syphilis Infection in Nonpregnant Adults and Adolescents: Screening : asymptomatic, nonpregnant adults and adolescents who are at increased risk for syphilis infection The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. A June 2016 *
Syphilis Infection in Pregnant Women: Screening: pregnant women The USPSTF recommends early screening for syphilis infection in all pregnant women. A September 2018 *
Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions: adults who are not pregnant The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to adults who use tobacco. A September 2015 *
Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions: pregnant women The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. A September 2015 *
Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling Interventions: adults 18 years or older, including pregnant women The USPSTF recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use. B November 2018 *
Unhealthy Drug Use: Screening: adults age 18 years or older The USPSTF recommends screening by asking questions about unhealthy drug use in adults age 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.) B Jun-20
Vision in Children Ages 6 Months to 5 Years: Screening: children aged 3 to 5 years The USPSTF recommends vision screening at least once in all children aged 3 to 5 years to detect amblyopia or its risk factors. B September 2017 *
Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions: adults The USPSTF recommends that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher (calculated as weight in kilograms divided by height in meters squared) to intensive, multicomponent behavioral interventions. B September 2018 *

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New Patient Forms Packet

Prospective patients need to fill out the three forms below and return to scheduling@theknightcenter.com along with copies of your insurance card and Driver's License or State ID. Incomplete forms will not be considered. See About -> Our Policies -> Processes -> Scheduling -> New Patients for more detailed information on becoming a new patient.

New Patient Oriententation

Practicing integrated medicine before it became trendy

We assume you’re here because you are interested in a different way of doing medicine. If that isn’t the case, read on and see if we’re the right fit for you. We have practiced internal medicine since 1998. We tend to attract patients who can't find an answer, haven't found someone who can help them, or because they're simply frustrated because they can't find a doctor that will explain their treatment plan (or lack thereof). As such, we've seen a lot of rare things. We have practiced integrative medicine long before it became in-vogue.

Understanding functional medicine

We also incorporate functional medicine into our practice but it's important to understand that much of functional medicine is based on new and exciting biological research but because it’s so cutting edge, sometimes it’s wrong. For example, a patient read about the benefits of L-arginine for treating chronic Lyme in a book by the most well-know herbalist in the country for treating this problem, however, recent research has shown that if you have the wrong mutation in a certain liver enzyme, not only will L-arginine not provide any benefits but will actually have the opposite effect. Even amino acids and supplements can backfire so we have to keep an open mind and continually seek new information.

lab consistency

We use one lab for lab testing with exception for some specialty tests. Different lab facilities use different assays. For example, a TSH (thyroid stimulating hormone) level measured at one lab could be totally different (and often is) when measured at a different lab. Consistency in assays and methods are important for monitoring levels, especially with hormones, for dood-decision making and long term monitoring. Reliable data is necessary to optimize levels.

hospitalists

Local hospitals generally use their own doctors. Years ago, internists cared for their patients if they were in the hospital. Because physicinas need to check on admitted patients daily, doctors created call groups to see each others patients on weekends and holidays. When a member of the group was "on call" he or she would see ALL of the patients of every member of the call group. Without being part of a group, most doctors would rarely get a day off. We have patients in the hospital so rarely, that we soon found that our weekends were more often spent treating people that were not our patients. This cooincided with a general overall trend and independent call groups were replacd by "hospitalists." Unfortunately, this creates the potential for mis-communications or no communication at all. This means patients need to let us know when they are in or have been in the hospital. It's important you do so to help us maintain accurate and complete medical records as well as coordinate care. Important: If you are admitted to the hospital call our office and let us know. Leave your name, date of admission, which hospital you are/were in, and to the best of your knowledge the reason for being admitted and if you've had any medication changes.

Keep a med list

Everyone who is mentally competent or a guardian or POA for someone should always carry a medication list that is up to date, including the name of the prescribing physician. It should also contain a list of any supplements or over the counter medications you are currently taking or have taken in last 3 months. Without this, other providers may prescribe or recommend a medication that interacts badly with something you may already be taking. If you use multiple pharmacies, a pharmacist may not catch it, either, and the risk of a poor outcome increases.

Help us help you

When requesting an appointment please consider the following issues and make us aware when you are scheduling your appointment:

  1. Appointment is a follow-up from a previous visit for managing a chronic condition such as diabetes, chronic pain or hypothyroidism.
  2. Appointment is for a work-required wellness exam
  3. Appointment is a follow-up from a hospital or ER visit
  4. Appointment is a follow-up or referral from another physician (and who)
  5. Appointment is for surgical clearance
  6. Appointment is for Annual Wellness Visit or preventative exam

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Insurance glossary

Glossary of health insurance terms

The first step to understanding health insurance is to become familair with some common terms. We hear things like co-insurance, co-pays, out-of-pocket expenses and a host of other insurance-related expressions that often seem to be different expressions for the same thing ... but they're not. Following is a list of insurance phrases and their definitions. This is not a comprehensive list, that would take up an entire site by itself! This is for educational purposes and not meant to be specific to every plan or policy that's available. Your policy or plan may use different terms or the terms used in your policy may have a slightly different meaning than they do here but this will help you get the gist. Being familiar with these may protect you from making expensive mistakes, as well as help you in selecting an insurance plan that will best fit your needs (it might also keep you in good graces with our accountant). Just remember, sometimes the "cheapest" plan will end up costing you the most.

A - D
E - H
I - O
P - Pre
Pri - Z


  • Allowed Amount

    The maximum amount which your insurance will pay for a given product or service. This amount is generally, but not always, a negotiated rate between an insurance company and a healthcare provider. Doctors oe medical groups often discount their fees to insurance companies to be part of the insurance company's network of preferred providers. The allowed amount is what they will accept as payment and is usually part of a negotiated contract. IMPORTANT:In cases where the provider is NOT in the insurance company network or does not have a contractual agreement with the insurance company (see Preferred Provider), this may be the maximum amount the insurance company will PAY for a given service but in the absence of a contract, they have no authority over the provider's charges. In that case the patient may be repsonsible for the difference between the allowed amount and the provider fee.

  • Appeal

    A formal request to your insurance to review a decision or initial determination. This often occurs when claims are rejected or there is additional supporting evidence that wasn't presented with the original claim.

  • Balance Billing

    Balance billing is when your healthcare providers charges the insured the difference between the allowed amount and their fee. For example, if the provider charges $225 for a given service for which your insurance company's allowed amount is $150, the provider may bill you for the remaining $75, the balance of the amount not paid by your insurance company.

  • Benefit Period

    Dates for which services are covered. Also defines the time frame in which benefits maximums, deductibles, co-insurances and out-of-pocket expenses are accured. Typical period is one year. IMPORTANT:If you purchase a health insurance policy on December 15 that has a benefit period that begins on January 1 fo the following year, you will not be covered for any medical expenses prior to January 1, nor be credit towards a deductible or maximums prior to January 1. Know your benefit period.

  • Co-Insurance

    Your share of a covered service as a percentage of the allowed amount for a given service. For example, if the allowed amount of an office visit is $150 and you have a 20% Co-Insurance, the insurance company pays $120 (or 80%) and you will be responsible for the remaining $30 (or 20%). IMPORTANT: You may still be responsible for the difference between the provider fee and the allowed amount. See Balance Billing.

  • Coordination of Benefits

    Process of determining which of two or more insurance policies will have the primary responsibility of processing/paying a claim and the extent to which the other policies will contribute. This often requires the insured to contact their primary insurer before any claims will be paid.

  • Co-Payment

    Your share of a covered service as a fixed amount subtracted from theallowed amount. For example, if the allowed amount of an office visit is $150 and you have a $30 Co-Payment, the insurance comapny pays $120 and you will be responsible for the remaining $30. IMPORTANT: You may still be responsible for the difference bewtween the provider fee and the allowed amount. See Balance Billing.

  • Deductible

    The amount you must pay before your insurance begins paying for covered services. For example if you have a $1500 deductible, your insurance will not pay for any services until you have paid for the first $1500 of charges. IMPORTANT:Not all services are subject to a deductible and some deductibles only include the allowed amount, where others include the entire provider fee. For example, an office vist to your PCP (see Primary Care Provider) may not be subject to a deductible but a visit to the emergency room may be. In this example, let's assume that's the case and you have a $1500 deductible. The ER fee may be $1000, but the allowed amount may only be $500. If your deductible includes the ER fee, you would be responsible for $1000 charge and use up $1000 of your deductible leaving only $500 remaining. After you use accrue an additional $500 in medical costs, your insurance would beging to pay for covered services. If your deductible only includes allowed amounts, you would be responsible for, and use up $500 leaving $1000 remaining on your deductible. You would have to accrue an additional $1000 of medical costs before you're insurance begins paying for covered services. IMPORTANT: You may still be responsible for the difference between the ER charges and the allowed amount. See Balance Billing.

  • Dependent Coverage

    Coverage for qualified dependents, typically a spouse or children under the age of 26.

  • Diagnosis Codes

    Translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. These are included in medical records and insurance claims to indicate the reason and symptoms for which you are being treated. For our use, these are derived from ICD-10, an international standard classification system.

  • Drug Formulary

    A list of generic and brand name prescription drugs covered by your health plan.

  • Eligibility Check

    Process used to validate your insurance coverage. This let's us know if your insurance is active. IMPORTANT:If the insurance information we have on file for you doesn't pass eligibility validation, your visit may be cancelled. Make sure you provide us with updated insurance information at least a week before your visit.

  • Excluded Services

    Medical services not covered by your insurance plan

  • Experimental or Investigational Treatment

    Drug, device, medical treatment or procedure not approved by the U.S. Food and Drug Administration and not considered the standard of care. IMPORTANT: These are not covered by most insurance companies.

  • Explanation of Benefits (EOB)

    Statement sent by your health insurance company explaining what medical treatments and/or services were paid for on their behalf. We use these to determine how to apply payments. These are generated when we submit claims to your insurance comapny.

  • Health Insurance

    A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

  • Health Maintenance Organiztion (HMO)

    Plans where you select a primary care doctor as your main healthcare provider. You will need a referral from your PCP to see specialists. IMPORTANT: Services undertaken without a referral from your PCP will not be covered except in emergencies.

  • Health Reimbursement Account (HRA)

    A tax-advantage account in which employers set aside funds to reimburse participating employees for covered healthcare costs.

  • Health Savings Account

    Employer benefit in which participating employees may save for future medical costs. Deposits to an HSA are not subject to federal income tax and may spread over multiple years. These are offered in conjunction with high deductible insurance plans.

  • In-Patient Services

    Medical services provided to patients admitted to a hospital.

  • Medically Necessary

    Services or supplies deemed as acceptable standard practice.

  • Network

    The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

  • Non-Preferred Provider

    A healthcare provider who is not part of a plan’s network. Costs associated with out-of-network providers may be higher or not covered by your plan. IMPORTANT:Know if your doctor is a participating network provider.

  • Outpatient Services

    Services that do not need an overnight stay in a hospital. These services are often provided in a doctor’s office or clinic, as well as in hospitals for specific outpatient procedures.

  • Out-of-Pocket Limit

    Maximum amount that a plan requires you to pay, regardless of set co-payments and/or co-insurance.

  • Physicians Services

    Health care services provided or coordinated by a licensed Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO).

  • Plan

    An legal insurance contract with specific terms and conditions, restrictions and covenants relative for covered healthcare services in exchange for a premium. Also called known as an insurance policy.

  • Policy

    An legal insurance contract with specific terms and conditions, restrictions and covenants relative for covered healthcare services in exchange for a premium. Also called known as an insurance plan.

  • Pre-Authorization

    A confirmation by your insurance company that a procedure, device or drug is medically necessary. Health insurance plans may require a pre-authorization for certain procedures before you receive them. IMPORTANT: Preauthorization isn’t a promise your health insurance or plan will cover the cost.

  • Procedure Code

    Translation of written descriptions of medical, surgical, and diagnostic services to communicate uniform information about medical services and procedures among physicians and insurance companies for administrative, financial, and analytical purposes. These are included in medical records and insurance claims to indicate what was done at a medical encounter. For our use, these are derived from Commom Procedural Terminology (CPT) codes, a medical code set maintained by the American Medical Association.

  • Pre-exisiting Condition

    Medical condition that started before a person's health benefits went into effect.

  • Preferred Provider

    A provider who has a contract with your insurance company to provide services to you at a discount. Preferred providers cannot charge you for the difference between their fee and the contracted price, Seeallowed amount.

  • Preferred Provider Organization (PPO)

    Insurance plan that offers more extensive coverage, allows you to select your in-network physician of choice and may offer limited coverage for out-of-network providers.

  • Premium

    Payments made to your insurance provider in exchange for insurance coverage.

  • Primary Care Provider

    A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant who provides or coordinates a range of health care services.

  • Provider

    A hospital, facility, physician, advanced practice nurse or other licensed healthcare professional.

  • Specialist

    A physician or healthcare provider with advanced training and focus on a specific area of medicine.

Network Participation

Below is a partial list of health insurance companies, government insurance plans and third-party administrators for which we are preferred providers. This list may not include various self-insured company and/or labor union plans. It also does not include Medicare Supplemental plans, often referred to as secondary insurance. These comapnies utilize the Medicare network. As a participating Medicare provider, we are also in-network for these companies.

Important: inclusion on this list does not guarantee coverage. We may only be "in-network" for certain select plans offered by some these companies. Please check with your insurance company, human resources department or agent/broker/producer for specific details. Also note that coverage for any plan is subject to the terms and conditions of your policy.

Important: Sorry, at this time we are not accepting Medicaid or plans provided by Medicaid contractors.

Knowing Your Policy

Diagram showing integrative medicine as convergence of modern and alternative medicine.
Failure to understand your health insurance plan can lead to huge medical bills and other unexpected surprises.

All too often, people don't take the time to understand the details about their insurance plan. In many cases, the selection they choose is based on cost when it should be based on cost/benefit. Unfortunately, this frequently leads to huge medical bills and other unexpected surprises. Although we are not insurance professionals, we interact with them in adminstrative and medical capacities on a constant basis and they play a vital role in our business. As such, over the years we've learned that few people understand health insurance in general, let alone the intracacies of their personal policy. And why should they? Insurance is complicated and it always changes. Throughout this site you'll see frequent references to insurance. It's even important enough to have it's own section. There's a basic knowledge deficit and general misunderstanding about health insurance that, if corrected, would reduce or eliminate these problems.

Important:Patients are responsible for all changes resulting from services provided by our facility. As a service to our patients we will bill most insurance carriers directly, however, the patient has primary financial liability. Below is, in our opinion, the minimum information someone should know about their insurance plan.

Total Costs

When evaluating total cost for insurance, consider how often you see a physician, if you frequently need emergency care, you take expensive medications, you're planning a surgery and if you have a chronic condition. Understand the following amounts for your policy and apply the cost to these considerations.

Premium - You pay a monthly bill to your insurance company even if you don’t use medical services that month.

Deductible - If your plan has a deductible, your insurance will not pay until you've paid the deductible amount out of pocket. The higher the deductible, the more you'll have to pay before coverage begins.

Co-pay and/or Co-insurance - In addition to a monthly premium and a deductible that must be satisfied before insurance begins to pay, many plans require the patient to pay a share of the cost of each visit. Co-pays are fixed amounts and due at the time of service and co-insurance is a percentage of the amount that you will be billed for. Some plans have co-pays for some service (office vists, for example) and co-payments for other services (labs, imaging, etc.

No-cost Services - Many plans provide annual physicals or preventative exams at no cost to the patient (premium excluded). These visits have very specific requirements and cannot be used as a "free" visit for specific conditions. They are also usually limited to once a calender year. Know the terms and conditions for free services and be sure to let the scheduler know. Otherwise, it may not be covered and you will be billed.

Know your plan type

Some plan types allow you to use almost any doctor or health care facility. Others limit your choices or charge you more if you use providers outside their network. Still, others require you to select a primary care provider and will not cover visits to other doctors without a referral.

Health Maintenance Organization (HMO) - A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally requires the patient to select a primary care physician beforehand and will not cover services from other primary care providers. HMO plans also require you to get a referral from your primary care doctor in order to see a specialist. A HMO plan generally won't cover out-of-network care except in an emergency.

Preferred Provider Organization (PPO) - A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Point of Service (POS) - A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans also require you to get a referral from your primary care doctor in order to see a specialist.

Exclusive Provider Organization (EPO) - A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).

Benefits

If you're uncertain about anything below, don't hesitate to contact your insurance agent, human resources department or your insurance company's member services.

Medication Formulary - Know what medications are covered and at what tier or price band. Some may have higher co-pays than others.

Labs - Some insurance plans cover labs, some cover some labs but not others and some do not cover labs at all. Know what your insurance company's terms on lab tests.

Imaging - Imaging is often necessaryin diagnosis. These include X-Rays, Computer Tomography scans (CT), Fluoroscopy, Magnetic Resonance Imaging (MRI), Mammographies, Nuclear Medicine scans, Positron Emission Tomography (PET scan) and Ultrasound. Similar to labs, coverage for these services varies based on the type of service and the conditon for which they're used.

Pre-authorization

Under medical and prescription drug plans, certain medications or services may need approval from your health insurance carrier, before they’re covered. In addition to medications, "pre-auths" are often required for tertiary services like physical therapy, chiropractic care or occupational therapy or outside diagnostics tests. Make it a point to know which services and/or medications require prior approval.

Network

Costs are lower when you go to an in-network doctor because insurance companies contract lower rates with in-network providers. When you go out of network you'll pay more because the doctor, hospital or clinic doesn't have agreed-upon rates. Most insurance companies keep lists of participating network physicians on their site but we've found they may not be updated or list us under our corporate name, Knight Medical & Rehab Center, Ltd. To be certain, contact our office or the insurance company directly. Also be sure to confirm that any speciliasts you're referred to are in your network.

Billing Process

Our billing process begins with your office visit. Everything related to your visit from the moment you are put into an exam room to the time you leave is entered in your medical record (don't worry, we're only talking about "health related" things). During your visit, information on vital signs, lab results, test results, addition to your medical history and notes about your visit are made in the record by your doctor. After reviewing, they will enter the diagnosis codes (why you're here) and the procedure codes (what they did) for that particular encounter. For a lot of visits this happens before the doctor leaves the room but if the diagnosis takes a lot of research or third-party test results, the "note" for that visit may not be completed for several weeks. When the note is finished, it is signed and can no longer be altered. A signed note triggers the start of the billing process.

Each signed note shows up in the billing queue. This means the doctor has finished the note and it is ready to be billed. Please note that the doctor selects the codes, not the biller. From the queue, the biller reviews the note for mistakes or omissions and, if none found, submits it to a clearing house. The clearing house takes all claims, regardless of the insurance company, and prepares then distributes each to their respective companies. This entire process is electronic so, in our case, "prepare" simply means ensuring that the information is properly formatted, satisfies all coding and platform criteria and goes to the right place for processing. At this point, 100% of the claim amount shows as owed by the insurance company.

Once submitted, software provides status updates acknowledge the claim was received, is in process, and accepted or rejected by the insurance company. If the claim is accepted, payment information is provided on an explanation of benefits document that goes us andthe patient. If the insurance company owes money, payment will usually appear on the next insurance company check run, a weekly process for larger insurance companies. Rejected claims also generate paperwork providing reasons why a given claim isn't paid. This includes inactive insurance, non-covered services, deemed medically unnecessary and a host of other reasons. Insurance companies have up to 30 days to respond to a claim.

The explanation of benefits (EOB) shows how payment responsibility is split between the patient and the insurance company. Each amount deducted from the claim charges are accounted for in the EOB and they are what we use to reconcile the claim with your account. The amount we bill you is provided to us by your insurance company. EOBs can be confusing and deserve a section of their own. More detailed information on EOBs can be found below.

Once the EOB is received, the biller takes the payment data and moves it to the correct account. If the patient had made a co-payment on the date of service, it would be used to offset the $25 the EOB shows as being withheld from their payment becuase it was owed by the patient as a co-pay. It would also tell us that the amount charged exceeded our contracted amount which would be written off. It would finally show the amount they paid and, when reconciled, everything would add up to zero. At this point, excluding any disputes or corrections, any remaining amount would show as owed by the patient. For example, a patient with a co-insurance of 20% had an appointment on 6/1. The note was completed on 6/2 but, prior to ther note being signed, billing didn't know the charge amount. On 6/3, the completed note generates an entry in the billing queue and, after review, the biller sends in a claim for a service that pays $150. The EOB shows that a check for $120 was recieved and the patient ws responsible for the remaining $30. During the reconciliation process, this liability is transferred to the patient and will be included on our next statement run.

Statements are sent on a monthly basis. If an EOB was received the day after your last statement went out, it may be up to another 30 days before you get a bill. Same holds true for checks you send to us. If your monthly statement goes out before we receive your check, your payment won't be reflected on your statement balance. if you're concerned, send an email to billing or contact our office. They'll have access to a real-time account balance. Due dates are calcuylated from the statement date.

Understanding Your EOB

Explanantion of Benefits or just confusion?

We used to read these when when we first realized it was our name in the "patient responsibilty" section. At least we did until we gave up trying to understand the "explanation of benefits" letterw we'd receive from our insurance company after every visit to a doctor, dentisit or other healthcare provider. Why worry? It always stated in big, bold letters "This is not a bill." So, they usually go straight to the trash or some file 's ignored until tax time.

If it's not a bill, though, what is it? It sure looks like a bill and usually has $ amounts next to labels containing the words "owe" and "paid". They also include an additional 3 or 4 double-sided pages of regulatory legalese but they rarely explain anything. In fact, they usually just create more confusion. The "EOB" is important, though. It shows the expenses your provider submitted to your insurance company for reimbursement payments (claim data) and how your insurance processed their request.

Important: Just as you get an EOB for each visit, your doctor's office also receives an EOB for each patient encounter. These are used for reconciling patient accounts, generating patient statements and tracking unpaid claims for follow-up and/or correction.

A better explanation ...

Yes, we understand that this isn't inuitive at all. EOBs contain all kinds of terms we've never seen in this context. With phrases like "write-off" or "contractual obligation" they look more like the outcome of a negotiation concerning your medical appointment that you weren't allowed to participate in. Actually, that's somewhat true...but probably not the way you'd think. In this section we're going to attempt to help you with understanding your EOB. If you know nothing about medical billing, you should review the insurance and the billing process sections before proceeding.

Beyond typical information about the policy holder, patient and plan ID details, the EOB has three main sections. Depending on your insurance company, they may be named a bit differently but for all insurance companies they can be broken down into general categories that are included on every EOB. These are Service Details, Claim Totals and a Summary. In the sample EOB shown below, these are found under the Claim Detail, What You May Owe and Total Claim Costs headings.

The list below is in reference to the numbered points on the EOB sample. All EOBs are layed out differently and use different terms but the concepts are the same for every insurance company.

  1. Policy Holder - Person named as the insured. This person is the guarantor for any financial liabilities from use of the policy as well as the policy itself. In this example, John Doe is the primary insured. He is whom the insurance company thinks of as their customer and is considered the "primary" policy holder.

  2. Patient - Person utilizing the service(s) that generated the EOB. This can be the insured or the insured's dependants such as a spouse or child,that are included in policy.

    Date Received is the date the insurance company received the claim for processing.

  3. IMPORTANT: Account Numbers are unique to each visit. This is not the same as the insured's fixed account number on insurance premium invoices or a patient's account number with their doctor's office. This number only refers to this specific appoinment, the visit of 1/1/2020 in this example. If Jane Doe had more than one visit on this explanation of benefits, each date of service would have a unique account number.

    The Member ID is the most important information as all references to coverage, eligibility and activation refer to this number. This may be unique to each person on the policy or shared among all persons. Shared ID's may also be appended to show the card holder is a dependent, sometimes, specific to the type of dependant. For example, John is the policy holder and Jane is John's dependent in this case. They may have the same Member ID number but, Jane's could have a "-2" at the end of the number and, perhaps, their child also has the same number with a "-3" appended. Dependent status, may or may not be included.

  4. Group is the name of the "group" to whom the insurance company is offering the plan. In most cases, this is an employer who purchases or manages an insurance plan for their employees. Groups also help identify self-insured firms. Self-insured firms frequently use commercial insurance companies for administration purposes only but not claim payouts. For example, if you work at Caterpillar, you may think you're insured by United Health Care but your claims are actually paid by Caterpillar. UHC only handles organizational functions like issuing cards and processing claims but the money moving in and out of the plan is Caterpillar's. In this capacity, insurance companies are acting as a third-party administrator (TPA). Self-insured firms usually have their own operating agreement which means their plans will have different requirements and coverage limitations than plans offered by the TPA in cases where the insurance company is acting as a commercial insurance company, not just a TPA. Caterpillar plans with UHC are different than UHC commercial plans. Difficulties can arise when a large company like UHC has hundreds of plans commercial plans, but their member cards, whether UHC is a commercial insurer or just a TPA, all look similar. The only way to tell if someone is in a Caterpillar plan by is by the group information on the card or contacting the insurance company directly, usually a slow and painful process.

    The Provider is the billing physician and the NPI is the unique National Provider Identifier for the billing physician. You can find details about physicians by entering their NPI number here.

  5. Group Number is simply more group detail. Larger companies may have their own group that's also identified by a group name but smaller companies are usually added to a group that includes many companies. In that case, there may be no logical correlation between the group name and group number but group numbers are unique to each company. In this case, we can tell a patient is insured by Caterpillar because the group number is 100400 even though every UHC card is virtually identical.Claim Numbers are unique to each claim submission and typically used as reference when interacting with an insurance company on a specific claim.

  6. Here's where it gets tricky...

  7. The Claim Detail section contains the items submitted for reimbursement along with dates, pricing and status. The Procedure Code defines what was done at your visit. So far, we know Jane Doe, a dependant of primary policy holder John Doe, went to see Dr. X on January 1, 2020. Based on the Service Description and Procedure Codes, we see a claim was submitted for one unit each of an office visit, a blood draw and a lab test which the insurance company received on 1/6/2020. I we can also see "why" they were being treated. Easy enough, so what's the rub?

    On each line is one of the three services billed on that visit. Here we see the Claim Status and then columns for Provider Charges, Allowed Amount and Provider Adjustmnent. Huh????

    Provider Charges are the provider's list fee for each of their services. In this case, the list prices are $167.00 for the office visit, $33 to have blood drawn and prepared for the lab and $200 the list fee for the ordered blood test. The doctor will submitt a claim in the amount of $400 for all services rendered at that visit.

    Allowed Amount comes from that negotiation we spoke of earlier that you left out of. If we our part of your insurance's company's preferred provider network, theallowed amount is a discounted price that we agree to accept as a condition of becoming "in-network" with your insurance company. Insurance companies want to pay the least amount possible and we want to be available to the most patients possible. For insurance companies with thousands of members, we can afford to reduce our prices because we will be busier tending to their massive client network. On the other hand, a large physician's group (a group of physicians working under one entity ... not to be confused with an insurance group name or number) with thousands of patients can demand higher reimbursement rates because their larger patient population is more valuable to an insurance company. This is the negotiation you missed out on and it can be quite the dance depending on the state of the industry and who has the most leverage. It can be very dynamic and has swung back and forth from groups to independants many times over the years.

    Provider Adjustment, frequently referred to as a "write-off" is the amount of the discount or the amount the physician "writes off" from their normal fees. This often leads to inaccurrate pricing applied to healthcare costing models because the "write-off" is not always considered. It can be substantial and it's not uncommon in a hospital setting to see charges of $10,000 reduced to a final payout of less than $3,000. IMPORTANT: If the allowed amount for a service is $100 and the doctor is "in-network", $100 is all a physician can collect... even if their list fee is $1,000,000! Don't get too hung up on the provider charges unless you didn't bother to do your insurance homework and find out that you're seeing a doctor that's NOT in your insurance company's network. If that happens, the charges are not limited by any contractual obligations and you may have to pay full list fees.

  8. What You May Owe accounts for the total amount your doctor can collect (allowed amount) for a service based on the contract between your insurance company and your physician, as well as your share of that total based on the contract (yes, your policy is a contract) between you and your insurance company. This section breaks down the figures showing the allowed amount less what your policy terms state you must pay in co-payments, co-insurance and/or deductible.

    In our example, Jane has a $20 co-payment for the office vist and $50 remaining on her deductible, which is also applied to the office visit. She also has a 20% co-insurance for the lab test which equals $5.80 (20% of the $29 allowed amount). Jane owes nothing for the blood draw because the doctor/insurance company contract likely has a clause that says any blood tests include the price of the blood draw. Combining services is referred to as "bundling." In essence, the doctor agreed to waive the cost of drawing blood and preparing it for testing in exchange for reimbursement for each actual test.

    IMPORTANT: The agreement you have with your insurance company and the agreement your doctor has with your insurance company are unrelated, at least directly. When you recieve service from your doctor you are engaging in a contract with your doctor. Any civil action resulting from a billing dispute related to that service will be directed at you, not your insurance company. In addition, if you refuse to pay your share of a bill, you would be violating yourcontract with your insurance company. If the doctor reports the violation, you may be dropped from the policy.

  9. Total Claim Cost This section rolls up the totals owed and paid. In our example, the insurance company paid the provider $63.20 under the terms of their provider agreement. Jane has to pay $75.80 under the terms of her insurance plan.

  10. Remarks provide the reason for adjustments and the codes used are standard throughout the health insurance industry. You can see a complete list of remark codes here. Comments are included for each line item with an adjustment. In our example, CO-45 for lines 1 and 3 tell us that the provider adjustments are due to the provider's initial charges exceeding the allowed amount agreed to in the provider/insurance company contract. Line 2, as vague is the wording may be, tells us that the amount charged for that service is not paid separately from another service. This means it has been "bundled" with another service. In this case, line 2 services are bundled with line 3.

In summary ...

Charges - Jane's doctor submitted a claim for reimbursement on 3 items for services performed at the Doctor's office on 1/1/2020. The procedure codes for these services were an office visit (99214), a blood draw (36415) and a blood test for measuring her Methylmalonic Acid content (83921). The charges came to a total of $400, $167.00 for 99214, $33.00 for 36415 and $200.00 for 83921.

Adjustments - Jane's doctor has a contract with Jane's insurance company and is in-network with Jane's insurance company. Per the terms of the contract between Jane's doctor and her insurance company, the doctor has agreed to adjust or write-off a portion of their charges by $261. The doctor will accept $110 for the office visit, has agreed to allow blood draws to be bundled with blood tests and waive separate charges for 36415. They will also reduce their fee for the actual test by $171.00. The amount that remains is the allowed amount.Jane's doctor will accept this amount as payment in full for these services as agreed in their preferred provider contract with Jane's insurance comapny. The doctor cannot collect more than that amount and writes-off the difference. The total figure to settle the claim is reduced from $400.00 to $139.00

Payment Responsibility - How the allowed amount is split between Jane and her insurance company is determined by Jane's insurance plan. This data is will be used by the physician to generate a bill to the patient. Jane's billing statement will include a $20 co-payment for the office visit, $50 for her remaining deductible and a 20% co-insurance for lab tests. Jane's total share comes to $75.80. The remaining $63.20 of the allowed amount is paid by Jane's insurance comapany.

The Math ...

  • Provider Charges $167.00 + $33.00 + $200.00 = $400
  • Provider Adjustment (Discount to Insurance Company) $57.00 + $33.00 + $171 = $261.00
  • Allowed Amount $400.00 - $261.00 = $139.00
  • Patient Share $20 + $50 + $5.80 = $75.80
  • Insurance Share $139.00 - $75.80 = $63.20

Credit & Payments

Accepted forms of payment

We accept Visa, Master Card, Discover, American Express and personal checks. Insufficient fund fee is $50.

Terms and Conditions

Standard due date is 30 days from the statement date. This may vary significantly from your visit date as multiple factors can affect the billing cycle. Check out the Billing Process in the Patients tab under Billing for further information.

Patients with invoices over 60 days past due will not be allowed to make an appointment until the account is brought up to date or adequate payment arrangements are made.

Patients with invoices over 90 days may be subject to collection activity. In addition to the amount outstanding, the patient may also be held liable for collection fees, court costs and attorney's fees.

Payment plans

Payment plans may be an option at our discretion. Arrangements for payment plans can be made at the front desk and will require a valid credit or debit card.