At the Kaplan Center we pride ourselves on the hands on, high-touch, close relationships that we cultivate with our patients. There is nothing like the comfort that patients feel when they are in the company of a health care provider who, at that moment, is only there for them.
But office visits are not always possible. Work, travel, having young children at home, and countless other situations, can prevent a patient from getting the care they need. Other situations, such as reviewing data with your doctor, checking in on a treatment protocol, or refilling prescriptions, simply do not require an in-person visit. Telemedicine, or “e-visits” with a doctor, is an easy and convenient alternative when physically being in the same room with your doctor is not possible or necessary.
Several Kaplan providers* are now using an online service called SecureVideo to schedule appointments with their existing patients that we call cloudvisits. Providers and patients connect with each other electronically, and have clear, face-to-face conversations. A visit can be scheduled so that our patients, who cannot take time off work or cannot leave their home, can maintain access to their provider which otherwise would not have been possible.
Our patients who have participated in cloudvisits have been impressed and thrilled with its simplicity and convenience. We still have our in-office visits, but the cloudvisits have been a wonderful additional service which has saved both time and money.
In the right circumstance, telemedicine can be an efficient, effective, and frictionless option for our patients, and can be done practically anywhere and anytime. Communication using SecureVideo is encrypted and HIPAA compliant.
Telemedicine is reimbursable by some insurance companies. If you have out-of-network benefits please check with your insurance company to see if telemedicine is reimbursable under your plan. The CPT codes (codes used to bill office procedures) are 99215 or 99214, depending on the length of your appointment.
*Participating providers:
Dr. Gary Kaplan
Dr. Lisa Lilienfield
Jodi Brayton, LCSW, MSW
Telemedicine appointments are only available for current patients of the Kaplan Center – and – who have previously been seen at our practice. Please ask your provider if a cloudvisit is appropriate for you.
“Leaky gut has been implicated in the growing number of food and environmental sensitivities affecting almost 25 percent of American adults. These are not food allergies, but delayed hypersensitivity reactions.1
As many as 40 percent of Americans are sensitive to gluten. One in 100 of those has a severe reaction in the form of an autoimmune disease, celiac disease.2
“Imagine gluten ingestion on a spectrum,” says Dr. Allesio Fasano, head of research at the University of Maryland Celiac Research Center. “At one end, you have people with celiac disease, who cannot tolerate one crumb of gluten in their diet. At the other end, you have the lucky people who can eat pizza, beer, pasta, and cookies – and have no ill effects whatsoever. In the middle, there is this murky area of gluten reactions, including gluten sensitivity or intolerance. This is where we are looking for answers.”3
Most doctors don’t know the difference. Some are unaware that gluten sensitivity can genuinely contribute to hundreds of diseases and that the symptoms may not manifest in the gut, but in other parts of the body.4
Years ago, we believed that celiac disease was a rare childhood syndrome. Today the average age of diagnosis is in individuals between ages 40 and 60. Celiac disease affects more than 2 million Americans – 1 in 133 people.5 Researchers have already confirmed that the dramatic rise in figures is not due to greater awareness. By testing old blood samples, they have shown that, in the last 50 years, the rate of celiac disease has increased fourfold.
Gluten intolerance is now estimated to affect 6 to 9 percent of the American population. Furthermore, people in their seventies, who have eaten gluten without problems their entire lives, are now experiencing gluten sensitivity.6
Unfortunately, gluten intolerance is sometimes viewed with skepticism. When the tests come back negative for celiac disease, many doctors dismiss their patients’ complaints rather than investigating further. Part of the problem is that, like allergy tests, gluten intolerance tests are not consistently reliable. While gluten intolerance is not an allergy to gluten, we have not yet found a definitive means of identifying it in the blood.
The only absolute way to determine gluten intolerance is to completely remove gluten from the diet for 6 weeks and see if the symptoms improve. It can be hard to tell. If there are other food intolerances and nutritional deficiencies at play, removing gluten may only eliminate some of the symptoms.
Peter Green, MD, director of the Celiac Disease Center, estimates that research into gluten intolerance is about 30 years behind celiac research.7 Without better research, patients are too often told it’s “all in their heads.” With a burgeoning series of product lines of gluten-free foods, estimated at $2.6 billion in sales last year alone, it is easy to assume that gluten intolerance is nothing more than a fad.8
It’s widely known that agricultural changes in wheat production over the past decades have altered wheat significantly and raised both its protein and gluten content.9 Some ascribe gluten sensitivity to the increase in our consumption of wheat. Gluten can now be found in everything from bread and canned goods to hand lotion and makeup.10 But the evidence is inconsistent. And the cause may lie in the bacteria in the gut itself. We’re beginning to suspect that gut bacteria determine whether the immune system treats gluten as food or as a deadly invader.11
In his studies of celiac disease, Dr. Fasano made an important discovery. He studied 47 newborns who were genetically at-risk for developing celiac disease. By the time they were 2 years old, these children had a fairly impoverished and unstable community of intestinal bacteria.12 As he continued to monitor their bacterial levels, the levels of lactobacilli declined in two children.
Both developed autoimmune diseases. One got celiac disease, and the other type 1 diabetes (which has a genetic proclivity similar to that of celiac disease).13
Dr. Fasano and his colleagues were excited. “Imagine what would be the unbelievable consequences of this finding,” he said. “Keep the lactobacilli high enough in the guts of these kids, and you prevent autoimmunity.”14
The questions is, was it the chicken or the egg? Which came first, the imbalance of bacteria or the autoimmune disease? Some studies show that intestinal inflammation accommodates bacteria that keep the inflammation going.15 As we’ve already observed, bacteria learn and fight hard to survive.
It’s a living system, where different choices can be made at any stage. Our genetics help determine our bacteria, but the bacteria can change us – turning genes off and on, adapting as they go. According to Bana Jabri, director of research at the University of Chicago Celiac Disease Center, even if the chicken comes first, the egg can contribute. “You have the same endpoint,” she says, “but how you get there may be variable.” Such complexity both confounds notions of one-way causality and suggests different paths to the same disease.16″
1 Lipski, Digestive Wellness
2 A. Fasano, “Zonulin and Its Regulation of Intestinal Barrier Function: The Biological Door to Inflammation, Autoimmunity, and Cancer,” Physiological Review 91, no. 1 (January 2011): 151–75, www.ncbi.nlm.nih.gov/pubmed/21248165.
3 Ibid.
4 Ibid.
5 A. Fasano et al., “Prevalence of Celiac Disease in At-Risk and Not-At-Risk Groups in the United States,” Archives of Internal Medicine 163, no. 3 (February 20, 2003): 286–92, www.ncbi.nlm.nih.gov/pubmed/12578508.
6 Melinda Beck, “Clues to Gluten Sensitivity,” Wall Street Journal, March 15, 2011, http://online.wsj.com/news/articles/SB10001424052748704893604576200393522456636.
7 Ibid.
8 Ibid.
9 Ibid.
10 Moises Velasquez-Manoff, “Who Has the Guts for Gluten?” New York Times, February 23, 2013, www.nytimes.com/2013/02/24/opinion/sunday/what-really-causesceliac-disease.html.
11 Ibid.
12 Ibid.
13 Ibid.
14 Ibid.
15 Ibid.
16 Ibid.
“When scientists realized that 70 percent of our immune system was located in and around our digestive systems, it was a staggering discovery. Unlikely as it seems, one of the primary reasons for this is bugs. We are only just beginning to comprehend how much we rely on these colonies of microscopic bacteria. Our health is dependent on the trillions of bacteria in our guts.
Ever since 1674, when Dutch scientist Anton van Leeuwenhoek first observed bacteria with a single-lens microscope, some of our biggest medical breakthroughs have involved getting rid of bacteria. The process of pasteurization, discovered by Louis Pasteur, was based on killing bacteria by heating milk to make it safer to consume. In 1905, Robert Koch won the Nobel Prize for proving that bacteria can cause disease, reinforcing the idea that bacteria are best avoided.
It has long been suspected that the bubonic plague (the Black Death), which wiped out an estimated one-third of Europe’s population from the 14th to 18th centuries, was caused by an infectious bacteria. Only as recently as November 2012 did anthropologists finally confirm that this devastating disease had indeed been caused by bacteria, after carefully examining the DNA of skeletons buried in “plague pits” throughout France, Italy, Germany, and the Netherlands.
Although they hadn’t known how the plague was being passed from person to person, physicians like Nostradamus, who recommended hand washing and clean linens (free from plague bacteria), earned their reputations by reducing the spread of the disease.
It’s stories like this that have led us to, rightly, associate bacteria with disease. By the 21st century, we’ve established a trend for keeping our environments as clean as possible, improving sanitation, dispensing vaccinations, taking antibiotics at the least sign of infection, and supporting a thriving industry in antibacterial soaps and cleaners.
Our enthusiasm for cleanliness may have taken us too far. We didn’t understand the nature of bacterial flora in our intestines and how vital they were to our health. The contemporary “hygiene hypothesis” suggests that it is the continual exposure to bacteria in early childhood that helps us build strong immune systems. When children are protected from contaminants, they are actually at greater risk for asthma, allergies, food sensitivities, and immune disorders.”
1 Lipski, Digestive Wellness
2 Carlo M. Cipolla, “A Plague Doctor,” in The Medieval City, edited by Harry A. Miskimin, David Herlihy, and A. L. Udovitch (New Haven, CT: Yale University Press, 1977).
3 Lipski, Digestive Wellness
Telemedicine – Another Way to Access the Doc
/in News, Wellness/by Lisa Lilienfield, MDAt the Kaplan Center we pride ourselves on the hands on, high-touch, close relationships that we cultivate with our patients. There is nothing like the comfort that patients feel when they are in the company of a health care provider who, at that moment, is only there for them.
But office visits are not always possible. Work, travel, having young children at home, and countless other situations, can prevent a patient from getting the care they need. Other situations, such as reviewing data with your doctor, checking in on a treatment protocol, or refilling prescriptions, simply do not require an in-person visit.
Telemedicine, or “e-visits” with a doctor, is an easy and convenient alternative when physically being in the same room with your doctor is not possible or necessary.
Several Kaplan providers* are now using an online service called SecureVideo to schedule appointments with their existing patients that we call cloudvisits. Providers and patients connect with each other electronically, and have clear, face-to-face conversations. A visit can be scheduled so that our patients, who cannot take time off work or cannot leave their home, can maintain access to their provider which otherwise would not have been possible.
Our patients who have participated in cloudvisits have been impressed and thrilled with its simplicity and convenience. We still have our in-office visits, but the cloudvisits have been a wonderful additional service which has saved both time and money.
In the right circumstance, telemedicine can be an efficient, effective, and frictionless option for our patients, and can be done practically anywhere and anytime. Communication using SecureVideo is encrypted and HIPAA compliant.
Telemedicine is reimbursable by some insurance companies. If you have out-of-network benefits please check with your insurance company to see if telemedicine is reimbursable under your plan. The CPT codes (codes used to bill office procedures) are 99215 or 99214, depending on the length of your appointment.
*Participating providers:
Dr. Gary Kaplan
Dr. Lisa Lilienfield
Jodi Brayton, LCSW, MSW
Telemedicine appointments are only available for current patients of the Kaplan Center – and – who have previously been seen at our practice. Please ask your provider if a cloudvisit is appropriate for you.
"What Gluten Does" An Excerpt from Total Recovery
/in Digestive Issues, Nutrition/by Gary Kaplan, DOThe following is the third in a series of excerpts on gut health from Dr. Gary Kaplan’s book “Total Recovery: A Revolutionary New Approach to Breaking the Cycle of Pain and Depression.”
“Leaky gut has been implicated in the growing number of food and environmental sensitivities affecting almost 25 percent of American adults. These are not food allergies, but delayed hypersensitivity reactions.1
As many as 40 percent of Americans are sensitive to gluten. One in 100 of those has a severe reaction in the form of an autoimmune disease, celiac disease.2
“Imagine gluten ingestion on a spectrum,” says Dr. Allesio Fasano, head of research at the University of Maryland Celiac Research Center. “At one end, you have people with celiac disease, who cannot tolerate one crumb of gluten in their diet. At the other end, you have the lucky people who can eat pizza, beer, pasta, and cookies – and have no ill effects whatsoever. In the middle, there is this murky area of gluten reactions, including gluten sensitivity or intolerance. This is where we are looking for answers.”3
Most doctors don’t know the difference. Some are unaware that gluten sensitivity can genuinely contribute to hundreds of diseases and that the symptoms may not manifest in the gut, but in other parts of the body.4
Years ago, we believed that celiac disease was a rare childhood syndrome. Today the average age of diagnosis is in individuals between ages 40 and 60. Celiac disease affects more than 2 million Americans – 1 in 133 people.5 Researchers have already confirmed that the dramatic rise in figures is not due to greater awareness. By testing old blood samples, they have shown that, in the last 50 years, the rate of celiac disease has increased fourfold.
Gluten intolerance is now estimated to affect 6 to 9 percent of the American population. Furthermore, people in their seventies, who have eaten gluten without problems their entire lives, are now experiencing gluten sensitivity.6
Unfortunately, gluten intolerance is sometimes viewed with skepticism. When the tests come back negative for celiac disease, many doctors dismiss their patients’ complaints rather than investigating further. Part of the problem is that, like allergy tests, gluten intolerance tests are not consistently reliable. While gluten intolerance is not an allergy to gluten, we have not yet found a definitive means of identifying it in the blood.
The only absolute way to determine gluten intolerance is to completely remove gluten from the diet for 6 weeks and see if the symptoms improve. It can be hard to tell. If there are other food intolerances and nutritional deficiencies at play, removing gluten may only eliminate some of the symptoms.
Peter Green, MD, director of the Celiac Disease Center, estimates that research into gluten intolerance is about 30 years behind celiac research.7 Without better research, patients are too often told it’s “all in their heads.” With a burgeoning series of product lines of gluten-free foods, estimated at $2.6 billion in sales last year alone, it is easy to assume that gluten intolerance is nothing more than a fad.8
It’s widely known that agricultural changes in wheat production over the past decades have altered wheat significantly and raised both its protein and gluten content.9 Some ascribe gluten sensitivity to the increase in our consumption of wheat. Gluten can now be found in everything from bread and canned goods to hand lotion and makeup.10 But the evidence is inconsistent. And the cause may lie in the bacteria in the gut itself. We’re beginning to suspect that gut bacteria determine whether the immune system treats gluten as food or as a deadly invader.11
In his studies of celiac disease, Dr. Fasano made an important discovery. He studied 47 newborns who were genetically at-risk for developing celiac disease. By the time they were 2 years old, these children had a fairly impoverished and unstable community of intestinal bacteria.12 As he continued to monitor their bacterial levels, the levels of lactobacilli declined in two children.
Both developed autoimmune diseases. One got celiac disease, and the other type 1 diabetes (which has a genetic proclivity similar to that of celiac disease).13
Dr. Fasano and his colleagues were excited. “Imagine what would be the unbelievable consequences of this finding,” he said. “Keep the lactobacilli high enough in the guts of these kids, and you prevent autoimmunity.”14
The questions is, was it the chicken or the egg? Which came first, the imbalance of bacteria or the autoimmune disease? Some studies show that intestinal inflammation accommodates bacteria that keep the inflammation going.15 As we’ve already observed, bacteria learn and fight hard to survive.
It’s a living system, where different choices can be made at any stage. Our genetics help determine our bacteria, but the bacteria can change us – turning genes off and on, adapting as they go. According to Bana Jabri, director of research at the University of Chicago Celiac Disease Center, even if the chicken comes first, the egg can contribute. “You have the same endpoint,” she says, “but how you get there may be variable.” Such complexity both confounds notions of one-way causality and suggests different paths to the same disease.16″
1 Lipski, Digestive Wellness
2 A. Fasano, “Zonulin and Its Regulation of Intestinal Barrier Function: The Biological Door to Inflammation, Autoimmunity, and Cancer,” Physiological Review 91, no. 1 (January 2011): 151–75, www.ncbi.nlm.nih.gov/pubmed/21248165.
3 Ibid.
4 Ibid.
5 A. Fasano et al., “Prevalence of Celiac Disease in At-Risk and Not-At-Risk Groups in the United States,” Archives of Internal Medicine 163, no. 3 (February 20, 2003): 286–92, www.ncbi.nlm.nih.gov/pubmed/12578508.
6 Melinda Beck, “Clues to Gluten Sensitivity,” Wall Street Journal, March 15, 2011, http://online.wsj.com/news/articles/SB10001424052748704893604576200393522456636.
7 Ibid.
8 Ibid.
9 Ibid.
10 Moises Velasquez-Manoff, “Who Has the Guts for Gluten?” New York Times, February 23, 2013, www.nytimes.com/2013/02/24/opinion/sunday/what-really-causesceliac-disease.html.
11 Ibid.
12 Ibid.
13 Ibid.
14 Ibid.
15 Ibid.
16 Ibid.
Reprinted from Total Recovery: A Revolutionary New Approach to Breaking the Cycle of Pain and Depression by Gary Kaplan, D.O., with permission from Rodale Books. Copyright (c) 2014 by Gary Kaplan, D.O..
To read Part 1 of this series, “Gut Feelings,” click here.
To read Part 2 of this series, “Hidden Immune System,” click here.
“Hidden Immune System”: An Excerpt From Total Recovery
/in Digestive Issues, Wellness/by Gary Kaplan, DOThe following is the second in a series of excerpts on gut health from Dr. Gary Kaplan’s book “Total Recovery: A Revolutionary New Approach to Breaking the Cycle of Pain and Depression.”
“When scientists realized that 70 percent of our immune system was located in and around our digestive systems, it was a staggering discovery. Unlikely as it seems, one of the primary reasons for this is bugs. We are only just beginning to comprehend how much we rely on these colonies of microscopic bacteria. Our health is dependent on the trillions of bacteria in our guts.
Ever since 1674, when Dutch scientist Anton van Leeuwenhoek first observed bacteria with a single-lens microscope, some of our biggest medical breakthroughs have involved getting rid of bacteria. The process of pasteurization, discovered by Louis Pasteur, was based on killing bacteria by heating milk to make it safer to consume. In 1905, Robert Koch won the Nobel Prize for proving that bacteria can cause disease, reinforcing the idea that bacteria are best avoided.
It has long been suspected that the bubonic plague (the Black Death), which wiped out an estimated one-third of Europe’s population from the 14th to 18th centuries, was caused by an infectious bacteria. Only as recently as November 2012 did anthropologists finally confirm that this devastating disease had indeed been caused by bacteria, after carefully examining the DNA of skeletons buried in “plague pits” throughout France, Italy, Germany, and the Netherlands.
Although they hadn’t known how the plague was being passed from person to person, physicians like Nostradamus, who recommended hand washing and clean linens (free from plague bacteria), earned their reputations by reducing the spread of the disease.
It’s stories like this that have led us to, rightly, associate bacteria with disease. By the 21st century, we’ve established a trend for keeping our environments as clean as possible, improving sanitation, dispensing vaccinations, taking antibiotics at the least sign of infection, and supporting a thriving industry in antibacterial soaps and cleaners.
Our enthusiasm for cleanliness may have taken us too far. We didn’t understand the nature of bacterial flora in our intestines and how vital they were to our health. The contemporary “hygiene hypothesis” suggests that it is the continual exposure to bacteria in early childhood that helps us build strong immune systems. When children are protected from contaminants, they are actually at greater risk for asthma, allergies, food sensitivities, and immune disorders.”
1 Lipski, Digestive Wellness
2 Carlo M. Cipolla, “A Plague Doctor,” in The Medieval City, edited by Harry A. Miskimin, David Herlihy, and A. L. Udovitch (New Haven, CT: Yale University Press, 1977).
3 Lipski, Digestive Wellness
Reprinted from Total Recovery: A Revolutionary New Approach to Breaking the Cycle of Pain and Depression by Gary Kaplan, D.O., with permission from Rodale Books. Copyright (c) 2014 by Gary Kaplan, D.O..
To read Part 1 of this series, “Gut Feelings,” click here.
To read Part 3 of this series, “What Gluten Does,” click here.