Welcome to the first of the Eugene Daily News’ relationship advice column. As a Licensed Marriage & Family Therapist and Licensed Professional Counselor specializing in working with couples, I’ve treated a wide variety of relationship issues, yet all of them seem to have one thing in common: Often the way couples try to solve problems IS the problem.My role as a couples therapist, is to help people see how even a small change in the way each partner interacts with one another can result in a significant improvement in relational satisfaction. As therapists focused on relationships, my colleagues and I at Eugene Therapy are known for our direct, straight forward approach to treatment. Most of us trained at the University of Oregon’s Couples & Family Therapy program and are in practice in the community. While an advice column isn’t therapy, we still plan to respond to your most pressing email/text/mail relationship questions in a similar ‘call it like we see it’ fashion.
From dating to living together to marriage, to questions about managing kids, chores and the in-laws, please send in your questions to advice@eugenedailynews.com and we’ll do our best not to disappoint!

Q: Whenever I bring up marriage, my boyfriend brings up his recently divorced parents. We’ve been dating four years, and I feel it’s time to take the next step, but he’s still hesitant to even discuss it. Any advice?

MZ: Sounds like you’re saying your boyfriend has cold feet. This feels like a real dilemma for you, but it’s also an opportunity. Let’s start with thinking about what NOT to do. You may be thinking about making demands, ultimatums or even playing ‘hard to get’. Think again. These attempts are likely to backfire. If you walked into a restaurant and the waiter demanded you chose a certain dish, the best the waiter could hope for is for you to acquiesce out of fear (but you’d likely never return to that restaurant). Similarly, ultimatums don’t work. They are recipes for resentment.

Given your partner’s experience of living through the divorce of his parents, his hesitation is completely reasonable. One might argue it’s actually a good sign that shows he IS thinking about you in a serious way but is realistic about the fact that many marriages do end in divorce.

Want to show him what a great prospect you really are? Then try validation. Not only with words, (for example, “It makes sense that you are thinking about your parents. Long term commitments can be really scary!”) but also with deeds. In some way he is saying to you, ‘I need space… I need time.’ The supportive and loving response is to grant it to him. Not as a gift or as giving in, but as both a demonstration of understanding and an opportunity for you to work on building your own individual life. Like they say on airplanes, put the oxygen mask on yourself before helping others around you. Similarly, take time to engage in activities outside the relationship. Exercise, dinners/coffee with friends, start a book club with your girlfriends, take a class. Do things for yourself that subtly say:

1) ‘I matter and I choose me’ and

(2) ‘By the way, if you were smart, you’d choose me too ’

Look, you can’t ultimately make people choose who or what you’d like them to choose. It may sound like a cliche`, but your best bet is to accept where he’s at right now, continue with your relationship as is, while you work on enhancing your own individual life. There’s a good chance he’d be more attracted to spending a lifetime with the ‘accepting, interested, engaged you’ rather than the ‘demanding, invalidating you’.

There is no guarantee this will work. But there is a guarantee that the alternative (demands, ultimatums) will not. But even if it doesn’t work out, you’ll end up with a better version of yourself!

Q: My partner and I have been seeing each other for 10 years. We have two great kids but we never seem to go on dates, or when we do, we end up talking about paying bills or other household chores.

MZ: This is a common problem. You and your partner started your lives together as romantic partners, but somehow along the way you may have turned into what seems more like business partners. This makes perfect sense. After all, so much of your time is spent managing kids, carpools and household chores let alone bills.

The secret to managing this is to agree to limit family business conversations to a specific day(s) of the week. For example, why not decide to have a once weekly partners-only meeting where say from 8 to 8:30 PM on Monday evenings, you discuss family business issues (bills, insurance, who’s going to take out the recycling).

The two of you then need to agree that barring a ’911′ situation (and by 911 I mean, foreclosure, very sick kid, you get the drift) you agree to NOT discuss family business issues other than the agreed upon day/time. This may sound rigid, but if you really think about it, this is exactly what the two of you did when you first started dating. You discussed how you feel about one another, what your goals, hopes and dreams are, what to have for dinner, when to have sex, etc. The way to return to those days of yore is to schedule dates and even mini-dates (like a 15 minute walk around the block) with your partner that will focus on one another and avoid all conversations about the laundry, diapers and changing the furnace filter.

Couples often find that when they set limits on family business discussions they inevitably find more time for one another.

• Marc Zola, LMFT & LPC - Eugene Therapy
  Marc Zola, LMFT & LPC is a psychotherapist specializing in relationship issues and is the founder of Eugene Therapy
  

  A graduate of the University of Oregon’s Couples & Family, Marc is also a National Certified Counselor and a Clinical Member of the American Association of Marriage & Family Therapists. Prior to starting Eugene Therapy, Marc was a psychotherapist for PeaceHealth & Sacred Heart Medical Center.

  Marc specializes in treating anxiety, depression and relationship issues. He has a knack for identifying problematic patterns of thought and behavior that tend to keep clients stuck and considers himself a “directive” therapist who readily provides honest feedback to clients.

  Marc shares his expertise with students as an adjunct instructor for the University of Oregon’s Couples & Family Therapy program. He is a popular presenter and a published author on the topic of best practices for treating the most challenging relationship issues. Marc also offers clinical supervision to LPC and LMFT interns and is on the clinical supervision registry for the State of Oregon.

  Eugene Therapy, is a private group practice providing mental wellness treatment for individuals, couples and families. Eugene Therapy LLC is located at 401 East 10th Avenue, Suite 330, Eugene OR 97401. 541-868-2004. Online at www.EugeneTherapy.com

  Marc Zola, LMFT & LPC is a psychotherapist specializing in relationship issues and is the founder of Eugene Therapy A graduate of the University of Oregon’s Couples & Family, Marc is also a National Certified Counselor and a Clinical Memb more...

The Medicare program has instituted an important change to the Annual Election Period for 2012 and many beneficiaries aren’t aware of it. The Annual Election Period (AEP) is the time that Medicare allows members to make changes to their health plan choices for the next year.

The Medicare AEP for the 2012 year began Oct. 15. Unlike past years, this AEP ends Dec. 7, which may leave procrastinators in a scramble. 

If Medicare recipients are not aware of the current changes, they could be left out in the cold. Photo courtesy of Medicare.org

Also, options for Medicare Advantage plans in Lane County have expanded. In addition to the stalwarts such as Providence, Regence and Health Net, local health insurer PacificSource is entering the market.

Like its competitors, PacificSource offers a variety of plans with varying monthly premiums, from zero to $78. 

Since Medicare plans vary, recipients must weigh their options to choose the right plan for their circumstances.

The two different plans are called Medicare Supplement/Medigap and Medicare Advantage and are used in conjunction with the original Medicare benefits.

With Medicare Supplements, plan benefits will be the same regardless of which insurance company you choose. The alphabet soup of standardized plans differs only in premium and in some joining requirements.

Also, Medigap plans do not include prescription drug coverage. Patients with Medicare Supplement may also wish to select a separate prescription drug plan (PDP) at an additional expense.

Medigaps allow patients to see any US doctor who contracts with Medicare. But it is not without its problems.

Some doctors don't accept Medicare patients. Photo courtesy of Medicare.org.

Continuous cuts in Medicare’s reimbursement to providers have resulted in some doctors refusing to see patients who only have Medicare or Medicare/Medigap plan.

But with a Medicare Supplement, aside from the premium, most members do not have additional cost-sharing. As long as it is a Medicare-covered benefit, the Medigap plan pays the remainder after Medicare has paid its portion.

People who have significant health problems and who know that they may require expensive procedures in the coming year may benefit from this option.

Medicare Advantage plans are very different from Medigap. 

Some Medicare Advantage (MA) plans have no premium. Unlike Medicare Supplement plans, MA plans are paid each month by Medicare, which covers the services that original Medicare covered.

MA plans that offer no-premium options have generally arranged the benefits and co-pays in a way that makes it financially feasible to do so. Many of these plans also include prescription benefits, and can be a good choice for consumers seeking to cut costs.

Some patients may have to pay more out-of-pocket fees if their doctor doesn't follow their particular plan. Photo courtesy of Mobilityspecialists.net.

MA’s co-pays for each service or benefit include daily charges for hospitalization, skilled nursing services, emergency room visits and ambulance transport.

Starting at the beginning of 2011, Medicare began requiring all providers to offer preventive services like routine physical exams, colorectal screenings and mammograms, at no cost to members.

Some MA plans require patients to choose one of its preferred providers. Such is the case, too, with many Health Maintenance Organizations (HMOs), which may also demand your primary doctor refer you in order to see a specialist. HMOs will not, in most cases, pay for doctors who are not on their list.

Preferred Provider Organizations (PPOs) work very differently.

If you choose a PPO, you may see any doctor anytime, as long as they contract with Medicare. If you see a doctor that contracts with your particular health plan, you may be entitled to lower co-pays.

Patients who see a provider not affiliated with their plan may have to pay more out of pocket. However, PPOs do no require a referral to see a specialist.

One of the greatest advantages of choosing an MA plan is that most include prescription drug benefits, and there is no additional premium for this benefit.

People who want to change their plan or simply want to get more information should contact the individual health plans, a licensed insurance agent or a SHIBA volunteer. SHIBA volunteers are impartial volunteers who offer assistance to Medicare beneficiaries and can be contacted through the Campbell Senior Center or the Willamalane Adult Activity Center.

NEXT INSTALLMENT:  Who needs a plan in addition to Medicare?  How do I choose a Prescription Drug Plan?

A newer, safer type of medical imaging has made its way to the Eugene area, and those in the medical field are seeing promising returns.

Oregon Imaging Centers recently received a three-year approval for PET/CT imaging from the most highly-regarded accrediting body, the Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories (ICANL).

PET/CT imaging and scanner from Oregon Imaging Center

Positron Emission Tomography and Computed Tomography, or PET/CT imaging, is a combination of two scans
that allow medical practitioners to pinpoint the location and extent of cancers, dementias and cardiac illnesses by looking at metabolic and structural changes in the body. 

Oregon Imaging Centers is the only center in Oregon approved for both oncological and neurological diagnoses, and only center approved by ICANL, which is considered the gold standard of nuclear medicine accreditation providers.

In 2007 an article published in the New England Journal of Medicine publicized the overuse of CT scans in the US, and the related cancer risk of exposing organs to low doses of radiation. Since then, media reports fraught with information about the dangers of high radiation levels have caused fear in many people about being overexposed.  The FDA also acknowledges that CT scans are associated with a higher risk of lifetime cancer and says the usage of adult-sized radiation doses in children can be particularly harmful.

The combined PET/CT scan delivers less radiation than a regular CT scan, so the danger of radiation is greatly diminished. And in the event that cancer is already suspected, the fear of low-dose radiation pales in comparison to other disease-related complications. Additionally, over 90% of the radioactivity from the PET portion of the scan is gone by the time the patient leaves the exam.  The only populations this diagnostic tool is contraindicated for are pregnant and lactating women, but even in lactating women the radiation is thought to be cleared from the breast milk within twelve hours of the test.

An example of (A) CT imaging, (B) PET imaging, and (C) combined PET/CT imaging. From Wikipedia/Renato M.E. Sabbatini, PhD

The PET/CT process uses an injected radioactive substance called fluorodeoxyglucose (or FDG) to highlight abnormal areas within the body. Similar to glucose, which fuels tissues throughout the body, FDG is taken up more eagerly by high-metabolizing abnormalities in the body. So areas that are more metabolically active, like cancerous tumors, draw attention to themselves through their greediness.

Neurological disorders such as Alzheimer’s and Parkinson’s diseases respond similarly in the brain. With an injection of FDG, the compound will accumulate in certain areas, which will then be highlighted on the PET scan images. Add the CT component (Computerized Tomography,) and you have a very specific picture of the disease.

PET(-only) scanners, which Oregon Imaging Centers used before receiving the new accreditation, can differentiate between malignant and benign lesions, and determine the spread of disease. Adding the CT component is incredibly helpful in identifying specific anatomic locations. The dual imaging technique of the PET/CT provides a much more specific picture of disease, especially when it comes to detecting cancer.  

The PET/CT scan is of enormous assistance in both diagnosis of cancer, and in evaluating the effectiveness of therapy.  Luke Breazeal, manager of the PET/CT Department at Oregon Imaging Centers said there are four key times to perform a scan: 

(1) When something malignant is detected or highly suspected
(2) to identify the extent
(3) in the middle of chemotherapy
(4) after completion of chemotherapy 

With just one scan, you can identify cancer, determine its extent in the body, and stage (or establish how far the cancer has progressed.)  For many types of cancer a PET scan can show if a therapy is effective: If a significant decrease in the tumor burden is not seen after a few rounds of chemotherapy, the therapy can be switched, saving valuable time, reducing cost, and increasing life expectancy.

PET image of a brain with Alzheimer's

Although over 90% of PET/CT scans address oncological disorders, it’s an incredibly helpful tool in neurological diagnosis and treatment planning.  In “dementia imaging,” Breazeal said, “we see characteristic metabolic patterns for each specific type of dementia.”   Each of the dozens of different types of dementia displays a unique pattern of glucose (and thus FDG) uptake, and identifying the correct type puts doctors on the right track to choosing a treatment plan. Before PET scans, the only way to definitively diagnose Alzheimer’s was through autopsy.

With the green light from ICANL, Oregon Imaging has seen about a 50% increase in volume for PET/CT imaging.  According to Breazeal, the clinic does about 80-100 scans a month, mostly for oncological purposes.  More information about Oregon Imaging Centers and its new accreditation can be found on its website at www.oregonimaging.com.

Another example of PET/CT fusion imaging of the whole body

1) improve the lifelong health of all Oregonians;
2) improve the quality, availability, and reliability of care; and
3) lower or contain the cost of care.

However the new CCOs are organized, ensuring an adequate primary care workforce will be a critical requirement for success. Primary care providers (PCPs) form the backbone of healthcare, and provide basic healthcare services – including initial assessment and treatment, referral to specialists, prevention counseling, and vaccination. In the last several decades, however, the percentage of physicians entering primary care has steadily declined. The lack of these providers has been directly related to how much less they are reimbursed than MDs and DOs (doctors of osteopathy) that choose to enter specialties (surgery, radiology, anesthesiology).

To help fill the gap, nurse practitioners and physician’s assistants have been trained at higher levels of knowledge and responsibility, and now offer primary care with varying levels of independence. In Oregon, nurse practitioners may practice independently but physician’s assistants are required to have a portion of their charts reviewed by supervising physicians. Regardless of their degree or level of training, all PCPs are expected to recognize situations beyond their scope and training, and to refer to other providers as needed.

Naturopathic physicians are similarly licensed by the state of Oregon to act as independent primary-care providers, and have authority and responsibility to diagnose and treat disease, order lab tests, refer to specialists, prescribe pharmaceuticals, and administer vaccinations. In addition, NDs have significant training in evidence-based botanical medicine, mind-body interactions, nutrition, and physical medicine that few MDs, nurse practitioners, or physician’s assistants have ever been exposed to. Training is a 4-year program, and requires all of the same pre-medical sciences that MDs and DOs take before starting their programs.

Recognizing the training NDs have undergone, the state of Oregon gives NDs broad authority and responsibility to practice independently.

Currently, the Oregon Health Authority credentials naturopathic physicians to act as primary care physicians through the Oregon Health Plan’s “Open Card” program. In most counties, however, the Oregon Health Plan is administered through local managed-care organizations. Despite ND’s legal authority and the recognition of the Oregon Health Authority, most of these local managed-care plans do not cover NDs in any capacity.

There is some logic to this resistance – most NDs offer therapies that are outside mainstream medical thought. Whether these therapies have evidence to support their use, have fewer side effects, or are less expensive, it is understandable that publicly-funded health plans might be reticent to cover such “alternative” therapies. Naturopathic doctors are also trained and licensed to provide “conventional care,” and naturopathic licenses hold NDs legally responsible for the patients that seek care. If somebody has a urinary tract infection and cranberry juice hasn’t solved the problem, NDs will call in the prescription for an antibiotic.

And what about those “alternative” therapies that NDs are so (in)famous for?  Debate certainly rages about the validity of many approaches, especially more esoteric approaches such as homeopathy and acupuncture, but when researchers have asked “real-world” questions about how NDs perform when managing patients (which is really where the rubber hits the road), results are almost uniformly positive – and include tremendous cost-savings. A 2010 study conducted by researchers affiliated with the University of Washington, found that patients using alternative therapies for such common conditions as fibromyalgia, menopause, and back pain spent up to $1410 less on healthcare for their conditions than on patients that didn’t use alternative therapies.

Several studies conducted by the Canadian College of Naturopathic Medicine and sponsored by the Canadian Postal Service have found that postal employees offered care by naturopathic doctors had comparable costs when working with an MD, but frequently had greater productivity at work and fewer side effects from conventional pharmaceuticals. Conditions studied so far have included rotator cuff problems, back pain, anxiety, and heart disease risk factors (blood pressure and high cholesterol) – all very common conditions seen in primary care.

Naturopathic physicians have the numbers to play a significant role in helping to alleviate the primary-care shortage. There are presently about 700 naturopathic physicians licensed in Oregon, and 22 in Lane County alone (most of those 22 are doing primary care in one form or another). The naturopathic college in Portland graduates about 80 new NDs each year – approximately the same number of primary-care MDs that graduate from OHSU. With increased opportunities to offer care within the state of Oregon, many NDs that would otherwise leave will be more likely to stay within the state.

There would be other benefits to incorporating NDs into the new Coordinated Care Organizations. It would become easier to share ideas and knowledge with other providers already firmly ensconced within the conventional medical world. Best practices from the realm of “alternative” medicine will have a better chance of saving the system money. Most importantly, the goal is to see patients living healthier lives.

On Wednesday, October 12, from 6-8pm at Campbell Senior Center (155 High Street), the Oregon Health Authority is seeking input from citizens in Eugene and surrounding areas about the future of publicly-funded healthcare in Oregon.  Give your support to the inclusion of NDs as primary-care providers in the new system.

- Bill Walter ND

Dr. Bill Walter, ND

In addition to his private practice at Golden Apple, Dr. Walter works with Lane County Community Health and HIV Alliance to provide wound care to underserved individuals on the streets of Lane County.