About Nisha Bunke

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So far Nisha Bunke has created 107 blog entries.

13, 1, 2021

Dr. Bunke in Authority Magazine

2022-01-04T04:04:50-08:00

From an interview with Candice Georgiadis Candice Georgiadis 

ASa part of my interview series with prominent medical professionals about “How To Grow Your Private Practice” I had the pleasure of interviewing Dr. Nisha Bunke, MD, FAVLS, RPhS.

Dr. Nisha Bunke is a venous disease specialist, who founded La Jolla Vein Care, San Diego’s only accredited vein center in 2010. She was the first physician in the United States to complete fellowship training in this specialty supported by the American Vein and Lymphatic Society and is a diplomate of the American Board of Venous and Lymphatic Medicine. She is also the author of the medical textbook, The Vein Book (Oxford Univ. Press 2013), numerous scientific publications, and CEO of Recova, Inc.

am a venous disease specialist, meaning I treat the entire spectrum of superficial venous disease affecting the legs, including painful varicose veins, leg ulcers and blood clots. This is a niche specialty that has been growing over the past decade because vein conditions are so common. I was the first physician in the United States to complete fellowship training in this specialty, which is supported by the American Vein and Lymphatic Society. Venous disease is pervasive. During the early years of my private practice, I also served as a volunteer clinical instructor at UCSD, where I treated patients at UCSD Medical Center as well as the Veteran’s Affairs Medical Center.

Earlier on, I did not plan on having a private practice. However, while working in university and government medical settings, I saw obstacles that prevented patients from getting fast and convenient access to vein care. I liked the idea of being able to control the patient experience and creating a concierge-style, individualized and patient-centered practice. Being a physician and business owner allows you to exercise both parts of the brain. The medical decision-making, science and data-driven part of the brain is ingrained in any physician, but the business owner side allows one to be creative, making creative decisions from areas ranging from website functionality and design to how to effectively market and grow the practice.

As a provider and business owner, I tried to do everything myself for many years. That is a quick way to experience burn out. For balance, I’ve learned to delegate things that can be delegated. As a physician, I can’t delegate patient care and my judgment, but I can delegate business-related roles, which is why it is valuable to surround yourself with a strong and supportive team. The right team members will make your job a lot easier.

When I’m seeing patients, I’m 100 percent dedicated to patient care, not considering business at all. With a heavy patient load, I used to find myself working on the business itself on the weekends and evenings, until I eventually hired other physicians and nurse practitioners to help with the patient load. This allowed me to have more administrative time, which is important for accomplishing work related to quality of patient care like quality assurance reviews, overseeing our facility accreditation and allowing time to have team meetings, staff training and other marketing and business administration tasks. If you really care about your practice, it makes sense to spend time on things that count — from the quality of care you provide to patients to the attention and training employees receive.

Ultimately, it is the practice owner’s responsibility for the quality of care delivered and upheld within the practice.

The biggest hurdle that is prominent in my mind is the financial hurdles medical practices tend to experience. I think you have to be open-minded that it can take several years to really become established, especially when your business is heavily reliant on word of mouth referrals. There is so much to prove, and it takes patience and, of course, time.

I had to learn it was all simply part of the process. Without failure, there are no learning curves to grow from. One of the most important things a person should keep in mind if they’re hoping to start their own practice is realizing there are going to be failures, just like any other business will experience.

Know your patients. You know your patients and what is in their best interest. Use this knowledge to your benefit and market your business and experience to the audience accordingly. If you have patient reviews and testimonials, for instance, learn from them to improve a future service or to boost your practice’s credibility and reputation. Knowledge is power. Take what you know about your patients and use that to reach future individuals who may not have even been aware they needed your service.

Be involved with the management of your team. Patients tend to compliment my staff often, and they say that employee attitudes trickle down from the top. I agree with this, and I have noticed if customer service is not on par, it usually is tied to the top. If there is a staff member who tends to be a little less friendly, maybe it’s because their boss isn’t too friendly themselves.

Research EMR options. This is a must! There are many different types of electronic medical record (EMR) options, some are specialty-specific. I have seen EMRs that are touted but would not be right for my practice because of my documentation preferences and need to incorporate ultrasound and leg images, or inability to utilize text and email appointment reminders, or lack of billing capabilities. All EMRs are very different. I recommend trying different EMRs out before committing to one.

Consider outsourcing billing. I outsourced billing for the first few years of my practice, which is a cost-efficient option for practices starting out. If you choose to do billing in-house, your billing expert needs to be experienced and detail-oriented.

Consider outsourcing HR. For small practices, it doesn’t make sense to hire a full-time HR professional. Instead, we use a professional employer organization (PEO) company to offer employee benefits, facilitate payroll processing, provide risk management resources, human resource consulting, employee training and more.

Yes, this was huge for me. I never wanted to charge people for my services. Most physicians go into medicine because it is an altruistic profession. At some point you realize that you have a special skill set that most people don’t have and that brings value. And while you want to make things affordable for patients, you will not be able to offer any services if you can’t pay the rent or pay employees. To mitigate this struggle, I have designated personnel to handle invoices and payments from customers.

If possible, I put my work down and start fresh at another time. I’ll choose to go for a walk, exercise when I am able to or pull my senior staff aside to talk or brainstorm ideas. Anything that will give me a mental break for a fresh, focused start.

My mentor was Dr. John Bergan, who I trained under during my fellowship. He was a world-famous vascular surgeon known not only for his academic brilliance, but also for his great bed-side manner. I had the opportunity to work with him at his private practice. I was able to observe his approach, how he treated people and made them feel important — from his staff to patients.

Every day, he had a pearl of wisdom I could learn, especially about giving presentations to other physicians.

He also taught me you can’t make everyone happy all of the time. As a physician, if one patient is upset or leaves a bad review, it can be taken to heart. You need to focus on the fact that you make most patients happy. The same with staff, there’s always someone who’s going to complain. You can’t make everyone happy all of the time.

I relied a lot on interfacing earlier on, from conferences and face-to-face instructional dinners to webinars educating physicians on what it is we do. It was a way to get to know people on a personal level, while also giving them a taste of your extensive knowledge and experience in the industry.

I can’t remember specifically any very bad advice. I can tell you that everything has been trial and error, so some people give you suggestions and you have to be open and know they might not work for your practice.

The classic, Good to Great: Why Some Companies Make the Leap and Others Don’t. Studying business failures is as important as understanding business successes.

Thank you for these great insights!

WRITTEN BY

Candice Georgiadis

Candice Georgiadis is an active mother of three as well as a designer, founder, social media expert, and philanthropist.

Authority Magazine

Authority Magazine

Leadership Lessons from Authorities in Business, Film, Sports and Tech. Authority Mag is devoted primarily to sharing interesting feature interviews of people who are authorities in their industry. We use interviews to draw out stories that are both empowering and actionable.

Dr. Bunke in Authority Magazine2022-01-04T04:04:50-08:00

2, 7, 2020

Ultrasound Findings of Normal vs. Diseased Great Saphenous Vein

2021-11-13T15:00:59-08:00

The Great Saphenous Vein (GSV) is the most commonly affected superficial vein to become diseased (valves no longer function and become leaky).  While venous reflux can involve the deep system and perforators, the superficial venous system is most commonly involved.  The superficial venous system consists of the great saphenous vein (GSV), accessory saphenous veins (AASV), small saphenous vein (SSV), several tributary veins and junctions where they connect to the deep system which include the sapheno-femoral junction (SFJ) and the sapheno-popliteal (SPJ).  Additionally, common anatomical variations of the SSV can occur, such as the presence of the vein of Giacomini (VOG) and a thigh extension (TE).

 

 GSV imaged

Normal GSV This is the GSV imaged on ultrasound in a longitudinal view. It is healthy without reflux.

GSV with reflux

GSV with reflux

Venous-valvular dysfunction within any of these veins may result in the appearance of varicose veins and can produce a range of symptoms.  Symptoms of venous insufficiency may include leg swelling, aching, heaviness, fatigue that is worse at the end of the day. Common nocturnal symptoms include restless legs and leg cramping. The GSV is most commonly affected, and is most frequently the source of varicose veins. Venous reflux can be determined by ultrasound.

 

 

Ultrasound Findings of Normal vs. Diseased Great Saphenous Vein2021-11-13T15:00:59-08:00

Get A Virtual Tour of La Jolla Vein Care

2020-09-17T17:32:25-07:00

Get a virtual tour of La Jolla Vein Care. See how we maximize comfort, relax and watch Netflix during treatment, no lobby wait times.

See our vein treatment center San Diego. La Jolla Vein Care is located in the Scripps Ximed Building on the Scripps Memorial Campus. Established in 2010, we have helped thousands of San Diegans achieve lasting relief of varicose veins. We have two, state-of-the-art medical suites in Ximed, located in suite 410 and 530. Typically suite 410 is our ultrasound imaging center and 530 is our procedure suite, but during COVID all patients are seen in suite 530. Relax, sit back, and watch a netflix movie during your procedure. See how comfort is maximized at La Jolla Vein Care. La Jolla Vein Care, a San Diego Vein Clinic is one of the region’s only accredited vein treatment and vascular imaging center.

Get A Virtual Tour of La Jolla Vein Care2020-09-17T17:32:25-07:00

What are the adverse effects of vein treatment?

2020-10-23T15:44:39-07:00

Adverse effects of vein treatment are uncommon.

Patients generally do very well with vein treatments, all of which have a low risk of complications. Most patients feel the benefits within a couple of weeks of treatment, for others it may take longer. With all treatments, the benefits need to be discussed along with the potential side effects or adverse events. The following are potential adverse effects from thermal vein ablations we tell our patients.

  • Aching over the treated veins is normal. This responds well to walking, ice packs, and anti-inflammatory medications such as ibuprofen (Advil, Motrin) or naproxen (Aleve).
  • Bruising over injection sites is also normal after vein treatment and resolves in about two weeks.
  • Hyperpigmentation over a vein can occur from blood pigments that are released as the vein is healing. It is more common in patients with large bulging veins and certain complexions. Hyperpigmentation tends to fade over many weeks if you stay out of direct sunlight.
  • Intravascular hematoma refers to a large varicose vein that becomes firm and tender days to weeks after treatment. This also responds well to ice packs and anti-inflammatory medications. We may also recommend a confirmatory ultrasound and/or offer needle drainage of the trapped blood to alleviate discomfort and minimize skin pigmentation.
  • Deep vein clots are very uncommon, and usually are limited to patients with poor mobility, advanced age, hormone treatment, and/or genetic tendency for clotting. We monitor all patients with ultrasound throughout treatment so we can detect clots at a very early stage before they cause a symptom. We may recommend surveillance ultrasounds, extra walking, and/or a short course of blood thinners.
  • Numb spot over a treated vein is another uncommon event after radiofrequency or laser vein ablation. This occurs when a branch of a skin nerve gets stunned during the heat treatment. It tends to improve over several weeks. The nerves that control the movement of the leg and foot are located far from the superficial veins.
What are the adverse effects of vein treatment?2020-10-23T15:44:39-07:00

La Jolla Vein Care Joins Health Excel IPA

2020-09-17T17:41:53-07:00

La Jolla Vein Care has joined Health Excel IPA and will be contracted with some new insurances beginning today, July 1st. This is exciting news and means that more people will have access to our vein care services including ultrasound diagnostics, leading edge vein treatments,expert physicians, and concierge-style practice, and customer service.  The contracted plans with Health Excel IPA are below:

Blue Shield HMO

Golden State

Alignment

Imperial Health

Brand New Day

According to Health Excels website: ‘San Diego County-based independent physician associations (IPAs) have joined forces to create a new administrative organization with the goal of providing enhanced healthcare services to patients and payers. The new entity, called Health Excel, counts more than 1200 Healthcare Providers as members — over 300 Primary Care Physicians, and over 700 Specialists — making it one of the largest independent organizations in San Diego County. Virtually every medical specialty will be represented by Health Excel doctors.’ To read more about Health Excel, click here to go to their website.

La Jolla Vein Care Joins Health Excel IPA2020-09-17T17:41:53-07:00

29, 6, 2020

Oh My! My Vein is Bleeding, What Now?

2021-11-13T13:15:32-08:00

Spontaneous bleeding or Hemorrhage caused by rupture of a varicose vein is a hidden danger of varicose veins.  It usually occurs in the small blue veins around the ankle and shin (blue blebs), and the amount of bleeding and blood loss can be significant.

Untreated varicose veins

Untreated varicose veins are at a higher than usual risk of bleeding or spontaneous rupture.   Over time, varicose veins become larger, and the vein wall becomes weak and stretched out. These veins, which are already weak are also under high pressure (because of venous reflux, or the ‘backflow’ and pooling of blood in these veins). As a result, the high pressure can cause the veins to spontaneously burst and bleed heavily. Because they are under high pressure, they bleed like an arterial bleed and patients describe the bleeding as ‘blood shooting across the room.’  The varicose veins that are susceptible are veins closest to the surface of the skin

I have studied over 100 patients who have had an episode of spontaneous vein hemorrhage. Most patients describe that it occurs during or after a warm shower (warm water causes veins to relax and dilate, allowing more blood to pool within the veins) or during sleep. It is painless and patients report that they notice it because they feel something wet in bed or if awake, they describe it as bleeding that ‘shoots across the room.’  Patients who are on blood thinners can lose large amounts of blood, especially if it occurs while they are sleeping. Some people have required blood transfusions. The small blue spider veins around the ankle are equally at risk of rupture as are the larger bulging veins.

Spontaneous Vein Hemorrhage After Warm Shower
This is a patient who experienced spontaneous hemorrhage of their varicose veins. Notice the appearance of the blue, bulging veins that we describe as, ‘blue blebs.’ These veins are dilated, weak, and are close to the surface of the skin. The pooling blood within these veins causes high pressure, ultimately resulting in a spontaneous rupture or hemorrhage. The bleeding is rapid since varicose veins are under high pressure.  This is a common condition that we see at La Jolla Vein Care. If spontaneous vein hemorrhage occurs when you are home, immediately place pressure with towels and elevate your leg on several pillows. Standing will make it bleed more. If the bleeding does not stop with these measures, immediately seek medical attention.

If someone you know has experienced bleeding from their varicose veins, they should be seen by a doctor. Treatment will prevent the veins from bursting again.

 

Oh My! My Vein is Bleeding, What Now?2021-11-13T13:15:32-08:00

3-Stage Approach to Vein Treatment

2020-09-17T17:58:02-07:00

When visible signs of venous disease such as spider veins, varicose veins, or skin changes are present, this is usually the tip of the iceberg, and an underlying vein problem is present. An underlying vein condition (venous reflux disease) can be detected with ultrasound. A treatment plan is focused on treating the underlying vein problems first, then working outwards.

image of an Iceberg as a metaphor for the hidden dangers of vein disease

Iceberg, a metaphor for the hidden dangers of vein disease

How Is Venous Reflux Disease Treated?

Step 1: The Underlying ProblemThe first step is to treat the underlying problem, the venous reflux. The specific pattern of venous reflux was detected by ultrasound. Venous reflux usually starts in the saphenous veins. The saphenous veins are most effectively treated with vein ablation procedures. This involves placing a small catheter within the vein and using heat or a solution to produce injury and eventual closure of the vein. The most commonly used treatments for the saphenous veins are radiofrequency ablation (RFA), laser ablation, mechanico-chemical ablation (MOCA or Clarivein), and in some cases Varithena Foam. The treatment recommendation is customized, based on where reflux is present and other clinical factors.

Step 2: Varicose Veins

After the underlying saphenous vein reflux is corrected, the bulging veins (varicose veins) can be treated by injecting a foamed medication that will cause them to scar and eventually dissolve (foam sclerotherapy), or to remove them using tiny incisions. The most common method is foam sclerotherapy.  This is also known as ultrasound-guided foam sclerotherapy (UGFS).

Step 3: Spider Veins

Spider vein treatment is always considered a cosmetic procedure. If improved cosmesis is a goal of treatment, make sure to discuss this with your doctor and plan on having cosmetic treatment as the last step. Spider vein treatment is accomplished by sclerotherapy, which is an injection of a liquid medication into the spider veins. Most patients use 3 vials, and have an average of 3 treatment sessions.  Ask your provider for an estimate about how many treatment sessions/ vials are necessary to get the results you want.

 

3-Stage Approach to Vein Treatment2020-09-17T17:58:02-07:00

Understanding What Your Doctor Is Saying About Your Veins

2020-09-17T18:42:20-07:00

If you’re not a vascular specialist, it may be difficult to understand the words used to describe your vein condition. Vein terms are not used in everyday life.  Especially, when it comes to the anatomy of the veins. Below is a glossary of the terms, we as vein specialists, use on a daily basis but may be foreign to the patient.  This is provided from the American Vein and Lymphatic Society (AVLS) healthyveins.org.

Anatomical Vein Terms

Anterior: The front of a body part.

Posterior: Back of a body part.

Deep Leg Vein: The veins that are deep in the thigh and leg that carry blood back to the heart.

Connective Tissue: This strong tissue is the white tissue that covers muscle.

Great Saphenous Vein: (sometimes called GSV or long saphenous vein) A long vein that can be seen just in front of the anklebone. This vein travels along the inside of the leg and thigh (about one-half inch beneath the skin in the thigh) until it empties into the deep vein called the common femoral vein in the groin.

Perforating Vein: A vein that passes directly from a superficial vein to a deep vein.

Popliteal Vein: The deep vein located behind the knee. The small saphenous vein originates from the popliteal vein.

Small Saphenous Vein: (sometimes called SSV, Lesser Saphenous Vein, or LSV) A superficial vein that starts at the outside of the foot and travels up the back of the calf where it empties into the deep vein (popliteal vein) in the crease of the knee.

Spider Vein: A tiny varicose vein that may be blue or red color that does not protrude above the skin surface and frequently looks like a spider. Common medical terms you may hear for spider veins are telangiectasias and telangiectatic veins. Slightly larger varicose veins that do not protrude above the skin are called reticular veins.

Superficial Vein: Any vein in the lower extremity above the deep fascia that covers the muscles of the thigh and leg.

Varicose Vein: A bulging vein that protrudes past the skin surface and usually measures greater than one-fourth of an inch (6.4 mm) in diameter.

Vein Function Terms

Competent Vein: Blood flow occurs in the proper direction back to the heart. Also referred to as Having No Reflux Or Normal Flow Direction.

Incompetent Vein: Blood flows in the wrong direction. Also referred to as a vein that has reflux.

Reflux: Blood that flows backward in the veins.

 

Anatomical Images and Explanations

Normal Blood Flow: After the blood has been replenished with oxygen in the lungs, it is pumped to the body by the heart. Blood that is pumped to the lower extremities is pumped back to the heart partially by the action of the calf muscle pump. The blood returning from the lower extremities in the deep and superficial veins goes past a series of one-way valves. These valves stop the blood from flowing backwards in the veins.

Reflux: The valves in the veins close just as blood begins to flow backwards. If the valves do not close properly, the blood falls backwards through the poorly closing or leaking valves. The veins downstream that are now unprotected by valves further upstream are exposed to the weight of an increasingly high column of blood. These downstream veins cannot endure the pressure of the column of blood and expand becoming snake-like in appearance. This causes the veins to bulge through the skin surface and become varicose veins.

Understanding What Your Doctor Is Saying About Your Veins2020-09-17T18:42:20-07:00

Do I Need Surgery for Varicose Veins?

2020-09-17T19:01:32-07:00

Non-surgical treatment alternatives for eliminating varicose veins

No! We’ve performed thousands of surgery-free treatments. 

Surgery is rarely performed these days to eliminate varicose veins. Modern endovenous procedures, which were first introduced around the year 2000, have replaced surgery for most patients. Endovenous became the standard of care over vein stripping surgery in 2007.  Treatment can be done in a doctor’s office, without general anesthesia, thereby reducing risks. At our facility, we offer multiple non-surgical treatment options so that vein care is individualized and based on what is best for the patient rather than on what is available. There are multiple non-surgical treatment options, including radiofrequency ablation (RFA), clarivein, laser vein ablation, endovenous laser therapy (EVLA), varithena foam, microfoam, ultrasound guided foam sclerohterapy, ambulatory phlebectomy.

go to our treatments page for more information

 

Do I Need Surgery for Varicose Veins?2020-09-17T19:01:32-07:00

How To Wear Compression Stockings

2021-11-15T12:48:33-08:00

How to put them on, tips, and troubleshooting common issues with compression stockings.

Compression stockings are an important part of conservative management and after-treatment care of venous reflux disease. It is important to wear compression stockings correctly and obtain a proper fit to make sure they are as comfortable as possible.

Applying stockings with ease:

  1. Turn your stocking completely inside out
  2. Locate the smaller foot hole of the stocking and tuck the foot in until you reach the heel
  3. Place your thumbs on either side of the tucked in foot hole, with the heel located on the bottom
  4. Put your foot in the stocking until the heel of the stocking has met your heel
  5. Grab the larger hole or top of the stocking (it should be hanging off your foot) and pull the stocking up onto your leg
  6. Inch and pull the stocking until it has reached either below the crease of your knee for knee highs, or the highest portion of your thigh for thigh highs.

Cant keep your stockings up? Try these tips!

1. When someone’s stocking is falling down, their first instinct is to tug at the top band to pull them back up. This is mistake #1! By tugging and pulling at the top band, it is stretching out the top of the stocking which will make it fall down faster and more often. Instead of tugging at the top, simply inch and pull the stocking up by the fabric that is at the ankle. This will allow for the stocking’s extra fabric to be moved to the thigh or calf and will keep the stocking up better.

Cant keep your stockings up

Wash and DRY the stocking

2. Wash and DRY the stocking! Stockings are very durable and can handle a washing machine and dryer. Putting a wet stocking in the dryer will bring it back to its original compression which will make the stocking stay in its rightful spot for longer. Just don’t use fabric softener when cleaning the stocking.

3. Is your skin dry? The silicone top band on most thigh-high stockings won’t stick to dry skin which will make the stocking slip down. Moisten skin with lotion, skin cream or even water to allow the stocking to stick to your skin.

close up of a woman's dry flaky itchy legs

Use proper size compression stocking

4. Be in the correct size! Stocking that is too small on the thigh will roll at the top making it nearly impossible to keep them up. Be sure to be sized properly to ensure proper fitting. There are even stockings that are made with larger calf and thigh ranges which may help those who have a “rolling” issue. Alternatively, to too small of stockings, stockings that are too big will fall right down! Don’t borrow stockings from friends to prevent being in the wrong size. Be sure to be fitted correctly to ensure the stocking is the correct size.

5. If none of the tips above help, be creative! You can use Spanx, suspenders to even safety pins to keep stockings from falling down.

Is the foot too tight? Some stocking brands run narrow. Signs the foot is too tight is toe numbness or foot pain. Talk to your doctor if you feel the foot is too tight.

How To Wear Compression Stockings2021-11-15T12:48:33-08:00
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