Ranking Doctors – “mine’s the best”

The baseball world elected Ken Griffey Jr. to the Hall of Fame with the highest percentage of votes ever.  Without doubt he is one of the best to play the game, deserving of all the honors he won over the course of his career.  Yet for all his success at the plate, he got a hit less than 1/3 of the time he was at bat.

I started to think about how other professions rank their members – athletes by statistics, business people by profit margins, attorneys by cases won, pilots by safety records, etc.  But how are doctors ranked?  Everyone dies eventually, so survival is not specific enough.  Ask anyone for a doctor recommendation and they will say theirs is “the best”.  After all, who would go to a sub par doctor (or any professional)?  We may not want to acknowledge it, but everyone can’t be the best – its statistically impossible!  As the punchline says, “What do you call the person who graduated last in their med school class?  Doctor”

How are doctors ranked?

Since there is no medical hall of fame, the first question to ask about a ranking is who is doing the ranking and what perspective are they coming from.  Insurers rank by “cost and efficiency.”  Doctors rank other doctors on reputation, technical skill and experience.  Patients rank us on their own experiences and expectations.

If you are a patient, you can look at multiple online or magazine sources for “Top Doctors” rankings and opinions. But just as I’ve hated movies and restaurants that got great reviews (and vice-versa), if what you need isn’t what the doctor you see provides, it’s not the right fit.

Insurers and Medicare rank doctors on how they perform on cost and utilization – they look for doctors that don’t deviate from the norm – not doing too much or too little.  In other words – those that do average things.

Employers have a different perspective – they want a doctor that fills a need – either specific skills or ability to see patients in a way that improves the reputation and revenues of their system.

How do you research a doctor?

When researching a doctor, you can check basic credentials – license, board certification, medical board sanctions are bare minimums.  Your first question should be – what are you seeing them for?  If you are looking for a diagnostician, such as an Internist, your needs are very different than if you are having heart surgery.  What you need will determine what you are willing to accept.  In your Internist, you want someone who listens to you, is empathetic and helps answer questions about your symptoms.  In a Cardio-thoracic surgeon you may care less about their bedside manner and more about their technical skills.  The length of your relationship is different as well – I’ve known many of my patients for over a decade, whereas an orthopedic surgeon who fixes your knee may only be part of your life for a few months until you are healed.

Most surveys of what patients say make a good doctor have little to do with training, malpractice complaints or cost and efficiency.  It is mostly a subjective assessment – personality, listening, empathy – the things we call bedside manner.  Studies bear this out as well – even when the outcome of care does not end well, doctors with good bedside manner and communication skills are sued less than those who are less liked by their patients.

I like to think I’ve got a good bedside manner – but also recognize that I’d have a lot of empty space in my schedule if I was wrong in 2 out of every 3 diagnoses!  The funny part is listening and using my “soft skills”makes getting the diagnosis right much easier – 90% of diagnoses are made by history.

I don’t expect to see my name on ESPN any time soon, I’m quite content when patients leave the office feeling heard, with a plan to move towards health.

The path to wellness begins with a proper diagnosis

Teachers are another profession without a hall of fame – but what if they had their own network?

Cover your nose – you’ll catch a cold

As the first cold weekend hits the NY area, people are bundling up to ward off the elements.  In the back of their minds, I wonder if they are hearing their mothers telling them they’ll catch a cold if they go outside without a hat. Truth of the matter is you may be better off wearing a scarf to cover your nose rather than a hat.

What causes colds?

Colds are caused by viruses – over 200 subtypes.  The most common belong to a family called Rhinovirus. These viruses take root in our noses and throats and cause infection.  The body’s immune system fights the viruses, and eventually you recover.  But between infection and recovery is fever, aches, cough and phlegm that make the world shun you and make you feel miserable.  So how do we prevent colds?
For generations, parents, grandparents and know-it-all neighbors have admonished those under dressed to bundle up or they will catch a cold.  However, a virus infects you when it attaches to the membranes in your nose or throat.  A hat doesn’t change that.  Why do we see more colds during the winter months?
It turns out that the Rhinovirus reproduces better at slightly below body temperature – as occurs when you breathe in cold air through your nose lowering the temperature in your nose. Being cold releases causes an adrenaline release in the system – which acts as a decongestant.  While making it easier to breathe, it also decreases the delivery of immune cells to the cold area, and drier membranes in the nose are more likely to crack, making it easier for the virus to get in. In addition, your immune cells do not fight as well at colder temperatures – allowing the Rhinovirus to take hold and multiply – and you catch a cold.

What can you do?

Colds are spread more from touch than breathing in virus particles.  We shake hands or touch something someone sneezed on, then wipe our noses, mouths, eyes, etc.  The best defense is to wash your hands.  Other prevention measures:
  • wipe down shared items in the office and home – computers, phones, tables, etc
  • surgical mask if you are sick (keeps you from spreading infectious particles)
  • if you have a weakened immune system due to medication or other condition consider wearing a surgical mask
  • keep your mouth and nose warm
  • and did I mention wash your hands?!
So maybe breathing through your hat instead of putting it on your head will prevent a cold!

 

Happy 2016

Wishing everyone a Happy and Healthy 2016!

To wrap up the year, some New Year’s Health Tips:

  • Moderation – in both food and drink will make 2016 easier to start
  • Make a commitment to exercise on January 1 – even a walk will give a sense of accomplishment
  • Dress warm if you will be at an outdoor event – layers and hats
  • If improving your health is part of your plan for 2016, do a set of body measurements – weight and waist circumference – you can’t know how much you improve unless you know where you start
  • Put your exercise commitments into your calendar
  • Don’t do another set of measurements for at least a month – you can see bigger change if you don’t micromanage things
  • Get a physical – baseline your health as well as your size

I’m not making any resolutions this year – but I am setting some goals

  • Exercise more during the work week
  • Unplug from electronics occasionally
  • Write 2 posts a month

What are your goals for 2016?

The path to wellness begins with a proper diagnosis

2015 – A time to reflect

2015 has been a year filled with change, and as I reflect back on all the events – both professional and personal – I thought I’d share some highlights and observations and maybe an insight or two.

Highlights of 2015

Observations of 2015

I’ve always been a fan of data – it helps me professionally, and I’ve been tracking my running (Runkeeper) since 2010, and have been tracking activity with a Fitbit since mid 2013.  What I realize that I do professionally that I don’t often do personally, is reflect on the data.  As a physician, at every patient encounter I reflect on information about a patient – medications, lab tests and symptoms – which can lead to insight for  their condition.

So I took a moment to reflect on my own data – so far in 2015

  • over 3,700,000 steps taken (some bigger than others)
  • I’ve run over 350 miles this year
  • My best running month was April, I ran 50 miles
  • My worst running month was July – I ran less than 10 miles
  • My average pace was 9:28 per mile
  • I average 6.3 hours of sleep a night
  • I wrote 17 blog entries
  • TheDiagnosisMD has been visited by over 1300 people

Insights

As I reflect, I draw connections

  • My running decreased over the summer significantly – partly because it was summer in Arizona, but also because there was a lot of transition being planned.
  • My running pace varied with the temperature – slower in the Arizona summer heat
  • Running in NYC involves more traffic and hills than in AZ!
  • My more popular blog posts are those that I write either from a more personal perspective or give an opinion, rather than a pure medical topic for the sake of education

So, as we move forward to 2016 I hope to stay consistent in running, and reflect on my data to see how I can improve.

I will write from a more personal voice, and hope to combine education with perspective to keep this blog interesting

I hope in my new role as Medical Director I can apply the same lessons – reflect on data to gain insight and improve they way we practice – allowing my colleagues and I to work smarter, deliver outstanding care to our patients and make our office one of the pre-eminent practices of Internal Medicine in New York City.

The path to wellness begins with a proper diagnosis  

Just an Internist

As I have been re-aquainting myself with NYC and meeting new people, one of the questions that invariably comes up is “What kind of doctor are you?”.  I answer, “An Internist”.  Usually that is followed by a question of what is an Internist, or if I specialize in anything.  After explaining what I do, I often get a response along the lines of – you are “just an internist”.
My very first blog post – Making a Diagnosis – Who Am I described my journey in becoming an Internist.  I put tremendous effort into developing my skills, my ability to communicate with people and gain their trust when they are at their most vulnerable.  20 years after graduating from medical school, I am still learning how to improve my skills, adapting to ever-changing environments in how medicine is practiced, and maintaining pride in a profession that has recently been quoted as having a 55% burnout rate.  So minimizing my efforts with “just an internist” is akin to telling a woman she’s just a mom.
The American College of Physicians put forth several efforts to explain Internal Medicine – both to its members and the public.  I came across an article from 2013 by Dr. Yul Ejnes about Internists being specialists in Internal Medicine – as opposed to cardiologists, gastroenterologists, and others who are sub specialists which explained this difference very well.  After reading it, I reflected on things I had seen and done in the 3 months I have been back in NYC.
I find I serve a few different roles with patients. Some patients have chronic illnesses that are already diagnosed, and they are connected to subspecialists to treat that diagnosis. What they lack is someone to help them manage all their other health needs. For them, although not directing their condition, I am helping them manage side effects of treatment and be sure that any other symptoms are evaluated properly and attributed to their condition. Others come with a new problem and need a diagnosis. Both roles require my diagnostic training, but also empathy and most importantly, communication to determine the next steps for the person in front of me.  This is what an Internist does – manage a person’s health while they deal with illness and diagnose new symptoms. 
I am just an Internist – I’m the physician you see if you have a genetic blood disorder that has been under a specialists care since you were under a year old, or you have diarrhea for 6 months and need a parasite diagnosed or you have shortness of breath for a month and need heart surgery. Just an Internist – the doctor who listens, guides and educates. Just an Internist, a physician specializing in Medicine.

Fighting the winter blues – a lighter look

The winter blues – now is the time they can set in – shorter, dark days, colder temps and holiday stresses all contribute.  Its also been a rough couple of weeks in the news – it’s easy to feel overwhelmed when terrible things happen.  However, if you look for it, there are ways to fight those winter blues – a lighter side of the news, medical stories that can be uplifting, and studies that can make you feel better about life choices you have made.

Winter blues

Seasonal Affective Disorder is the official name for depressive symptoms that surge during a particular time of the year and resolve when the season is over.  Winter is the most common season for this – while the holiday season is supposed to be fun, for many it can be quite stressful and lonely.  It can be treated as any other depressive disorder – with therapy, exercise, medication, biofeedback or light therapy.  In fact, a recent study showed that light therapy works for non-seasonal depression as well.

Fun Studies

Some of these I’ve highlighted in the past, but some interesting and fun studies – although not necessarily the most scientific – maybe a smile will fight the winter blues.

Chocolate better than exercise for brain preservation – actually looked at high dose flavanols (talking a kilogram of cocoa daily) vs exercise.

Coffee use associated with lower mortality – perhaps my favorite article as it affirms my beverage choice!

The firefighter who was given a new face @NYULMC -what an amazing application of technology and medicine!

Sleeping in on weekends and holidays may increase your risk of heart disease and diabetes – I’ve always told patients that having a consistent wake up time makes for better sleep!

Remember moderation, activity and good sleep go a long way in getting through the holiday season without excess weight gain – and can help you fight the winter blues.

The path to wellness begins with a proper diagnosis

 

Processed meats – cancer risk or hype

Bacon is perhaps the archetypical of processed meats – whether typical US or Canadian – it is one of the most identified foods by sight or smell.  Recently, the World Health Organization (WHO) classified  processed meats as a cancer risk, equating it to smoking.  How did they come to this decision, and can we infer the same risk about all meat – processed or not?

What did the WHO say?

The WHO evaluated data from about 800 studies of meat intake and cancer.  About 14 of them were designed well enough to analyze the information.  There were another 15 studies that had strong design to help with the decision-making.  Based on these 29 studies, they found evidence that processed meat increased cancer risk – specifically colon cancer by about 17%.  The data for red meat in general was not strong enough to make an association.

How should we interpret the WHO statement?

The association of processed meats and GI tract cancer has been known for quite some time.  In cultures where these foods are consumed regularly, stomach cancer has had an increased rate, leading to screening programs.  The statement from the WHO adds strength to the association, and should encourage people who have multiple risks for colon cancer to consider their diet as a controllable  risk factor.

What does this mean for most people?

The risks for colon cancer are age, smoking, a low fiber diet, family history and now processed meats.  Just like most health decisions we make, our diets should be modified based on our risks.  Moderation, or occasional consumption of processed meats is a better choice than daily consumption.  Of course, getting a colonoscopy based on your doctor’s recommendation further minimizes the risk of developing colon cancer!

Life is full of choices – moderation and a varied diet seems to be one of the better ones.  In the words of Joe Jackson, “Everything gives you cancer”

The path to wellness begins with a proper diagnosis.

 

Back to School

It’s that time of year in NYC (I know other parts of the country already started) when buses are filled with children sporting back packs, tales of summer vacation are told and germs are spread.
In my office, it is also the time of year in which adults get re-exposed to germs they haven’t seen in years – the kids get a sniffle at best, and the adults (especially new teachers) feel like they’ve been hit by a Mack truck! Why is this?  What is it about “kid germs” that affect adults so severely?
The reason for this comes from our immune systems. The fevers we get and the aches we feel are a result of our bodies response to the infection. The more our immune systems get activated – the worse we feel!
Our immune systems develop memory. That’s why you only get certain diseases once. If you are exposed again later in life – the memory of the infection may have faded – and your body responds in full force.  When you are exposed to similar infections multiple times – or if you are vaccinated against a disease you body can respond faster and with less inflammation – and you don’t feel sick!  An MMR – measles, mumps, rubella – vaccine given in childhood and an adult booster gives enough immune memory to last a lifetime.
To help stop the spread of these infections basic hygiene is our best defense – HAND WASHING with soap and water or hand sanitizer.  Covering our mouths when we cough and sneeze; and taking our FLU SHOTS.
I wrote about flu shots last year.  Recent politics aside, there is no danger of getting the flu from the flu shot.  There can be side effects, depending on if you have an infection brewing or how strongly your immune system reacts to the shot, but there is no live virus in the vaccine to transmit disease.
The strains in this years flu shot are different from last year, and early reports show a good match between flu strains we are starting to see in the public and what is in the shot.  So get your flu shot, and feel better through the season!

Remembering

As I head to the office this morning, my first September 11 in NYC in 3 years, like most Americans I reflected on that day 14 years ago.  My wife was about 10 weeks pregnant, the Giants played Monday Night Football the prior evening and we had just put in a bid on an apartment the day before. 

I was seeing patients when my wife called to tell me the first plane had struck.  At first I thought it was a joke, and waited for the punchline. Then I saw reports on a news website. The internet became so congested, we couldn’t get updates, and the office turned a radio to an AM news station for updates. 

After a couple of hours, as the City began to organize its response, myself and 2 of my partners were driven across 23rd St in a police car to Chelsea Piers where the medical response area was being established.  At each intersection was a National Guard armed vehicle manned by soldiers with machine guns and serious expressions. We walked into an empty catering hall set up like a scene from MASH – rows of operating tables without dividers. The medical lead went through triage procedures, and we waited for the wounded to arrive.

And we continued to wait. No one came – the immediately wounded and rescued were brought directly to hospitals before we were set up.  Almost everyone else walked away – or didn’t. We couldn’t reach our families as cell phones were not working. After several hours, we were off duty and I walked home to the Upper East Side as all transportation was shut down. Later, I would find out the numbers of people who didn’t get to go home that night; the patients I lost or who lost spouses, high school classmates and family friends. 

Being out of NYC for the past 3 years I always felt guilty not being here. So today, back home again, I recall the day, the response, and the numerous stories similar to mine of those that were here.  Remembering  that everyone’s experience was so intense that they can’t be compared. And grateful to be in New York City.