By the numbers – my 2016

The end of 2016 – and every year – brings out the numbers – 10 best events, top news stories, greatest moments in sports, etc.  People have a natural need to quantify and rank things.  It gives us a sense of control over our lives – very important in a year that so much seemed beyond our control.  I am no different – living my life by the numbers.  I track my activity and sleep with a Fitbit, my runs with Runkeeper, occasionally track my calorie intake with Lose It! I track the number of patients I see every day, the articles I post on TheDiagnosisMD, number of hits it gets.  While the numbers are not the sum of all that is important in my life, it is an interesting lens with which to view it through!

Blog

  • 11 posts – missed my goal of 2 per month
  • Wrote 4/11 in January – meaning I went months without updating TheDiagnosisMD, other than via observations on Twitter and Facebook.
  • 824 people visited this blog in 2016 – less than in 2015 – perhaps an indicator of the lack of consistency last year!
  • In 2017, not only do I want to write more – I want to write consistently.

Activity

  • Tracked 4,463,882 steps – over 700,000 more than 2015 – NYC is a walking town for sure!
  • Ran 375 miles – 25 more than last year
  • Average distance per run 5.4 miles
  • Average pace of 8:56 per mile –  32 seconds per mile faster
  • I sleep an average of 6.5 hours per night – 12 minutes more per night than 2015

Work

  • Not going to attempt to count hours!
  • Became more involved in a leadership role in our practice and the Department of Medicine
  • Was co-investigator on a grant submission (decision pending) to develop a clinical research project and education program
  • Taught medical students and residents
  • 2940 face to face visits with patients

This last number strikes me as incredible – not for its absolute value, but the opportunity it represents.  2940 chances to make a difference in someone’s life.  2940 shared moments of success, failure, hope and fear as people cross my path.  My goal in 2017 is to make the most of these moments – for myself and my patients!

What are your goals for 2017?

The path to wellness begins with a proper diagnosis

Don’t wait for New Year’s – exercise now!

Wishing everyone a very Happy Thanksgiving – I’m thankful for the opportunity to continue sharing my thoughts on health with everyone!   I know the holiday season is here – because last night when I was walking my dog I saw the sidewalk Christmas tree vendors setting up!  I also knew a big meal awaited me this evening – so I went for a run this morning to prepare.

Starting an exercise program is a recommendation I make everyday – to patients, family and myself.  The answers are often the same – “I know I need to exercise, but I don’t have time”, “I have bad knees”, or even “I don’t know if it is safe for me to exercise.”

Everyone faces hurdles in developing a routine.  Change is hard.  We go through periods where we exercise regularly, then the pattern is broken.  Getting started again is much more difficult.  Besides getting back on track, there is muscle soreness and risk of injury when coming back too fast.  But what about heart risks?  There are stories of people having heart attacks during marathons and other races, or even professional athletes who have heart attacks despite being in presumably peak physical condition.

Regular exercise has repeatedly been shown to reduce the risk of heart disease, diabetes and stroke.  It has also been linked to lower rates of certain cancers.  However, in what may be one of the more profound ironies of life, the risk of a heart attack goes up when you first start to exercise – the older you are when starting and the more intense the activity – the greater the risk!

Statistically higher – but meaningful?

The good news is while the risk of a heart attack or dying when first exercising is increased compared to sitting on the couch – it is still exceedingly rare!  To be clear – if you already have heart disease these numbers don’t apply – I am referring to people who don’t have existing disease and are starting to exercise to keep it that way!  If you already have disease – exercise is essential for you, but you should speak to your physician about how to safely start (this is why cardiac rehabilitation programs after a heart attack are so important).

The risk of a fatal heart attack is literally 1 in a million  – this number comes from studies of people having heart attacks at the gym (over 22,000,000 hours of exercise evaluated) and half/full marathons – and most of the people in these settings had pre-existing heart disease.  That risk goes down with repetition – so the more you exercise the less likely you are to experience an exercise induced heart attack.

Start now – or pay later

The holiday season begins now.  Snacks start arriving in the office, there are holiday parties and dinners and more alcohol than usual – yet over a month before the inevitable New Year’s Resolution to exercise more!  Think about starting now.  Regular exercise now may not make you lose weight – but can limit the gain from all the festivities.  A habit started now will make a resolution unnecessary!

So follow common sense – start gradually and consistently, and increase the intensity of your activity as your body gets used to exercise.  Don’t let something very rare keep you from achieving your best health.  As Nietzsche said, “That which does not kill us, makes us stronger.

The path to wellness begins with a proper diagnosis”

It is important for me

It’s been a very busy month – and I noticed two things had gotten pushed back – my running and my writing.  Every weekend I’d say to myself, “I want to go for a run today” or “I should update my blog”…  And then life happens.  Work obligations, holidays, bad weather, family needs, or just being tired and unmotivated.  Next thing you know, it is the 3rd week of April, and I’ve only gone running twice this month.

I tell people every day they need to be more active.  Some take it to heart, others ignore it, but I suspect most end up where I’ve been this month – I know I should do it, but unable to turn that knowledge into action. This weekend was particularly busy, and I told myself yesterday that I should run this morning.  In psychology, this is known as the Prochaska Model of Transtheorectical Change.

As has been the pattern lately, I slept a little later than I planned.  Then I got my running stuff together.  I had coffee (even before a run, yes) to finish waking up, and then got a distracted by email and tidying up the things I didn’t finish last night.  Thinking about the things I wanted to do today, I started to convince myself I didn’t have time to run.  Just like last weekend.

In my mind I made excuses about putting my obligations first, and felt myself becoming resentful of the things in my way.  Rationalization is very easy, and I began to accept that another day would go by without a run.  Recognizing that 9am really wasn’t too late in the day to run, I said to myself – “It is important for me to run today.”  That change got me to open Runkeeper and start Spotify run (Funk n Soul playlist) on my phone and get outside!

That small change in my mental dialogue (a fancy way of saying talking to myself) made the difference.  It changed running from something I’d like to do, something optional, to something required – as important as the other obligations I was using as an excuse to not run.  That was the key for me to find the link between motivation and action.  Now to see if I can use that to help my patients do the same!

The path to wellness begins with a proper diagnosis

Tell Me What You Want

I am asking readers to tell me what you want.  Not in general, but at a health or wellness talk.  A few weeks ago I was asked to speak at a wellness seminar given at a company for its employees about heart health.  The talk was well received, and we had a good discussion after my presentation.

What struck me was how willing people were, in a room full of co-workers, to ask questions about their personal health.  In the office, we have safeguards to protect privacy at check-in, in the waiting room and at check out.  Yet in this conference room, with people they know listening, I was told about cholesterol results and other tests, treatments they were given, etc.  Granted, we were talking about heart disease, which may not seem as socially or professionally awkward as some other topics, but it still surprised me.

It also made me wonder – what did they want?  My professional interpretation and opinion of their situation, or validation that the choices they had made in their own care were “good choices”?

I did my best based on the information people gave me to address their concerns, while encouraging them to speak to their doctors.  Some had questions understanding what they were treating or how to interpret their results.  Others had decided to try a different therapy (often homeopathic) than what their doctor recommended and wanted my approval – so the answer to my initial question is “both”.

I found it to be a little uncomfortable being asked to approve someone’s decisions with limited information, especially if I didn’t “approve.”  However, the talk and Q&A are for the attendees, not me, so I did my best to give a recommendation and encourage discussion between the person and their doctor.

This is a copy of the talk I gave – I want to thank TheVisualMD for the image support in the talk.

My question to you – if you went to a talk like this what would you prefer?  A general Q&A or time at the end to make a mini-appointment to discuss your questions one on one with the speaker?  Tell me what you want!

The path to wellness begins with a proper diagnosis

Zika Virus – an update on the latest developments

Mosquito born viruses are nothing new, nor are viruses that harm a fetus if the mother gets infected while pregnant. (chicken pox, rubella)  So what makes a country (El Salvador) tell its women not to get pregnant for 2 years?

What is Zika Virus?

Zika virus is in the same family of viruses such as West Nile, Yellow Fever and Japanese Encephalitis.  It is not a new virus, being first seen in Africa n the 1940s.  With world trade, like other insect borne viruses, it has spread.

Zika virus is contracted when bit by an infected Aedes mosquito.  It generally causes a flu-like illness, and resolves in a week or so.  Most people who contract it do not seek medical attention or realize that they even had Zika, assuming it was a more typical cold or flu.

In the past year, however, Brazil and other countries in Latin America have reported a huge increase in babies born with microcephaly – small skulls and incomplete brain development.  Babies born with microcephaly have developmental issues ranging from mild functional delays to severe birth defects. Infection with Zika virus during pregnancy has been linked to the increase in microcephaly, prompting the World Health Organization to call Zika an epidemic.

Currently, there is no treatment for Zika virus, and there is no vaccine. Efforts are being focused on prevention – avoiding areas with high rates of Zika and controlling the mosquito population/avoiding mosquito bites.

Zika has been shown to be transmitted via sexual contact and blood transfusion, but there have not been any documented cases of microcephaly from these routes of infection. There is no evidence that getting pregnant after recovering from Zika causes harm.

What is currently being done?

  • Vaccines are in development, but it will be at least 3 years before a vaccine is available
  • Research is being done on mosquitoes – giving them infections that make them unable to transmit the virus
  • Research on how to prevent microcephaly from occurring in the setting of an infection is ongoing

Current recommendations

  • El Salvador advised women to avoid pregnancy for 2 years
  • CDC travel advisories have been issued for women of childbearing age and pregnant women to avoid countries with Zika
  • Avoiding mosquitoes – bug spray and protective clothing if traveling in endemic areas
  • Men who have traveled to Zika areas are advised to use condoms with their pregnant partners for the duration of the pregnancy
  • New York’s Department of Health is offering free testing to all women of childbearing age within 2 weeks of travel to an endemic area, with or without symptoms

Take home points

  • Zika virus causes a typical flu like illness in most people
  • It has been linked to microcephaly in infants of women infected during pregnancy
  • Current efforts are aimed at preventing bites/exposure to Zika
  • If you have recently been to an area where Zika has been transmitted, testing is available through the CDC and local Departments of Health

The path to wellness begins with a proper diagnosis

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!

 

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