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”

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

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.

Start Spreading the News…

Start Spreading the News…

I am thrilled to announce the next phase in my journey as a Physician.  After 3 years in Arizona, I am returning to NYC and will be practicing at NYU Langone Medical Center’s Internal Medicine Associates.

I have thoroughly enjoyed living in Arizona – it was a wonderful experience for my family, and I have grown as a physician.  I learned new skills, encountered diagnoses that I don’t often see on the East Coast and saw a two health care system merge and deploy a new Electronic Health Record system.  All changes that helped me see the challenges that both physicians and patients face in the coming years.

As I shared the news with my colleagues and patients in Arizona, the response was usually “sad for me, happy for you” and jokes about getting out of 119 degree summer days.  I am grateful for the support I have received!

Since I trained and had been affiliated with NYU since graduating from medical school, the news of my return has been like coming home – incredible enthusiasm from colleagues and former patients alike.  A response that again makes me feel grateful for the relationships I have built over the years – and reminds me of why I chose Internal Medicine as a career.

So I will say goodbye to excellent Southwest fare (best guacamole ever), and hello to Atlantic Ocean sushi, real bagels and pizza!  And look forward to NYC saying “AAHH”

Wishing health and happiness to all, and to more blogging now that my summer of transition is coming to a close.

The path to wellness begins with a proper diagnosis

Reality Check – why an Internist is important

It was a typical Monday for an Internist – lots of phone calls, catching up on results that came in over the weekend, a full office schedule.  I was about to go see my next patient when my assistant said that Dr. X was on the phone about a patient, could I take the call.  I popped into my next patient’s room and told them I’d be 2 minutes – they said no problem and I went to my office to take the call.

The call was from a sports medicine fellow working with a specialist that I’d sent Mr. Smith to (name changed).  I met Mr. Smith about 2 months ago, he had new onset high blood pressure and complained of back pain.  We’d started some blood pressure medication and he was seeing the sports medicine specialist to design an exercise program for his back.  He’d gotten an MRI as part of his evaluation, and instead of showing the expected herniated disc, it showed metastatic cancer – from where, we did not know.  We called Mr. Smith and had him come in the next day to review his scan.

I met with Mr. Smith and his wife the next day.  I took them through the scan findings, explaining what we could and couldn’t tell.  He told me his back wasn’t too painful, and the specialist was helping manage it.  We talked about a plan – blood tests and CT scans to find the source of the cancer.  I told them I’d speak to an oncologist – and arranged his appointment with him.

Two days later, I had the blood work and his CT results, and we met again.  The news was not good – there were extensive metastases in his spine and it looked like lung cancer – though we still couldn’t be sure.  I sat with the Smiths, and we discussed a plan.  They’d be seeing the oncologist in a couple of days, I’d already sent there results over.  We discussed the next steps, what the oncologist would likely do next.  We talked about how he hadn’t been sleeping well, and that I could help with that.

The Smiths left – and I was drained.  It was very emotional telling someone who felt fine they have metastatic cancer.  Yet we both left the encounter optimistic.  The Smiths understood they have an uphill battle, but together they felt informed, guided and supported.

How Mr. Smith does is mostly out of my hands – yet I know I played a huge roll in getting them ready.  I did all the things I love about medicine – bonded with a patient, made a diagnosis, educated them and got them ready for the next steps.  This is Internal Medicine, and why I do what I do.

Everything Old is New Again

Last week, I had a third year medical student shadow me in the office; something I hadn’t done since leaving my old practice in New York City.  Having a medical student changes your day significantly – I find I may be more formal, I spend time filling the student in on a patient’s history, and explaining my thinking and the science behind each case.  My first thought at having a student again was – there is no way I’m going to be able to stay on time!  

One of the things I love about Internal Medicine is the variety of illnesses I see.  While some days feel like I saw the same person 10 times, explaining each person to a student reminded me of the story behind the “same diagnosis” – what makes each person unique.  She asked me why I made a choice to treat one person in a particular way and another differently – because all people are different and have unique features that need individualized treatment.

Our second patient was an older man with swelling in one of his legs.  We discussed the usual suspects – too much fluid, heart failure, trauma were all reviewed.  We also discussed a blood clot (known as a DVT).  As we went through his story and medical history, we decided that it was important to rule out a DVT – the risk of missing it made the decision to get a sonogram on his leg easy.  Later that afternoon we got a call from the radiologist and indeed there was a blood clot in his leg.  Now, when I was training, that call would have triggered a 3-5 day hospital stay while his blood was thinned.  But on this day, it triggered a call to the pharmacy to start a pill and schedule a follow-up appointment a few days later.

The rest of the day was similar – hypertension, diabetes, cold symptoms, until our last patient.  A woman had a bat in her house and had read that people may need to be treated for rabies even without direct contact with the bat.  It turned out, as it usually does in these situations, my student had reviewed this topic recently and was able to teach me – in the situation we faced – we could reassure the patient that no treatment was recommended.  I got to teach my student, and she taught me.

Later that week I traveled to New York City to attend a conference on Cardiovascular Risk Management.  It was my first trip to my old hospital since moving to Arizona.  Reconnecting with friends and colleagues was great and seeing how NYU Langone Medical Center has finally begun to recover from the devastation of Hurricane Sandy was heartening.

So by returning to my roots over the past week – teaching and learning – I feel refreshed.  What seemed old is new again and the stresses of uncertainty in health care gives way to the art and science of helping people lead healthier lives.

 

Misdiagnosis – A Second Opinion

Earlier this week, I saw a segment on the Nightly News claiming 1 in 20 people have a misdiagnosis – based on a new study that had come out that day.  That error rate translates into 12 million Americans per year.  As a physician I find that number startling.  As a physician who specializes in making the proper diagnosis, and who advocates that you can’t be well without a proper diagnosis, I wanted to delve deeper into this report.  If accurate, I am making 1 or 2 mistakes a day!

What was the study about?

So how did they make the claim that 1 in 20 patients have a misdiagnosis?  How was a misdiagnosis defined?

The study looked at 3 earlier studies and combined the results.  One was a study in a primary care setting that defined a potential error as an unscheduled hospitalization or return visit within 14 days of the initial appointment.  Then they looked at the records of those cases to decide if a misdiagnosis occurred – defined as the information to make a correct diagnosis existed at the time of the first visit.

The other 2 studies looked at delay of diagnosis for colon cancer and lung cancer.  They defined a misdiagnosis as lack of follow-up of a “red flag” – an abnormality or symptom that should trigger further evaluation.

What did they find?

In the primary care study, they found 177 errors in 1343 records.  In the colon cancer study, they found 26 errors in 291,773 records.  Finally, in the lung cancer study, they found 127 errors in 587 records.  These results were combined and applied to the US population to come up with the number of 1 in 20 mistakes or 5% of the US population having a misdiagnosis – based on 330 errors found in 293,703 actual reviews.

What does this mean?

No profession is perfect – we are all human – so errors are a matter of consequence – if I was a baseball player who had a .950 batting average, I’d be playing for the Yankees.  Errors happen in medicine, just as in any profession.   It is less critical if you are told you have allergies when you have a cold – both are treated similarly and not life threatening.  However, being told your chest pain is heartburn when you are having a heart attack can have serious consequences.

A misdiagnosis is a serious issue.  Trying to define the rate and circumstances where a misdiagnosis occurs should be studied more, and ways of improving the practice of medicine explored.  I do feel the statistical manipulations in this study and generalizing their results to the entire US population oversimplified this issue.

I reviewed the thought process of a physician in an earlier post.  It involves re-evaluating a person’s symptoms as more information comes in.  Being willing to reconsider a diagnosis is key to being a good doctor – and avoiding a misdiagnosis.

I hope this review of a headline helps put it in perspective.  I plan to do this regularly – a second opinion of health news.  So, if you see or read a story you’d like to learn more about, let me know – I’ll give you A Second Opinion.

The path to wellness begins with a proper diagnosis

Diagnosis of Arthritis

One of the most common reasons people go to the doctor is for joint pain.  “My knee hurts and swells after I walk, it hurts when it rains or it takes me awhile after I wake up before I can move well” are all often heard symptoms in patients with arthritis.  In a recent Center for Disease Control publication  22.7% of adults (52.5 million people) reported being told by a doctor they had arthritis, and 9.8% (22.7 million people) stated that their activity levels were reduced because of arthritis.

But what is arthritis?  Arthritis is inflammation in a joint.  There are multiple causes and types of arthritis, each with its own set of symptoms, complications and treatment recommendations.

The two main types of arthritis are Osteoarthritis and Autoimmune Arthritis.  They share some features and are very different in others.  Common symptoms between the two types are pain, joint swelling and stiffness.  Which joints are involved and the pattern of swelling and stiffness can differentiate between the two.  In addition, X-ray and blood test results are different in Osteoarthritis and Rheumatoid Arthritis (the most common form of Autoimmune Arthritis).

Osteoarthritis

Osteoarthritis is generally referred to as “wear and tear” arthritis.  It occurs when a damaged joint fails to repair itself.  Osteoarthritis can effect only 1 joint, a few joints or be generalized.  It is the most common joint disorder.  It’s major symptoms are:

  • joint pain
  • restricted movement in the joint
  • loss of function

In general, osteoarthritis pain gets worse with use and improves with rest.  There can be stiffness in the morning which usually improves in under 30 minutes.  Usually, the appearance on an X-Ray does not match the symptoms – so a person with osteoarthritis could have significant pain but a normal X-ray.  Blood tests show normal to minimally elevated signs of inflammation.

Osteoarthritis of the hands involving the end of the fingers

The most commonly affected joints are:

  • Knees and hips
  • Junction of the fingers and hand
  • Finger joints and bunion joint of feet
  • Joints at the base of the neck (cervical spine) and the lower back (lumbar spine)

Other joints can certainly be affected, especially in the setting of a prior injury.

Another specific characteristic of osteoarthritis is the pattern of joint pain.  Osteoarthritis tends to involve one joint at a time, where as rheumatoid arthritis tends to involve joints on both sides of the body at the same time.  The knee is the most common joint affected.

In terms of treatment, the guiding principle is to focus treatments based on a patient’s symptoms and functional issues.

  • Weight loss and exercise can improve knee and hip pain dramatically
  • NSAIDs (ibuprofen, naproxen)
  • Topical pain medications (capsaicin, topical NSAIDs)
  • Joint injections
  • Supplements – there is some evidence but the quality of the studies is poor
    • Vitamin D
    • Glucosamine-Chondroitin
    • Tumeric, Paeony and Miatake have been shown to have properties similar to NSAIDs

Rheumatoid Arthritis (RA)

Like all the autoimmune arthritis syndromes, RA is an illness that affects more than just the joints.  It is characterized by inflammation that causes joint tissue damage.  There is a genetic predisposition as well as environmental triggers that are not well-defined.  The peak age of onset is between 30-50 years of age.

A typical patient will present with some of the following:

  • Pain and stiffness in multiple joints – usually the wrist and fingers first
  • Morning stiffness that lasts for more than 1 hour
  • Fatigue, fevers, weight loss

In 2010, the American College of Rheumatology updated the criteria for making a diagnosis of RA.  It is a point based scale that  take aspects of multiple features including joint pain, physical and lab features of the illness to give a score that helps make the diagnosis.  The updated criteria can be found here

20131117-070143.jpg
Hand changes from severe Rheumatoid Arthritis

Blood tests for RA are not an absolute requirement, but two specific tests, Rheumatoid Factor and Anti-citrullinated protein are positive in about 50-60% of people.  In addition, a test for inflammation like C-reactive protein or sedimentation rate can be used to follow disease activity.

X-rays of the hands and feet are usually done at the time of diagnosis to check for joint damage.  Once the diagnosis is established, treatment should be quickly and aggressively started – studies have shown that treating aggressively early in the disease can lessen permanent damage.

The goals of treatment are:

  • Minimize pain and swelling
  • Prevent joint deformity and damage
  • Maintain quality of life
  • Control non-joint symptoms

Treatments for RA are called DMARDS – Disease modifying anti rheumatic drugs – are grouped into Biologic and Non-biologic treatments.  Non-biologic treatments are medications such as methotrexate that are used to reduce inflammation.  Biologic medications are newer treatments that block cytokines – chemicals that promote inflammation – such as Tumor Necrosis Factor (TNF).  They are usually given either intravenously or by injection.  Steroids and joint injections can also provide relief.  All treatments have potential side effects that patients need to discuss with their doctors to determine their proper therapy.

Some supplements have been shown to be effective at improving symptoms – fish oil when combined with DMARDS improved results over medication alone.  The supplements with NSAID like activity can also improve symptoms.  Exercise has been shown to decrease inflammation in joints as well as improve joint function, and should be part of every treatment regimen.

How does this affect my practice?

It takes a good history to differentiate Osteoarthritis from RA.  So working with someone to get a sense of their type of pain, and how it affects them on a daily basis is essential to a proper diagnosis.  Arthritis is a diagnosis with many subtleties – each variation carries its own specific issues, treatments and side effects.  The proper diagnosis provides the foundation for safe and effective treatment.

The path to Wellness begins with a proper Diagnosis

Test me for everything

An Annual Physical is one of my favorite visits. It’s an appointment specifically designated to review your health – both where you are now and where you are heading. It’s the body’s status update. It’s also where I feel I get to know a person a little better, more about your life in general, not just your blood pressure or back pain. Besides having a conversation about your health, a blood test is usually performed. Often, when we get to drawing blood at a physical exam, a patient will say, “Test me for everything.”  Obviously, everything is not possible – so a discussion of what “everything” entails is needed. 

Often, patients use “everything” as a signal for testing for sexually transmitted diseases (STDs).  It is important to know that HIV can not be tested for without your request – so do not assume it is being tested – ASK FOR IT!

Other STD tests usually include HIV, syphilis, gonorrhea, chlamydia and Hepatitis B & C.  Herpes can be tested for in the blood as well, but the test only shows whether a person has been exposed to the Herpes virus, it does not give information on contagiousness or disease activity.

HPV is tested for in women during a PAP smear.  It is a test done on cervical cells – it is not a blood or urine test.  There is no test for men for HPV, unless there is a lesion – usually a wart – that can be biopsied.

So what are the usual blood tests done at a physical?

It depends on your age and gender. The blood tests I order fairly universally:

  • blood count (CBC)
  • sugar (glucose)
  • liver function (AST, ALT)
  • kidney function (BUN, Cr)
  • lipid panel (cholesterol)
  • thyroid function (TSH, Free T4)
  • urinalysis

Often tested, but not “mandatory”

  • iron levels
  • vitamin B12
  • vitamin D

Other tests determined by age, gender or a medical condition

  • high sensitivity C-reactive protein (cardiovascular risk)
  • hemoglobin A1c (for further assessment of diabetes)
  • urine protein (for people with diabetes or hypertension)
  • prostate specific antigen (PSA) – this is ordered after a discussion about risk and benefits
  • other tests can be considered depending on individual risk – advanced lipid testing, imaging studies, stress tests – these depend on your specific medical needs and are not “one size fits all”

Do I have cancer?

One of the most common questions asked when we draw blood is can you tell if I have cancer? Blood tests for cancer or genetic information are not routinely done, with the exception of the PSA in men for prostate cancer.  While there are tests that exist for following some cancers, they have not improved diagnosis – especially the CA-125 test that is touted in many email chain letters for finding ovarian cancer – it is not a diagnostic test but rather a test for following someone with ovarian cancer. Using tests improperly leads to confusion, anxiety, more testing and misdiagnosis!

More cancers can be detected or screened for with specific tests other than blood tests. Colon cancer, breast cancer, cervical cancer and lung cancer all have screening tests (procedures) that improve detection. There are many guidelines as to when these tests should be done – the bottom line is that each person should discuss their individual risks with their doctor to determine what tests should be done, as well as when and how often!

This leads to the biggest issue of testing – interpreting the information in a meaningful way for you.  The FDA recently forced a home genetic testing company, 23 and Me, to stop marketing their kits due to quality and interpretation issues. As more tests are developed, our need to synthesize this information to make good decisions is becoming more apparent.

So, “everything” means different things to different people – so be specific if there is something you wish to have tested.  You can’t assume it is part of everything.  An Annual Physical gives you a snapshot of where you are, and serves as a guide for how to get to where you want to be. Have a conversation with your doctor about your health fears – an annual physical is the time to chart your path to health!

The path to wellness begins with a proper diagnosis