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!

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.

E-cigarettes – deterrent or path to addiction

Recently, the CDC published its 2014 National Youth Tobacco Survey – which looks at smoking in middle and high school students in the US.  As a physician, but more as a parent of a newly minted teenager, the results were of great interest – and concern.  While cigarette use declined in high school students, e-cigarettes and hookah use tripled – and surpassed cigarette use for the first time.  E-cigarettes are not regulated by the FDA or subject to current tobacco marketing laws – allowing companies to market directly to teens with flavors more like candy than tobacco – something traditional tobacco companies have not been able to do since the 1970s.
The increase is not surprising – e-cigarettes are marketed as safer, they are easier to access and less expensive than cigarettes.  The real question, and one that comes up frequently in the office, is if they can help people quit smoking regular cigarettes, and are they safer?

Are e-cigarettes safer? 

There is not great data available yet.  What we do know is that the vapor produced contains particles that can irritate the lungs, and that it contains chemical byproducts such as formaldehyde – but in much lower concentrations than traditional cigarettes.  They also contain nicotine, the same addictive drug in cigarettes.  Nicotine affects brain development, may promote tumor growth and interfere with chemotherapy.  Nicotine also constricts blood vessels and increases blood pressure.  That increases stresses on any plaque buildup in a blood vessel – a precursor to heart attack and stroke.

Do e-cigarettes help you quit?

Again, the studies are still in progress.  There is some data that smokers who switch to e-cigarettes refrain from tobacco longer than those who try to quit while still using tobacco.  Neither the World Health Organization or the American Heart Association recommend e-cigarettes as a smoking cessation method.  There is no information yet as to whether those who switch to e-cigarettes quit nicotine completely, or have simply switched from one addiction to another.

How does this affect us?

So, while we await studies to more definitively address the safety question, what am I telling patients about safety?  Obviously, the best choice is not using any nicotine product.  If you are deciding between tobacco and e-cigarettes, it is reasonable (but not proven) to assume there is a lower lung cancer risk with e-cigarettes, but no data on oral or head and neck cancer.  However, since there is nicotine in both products, I advise people that there is still similar heart disease risk.  There is also no path to stopping e-cigarettes, unlike other nicotine replacement methods like the nicotine patch – which gradually reduces the dose delivered.  Studies are ongoing, so hopefully we get good information to make healthy decisions.  In the meanwhile, the FDA is seeking ability to regulate these products, and limit their marketing to children.
The path to wellness begins with a proper diagnosis

Annual Physical Exam vs Personal Health Assessment

I read a piece in the New York Times this week questioning the usefulness of a yearly checkup with your doctor.  It cited a study from 2012 that said that people who went for an annual exam did not live longer, avoid the hospital more or visit the doctor less.  A similarly themed Op-Ed piece was written by Ezekiel Emanuel earlier this year.  With all due respect to Dr. Emanuel and the New York Times, I will disagree, although with a caveat.
The usefulness of anything depends on how you define it and the what you seek to accomplish.  A checkup that ticks off boxes on a form for an insurance discount – maybe checking blood pressure, weight, blood sugar and cholesterol may identify some people with a health issue.  A fuller exam that looks at when recommended screening exams and vaccines were last done may increase health care usage, but no one argues that a colonoscopy at the right time in one’s life can be life saving and cost-effective.  Medicare covers an annual wellness exam, designed to identify those things that cost medicare money and increase health expenses – dementia, falls and depression.  It also requires a discussion about advanced directives – what a person does or doesn’t want done if they get too sick to make decisions for themselves.  It does not cover lab work, blood pressure checks or other “problems”.  In fact, there is no “laying of hands” at all.
The argument often cited for the yearly exam is relationship building.  If you see your physician when you are well, it is a chance to know what your baseline is, and later you are not trying to establish a relationship in a crisis.  There are pros and cons to this argument – in a mobile society, when you are young, will you have the same doctor when you get ill?  Or do you view your relationship as an insurance policy?  You have the relationship, and hope not to use it.  If there wasn’t precedence for this, wouldn’t we only buy auto insurance after the accident?  Or do you view your physician as a trusted advisor, investing in your health like you might your financial portfolio, with regular review to try to optimize things?

So what do I think of an Annual Exam?

The issue with studies on physical exams are multiple – inconsistent definitions, goals and outcomes make it hard to compare results from various studies.  Besides the studies the NY Times quoted, there are several studies that show recommended screening occurs more in people who come for annual physicals, and that there are health benefits – such as identification of high blood pressure – which has no symptoms and won’t be found until it is too late.
I believe in a yearly checkup.  However, I think the definition needs to change, and it has a very specific goal.  Personal Health Risk Assessment.  All the studies are based on large populations, and when I am with a patient, the most important thing is that person across from me.  We can use population data for a discussion, but what really matters is your risk.  So I like to use the opportunity of an annual exam to go through a person’s history, family history, social history and medical concerns.  Using that information, we can use population studies and decide what studies are appropriate for you!  We can look for the things you are at highest risk for and are most concerned about.  We can decide on a risk reduction plan once we have testing data back.  Can I guarantee you will be healthier for it? No, life does not come with guarantees.  We will be able to say that we identified your risks and did our best to reduce them.  We come away with information and recommendations that are specific to you.  I know your health risks, fears and concerns, and can provide advice that addresses them.
Will you live longer for our time together?  I don’t know.  Can you live better for it – absolutely!
 The path to wellness begins with a proper diagnosis