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.

Personalized Medicine isn’t necessarily Personal

3 months ago our family dog got sick.  Her liver was very inflamed.  The evaluation revealed copper deposits in her liver.  This was likely due to a genetic defect – very common in several breeds in dogs, but not common in hers.  Despite efforts to remove the copper with medication, the damage was too severe, and we lost her about a month ago.
This prompted some research into her family history – one “cousin” died from liver issues, but it was not known if it was copper related. There is a blood test that can see if a dog had the “copper” gene and my wife and I started discussing what we would have done differently if we had known.   
Since cloning the human genome, we have identified genes and mutations associated with cancer, drug sensitivities and the risk of other chronic conditions.  We have also identified mutations that may not have any impact on health, and others that the impact is unclear or unknown.
Using that genetic knowledge to direct diagnosis and treatment is called personalized or precision medicine. It was mentioned in the Federal Budget for 2016 and the National Institutes of Health is dedicating significant research money to it.  There have been several direct to consumer companies offering to read your DNA and tell you what diseases you are at risk for.

How is this done and what can you really learn?  

Precision Medicine assumes that by running a person’s DNA code you will get results that shows what diseases you are likely to get – heart disease, diabetes, cancer, etc.  For those diseases you already have, it can tell you which medications are most likely to be effective.  Plans can then be developed to treat illness and recommend screening programs based on one’s DNA code – offering medications with the best chance of success to those with the proper codes and not giving them to people who are not likely to respond or be at increased risk of toxicity.
There are already examples of this in use today.  We avoid medications in people with certain genetic markers because they are more susceptible to side effects (people may be more or less sensitive to certain blood thinners based on their DNA). Many cancers, from lung to breast to lymphoma and leukemia have genetic markers run to see what treatments are likely to work. Perhaps the most famous use of genetic testing determining treatment is Angelina Jolie.  She tested positive for the BRCA1 gene greatly increasing her risk of breast and ovarian cancer.  She then elected to have mastectomies and her ovaries and uterus removed before any cancer developed.
Genetic based diagnosis and treatment has the potential to change the way we evaluate risk and treatment.  However, checklist testing and treatment is not personal.  Blind application of data to a person without context (history) reduces medical care to algorithms and formula without the personalization it is supposed to offer. There is a social and ethical side to the use of genetic information that we are just beginning to understand, from privacy laws to insurance regulation to job security.  Would you hire someone you knew had an increased risk of and potentially expensive illness if you were responsible for paying for their care?  Would you marry someone knowing their illness potential?  Have children?  These are all issues that need to be sorted out as we move into this new paradigm for healthcare.
Most importantly, people need good information on what their tests mean.  Many of the kits available now report mutations that aren’t clearly associated with disease.  The FDA ordered one company to stop selling its test and services due to non-compliance with testing regulations.  They have since started selling a very specific test for a single condition, but not a general DNA analysis.  The next age of primary care will involve helping people curate and collate their genetic information.

Do I worry that the genetic classification of diagnosis and treatment will make me obsolete?  

To the contrary, I think it can make me better at what I do.  I already strive to get to know my patients, understand how health or lack thereof fits in the rest of their life.  We discuss risk for future disease, concerns about hereditary and what medicines are best for them.  That is personalized medicine.  Getting to know my patients at the genetic level can only strengthen that bond.  Using the information we get from genetic testing and putting it in the context of the person sitting across from me is how we put the Personal in Personalized Medicine.

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.

What is a Diagnosis? A rose by any other name?

You go to see a doctor with a painful shoulder. You tell the doctor that you can’t sleep because of the pain, and the doctor starts to make assumptions about your symptoms.  Before you get a chance to tell the doctor your story, you are told you slept on it wrong, and given a prescription for anti-inflammatory medication.  You don’t really improve and so you see another doctor for a second opinion.  A full history is taken, and you tell the doctor that you play softball on the weekends and you collided with the catcher while trying to score.  The doctor examines you and tells you that you likely have separated your shoulder.  An x-ray is ordered and it shows a shoulder separation.
Unfortunately, quick, easy answers and assumptions frequently lead to an incomplete diagnosis or a misdiagnosis.  These carry costs – your time and your money spent finding the correct answer, but more importantly, your health – which is why you go to the doctor in the first place.  Your story is like a puzzle, separated pieces that depict your diagnosis – the doctor has to put them together.
Your doctor needs to ask the right questions and listen to you to put your puzzle together.  It is what I am trained to do – make a diagnosis.  But what is a diagnosis?

  • A label
  • A code
  • A starting point for treatment

A diagnosis is a term with medical meaning.  It is comes from a physician’s synthesis of a patient’s symptoms, history, physical findings and laboratory findings.  A proper diagnosis is essential to begin a journey towards Wellness!

How does a doctor approach making a diagnosis?  We start by making a list – called a “differential diagnosis.”  As we take a history from a patient we start listing diagnoses that fit the symptoms.  As more of the story unfolds, the list is adjusted, the order is changed, items added and removed.  Then we examine the patient, and again revise the list based on our findings.

Tests are then ordered to do two things.

  • Definitely remove an item from list.
  • Confirm items on the list.

The approach to testing, however, doesn’t always focus on the most likely – there are other factors that determine the order of the tests.  If being wrong about a diagnosis has severe consequences, it may be tested for first even if less likely.

Finally, all the information gathered from the history, physical and diagnostic testing are put together and the list is put into a final order and a diagnosis is made.

If a treatment works, it confirms the diagnosis choice from the list.  If a treatment doesn’t work, the list needs to be re-examined and the history revisited to see what information was missing or not emphasized.  This is a crucial time in communicating with your doctor – they need to know what you are experiencing.  Based on that re-evaluation new tests may be ordered to further refine the list, and so on, until the final answer is revealed.

So what?  Why is this important?

First and foremost it determines treatment.  A diagnosis of Strep Throat requires treatment with antibiotics; a cold does not.
The diagnosis is what is used by insurance companies to approve tests and medications.
Diagnoses determine life insurance rates!

A diagnosis represents the last piece of the puzzle being put into place; it allows you and your doctor to chart a course of treatment and find direction after the confusion of not feeling well.

Without a proper diagnosis, you wander in the medical field, so remember:

The path to wellness begins with a proper diagnosis

 

Making a diagnosis – Who am I?

As you sit in the doctor’s office for the first time, your eyes note the array of diplomas and plaques on the wall. You have never met this doctor before, but your friend said they were good, or you picked them out of a book, or you were referred by another doctor, and you are about to share intimate details of your life with them. You have questions about how you feel, and you are going to get a diagnosis. But who is the person behind the plaques? What do all those fancy diplomas mean? After all, they call the person who finished last in the medical school class the same thing as the first – “Doctor”. Doesn’t it make sense that you know something about this person who is going to ask you personal questions and examine you? Shouldn’t you know more about this person you call “Doctor”? Well, I think the answer to this question is YES! So who am I? Keep reading…

All doctors are trained to make diagnoses, some within specialities – orthopedists, neurologists, surgeons, etc.  Most diagnoses are first evaluated by a primary care doctor.  There are several specialities that make up primary care doctors – who you see will depend on age, who practices where you live and possibly your gender.  Examples of primary care doctors:

  • Family Practitioner – a physician trained broadly to care for a person from birth to death
  • OB/GYN – a physician trained in women’s health and pregnancy care
  • Pediatrician – a physician who specializes in the care of children
  • Internist – a physician who specializes in the care of adults

How did I get here?

I am an Internist.  How did I come to call myself this?  Who am I behind other than the plaques on the wall? After graduating from college at Case Western Reserve University in Cleveland, OH, I attended the Albert Einstein College of Medicine, in the Bronx, NY, earning my MD with Distinction in Research.  I then spent 3 years as an intern and resident in Internal Medicine at New York University Langone Medical Center and Bellevue Hospital in New York City, completing the training to be a licensed physician.  I then served for an additional year as a Chief Resident for my program helping train the recent medical school graduates.  It was during this year that I took and passed an exam to become Board Certified in Internal Medicine by the American Board of Internal Medicine (ABIM).

 

I joined a prominent medical practice in NYC remaining on faculty at NYU School of Medicine.  During that time I refined my diagnostic skills, continued to train medical students and residents and eventually earned the rank of Assistant Professor of Medicine at the NYU School of Medicine.  After my first 10 years in practice as a Internist, I was tested again by the ABIM as part of a recertification process and again passing a comprehensive exam to remain Board Certified.

 

In 2012, after 13 years with my practice in NYC, my family and I decided to relocate to Phoenix, AZ where I joined Scottsdale Healthcare to bring my skills to a practice in the Arcadia area of Phoenix.  During my first year in Arizona, the American College of Physicians (ACP), which is the national society for Internal Medicine, elected me to Fellowship after a review of my professional work.  Doctors who have the initials FACP after their names have earned this distinction.

 

What is next?

This has been my path so far as an Internist.  I hope I have given you an appreciation of what the journey is like.  Along my journey I have worked with tens of thousands of patients to take the lead in helping them identify risks to their current and future health and well-being; prevent problems, and find the diagnoses that threaten their health today. It is with the realization that a proper diagnosis sets the foundation for all future health issues that I begin The DiagnosisMD blog.  My goal is to explain why a diagnosis matters, shed some light on the process a doctor uses to make a diagnosis, and explore interesting and timely topics in medical news.

So what is an Internist?  The ACP defines it as:

“Internal Medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment and compassionate care of adults across the spectrum from health to complex illness.”

Or as one of my patients from NYC used to say, “You are a Doctor’s doctor.”

 

I hope you enjoyed this look into my journey as a physican so far, and look forward to sharing my thoughts and reading your comments along this journey.

 

The path to wellness begins with a proper diagnosis