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

Drug Holidays – what are they and when to consider

A drug holiday is a conscious decision to stop a medication.  The reasons to do so usually revolve around “seeing if I still need it” and side effects.

I was interviewed by Sara Klein in Prevention Magazine on this topic.

Click here for the story!

http://www.prevention.com/health/drug-holiday-facts

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

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

Happy 4th of July – Keep it SAFE

As we enjoy the 4th of July, a reminder from TheDiagnosisMD to stay safe this holiday weekend.

Fireworks are beautiful to watch – the sounds, color and spirit evoke great memories for many.  Some of my favorite 4th of July memories

  • 20 years ago on call during my 4th day of Internship at Bellevue Hospital watching 2 minutes of fireworks on the East River from the cafeteria window
  • A fireworks show at Pine Hollow in Long Island, NY with friends after a BBQ dinner
  • Fireworks at my daughter’s camp while serving as the camp doctor

What each of these events had in common was that they were done by professionals, with firefighters on standby to be sure that everyone was safe.

Emergency Rooms see over 5000 firework related injuries a year, with half of them in people under age 20!  Fingers, eyes and burns are the most common injuries.  Even sparklers burn at close to 2000 degrees – so children should not use them without close supervision!

So lets enjoy the show – let those who are trained entertain you – and keep it safe!

http://www.cpsc.gov/en/Safety-Education/Safety-Education-Centers/Fireworks/
http://www.cpsc.gov/en/Safety-Education/Safety-Education-Centers/Fireworks/

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
 

Colon Cancer – An Ounce of Prevention….

Breaking bad news is one of the hardest parts of my job.  There are times that I have to tell someone they have a new diagnosis – whether diabetes, a sexually transmitted disease or cancer – and it is not easy.  It is even more difficult when I know that some diagnoses can be PREVENTED!  So I am a huge advocate for preventing a disease whenever I can.  March is Colorectal Cancer Awareness month – and this week’s post is an update on how to prevent ever having to hear your doctor utter the horrible words – “You have colon cancer.”

Colon and Rectal cancer will be diagnosed in over 125,000 people in the US this year.  Over 50,000 people will die from it.  Colon cancer is the 3rd most common cancer in the United States.  And the majority of cases are preventable.  So how are colon and rectal cancer prevented?  By screening for them – doing tests that look for cancer – or ideally pre-cancerous lesions, and removing them.  How do we decide when and what tests to do?  By looking at your medical history and your family medical history and determining your risk.

For those at average risk, the current recommendations for colon cancer screening is to begin at age 50.  Why age 50?  At age 50, the likelihood of colon cancer or a colon polyp – a bump in the tissue of the colon that can turn into cancer – becomes high enough that the benefit of doing a test and removing the lesions outweighs the risk of the testing and the procedure.

So what increases your risk of colon or rectal cancer?

  • Colon cancer or precancerous polyps in a first degree relative (parent, sibling)
  • Prior colon polyps yourself
  • A  history of Ulcerative Colitis
  • A family history of a hereditary colon cancer syndrome – familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC)

How do we screen for colon cancer?

  • Fecal Occult Blood Testing (FOBT)
  • Colonoscopy
  • Flexible Sigmoidoscopy
  • Barium Enema
  • CT Colonoscopy (also called a Virtual Colonoscopy)

 What are the advantages and disadvantages of each screening method?

  • FOBT  – done yearly; a small amount of stool is placed on a card, and a chemical added to see if there is any blood in the stool.  Best done with 3 consecutive bowel movements at home and returned to the doctor.  This helps detect cancer because polyps or cancer often bleed.  If blood is detected, a colonoscopy is required.
  • Colonoscopy – this a procedure,  done under anesthesia or sedation, where a flexible tube with a camera is inserted in the rectum and passed through the entire colon.  It directly visualizes the colon and any polyps can be removed (preventing them from becoming cancer).  It should be done at least every 10 years (if totally normal) and more frequently depending on risk and findings.  The 10 year interval is based on studies that show it takes about 10 years for a polyp to turn into cancer.  It requires a “prep” – emptying the colon of any stool the day prior to the procedure.  This is the “gold standard” for colon cancer prevention.
  • Flexible Sigmoidoscopy – this is a procedure, where a flexible tube similar to a colonoscopy tube is inserted in the rectum, and the first two feet of the colon are looked at for polyps or cancer.  If they are detected, they can be removed.  It requires a prep to clean the colon.  It can miss any polyps beyond the two feet of colon closest to the rectum.  If any polyps are found, either a colonoscopy or a barium enema to look at the rest of the colon are recommended.
  • Barium Enema – this is an X-ray test where barium is inserted into the rectum and outlines the inside of the colon.  An X-ray is taken to see the outline, allowing polyps that change the outline to be seen.  It requires a prep before the procedure to empty the colon.  If the study is abnormal, a colonoscopy is required.
  • CT Colonoscopy (Virtual Colonoscopy) – a study using a CT scan and computer reconstruction to see the inside of the colon, looking for polyps or cancer.  It takes less time than a traditional colonoscopy.  There is radiation exposure. It does require the same prep as a colonoscopy, and a small tube is inserted in the rectum to pump air into the colon to allow for better imaging.  If the study is abnormal, a colonoscopy is required.

How does this affect my practice?

I recommend a colonoscopy for all my patients over 50 years old.  If there is a family history of colon cancer I recommend starting 10 years before the relative’s age when they had colon cancer or age 50 – whichever is sooner.

Most people dread the prep – cleaning out their colon more than the procedure itself.  Most people sleep through the actual procedure.  The preps have gotten better in that you don’t need to drink as large a volume of liquid as in the past.  It could be considered the most useful cleanse ever!  

I also recommend FOBT yearly between colonoscopies, though current guidelines to not require this.  I make this recommendation because FOBT is easy, and people may delay their colonoscopy or a polyp may develop a little faster than the usual 10 years.

As far as flexible sigmoidoscopy and barium enema, I only recommend them if there is a reason a colonoscopy can not be done.  CT colonoscopy gives a great image of the colon, and if totally normal gives good reassurance that there is no colon cancer.  However, if there is an abnormality, a colonoscopy must be done, requiring a second prep and procedure.

Colon cancer is preventable – and if diagnosed early, curable.  The important thing is to talk to your doctor about your risk and get screened – any method of screening is better than nothing!  I recommend colonoscopy as it allows the best visualization of the colon – and removal of polyps at the same time – one stop shopping.  Telling someone we prevented them from getting cancer is much more fulfilling than telling them they have colon cancer!

The path to wellness begins with a proper diagnosis

Some useful links:

CDC colon cancer screening guidelines

American Cancer Society colon cancer detection guidelines

American Cancer Society colon cancer overview