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

Ranking Doctors – “mine’s the best”

The baseball world elected Ken Griffey Jr. to the Hall of Fame with the highest percentage of votes ever.  Without doubt he is one of the best to play the game, deserving of all the honors he won over the course of his career.  Yet for all his success at the plate, he got a hit less than 1/3 of the time he was at bat.

I started to think about how other professions rank their members – athletes by statistics, business people by profit margins, attorneys by cases won, pilots by safety records, etc.  But how are doctors ranked?  Everyone dies eventually, so survival is not specific enough.  Ask anyone for a doctor recommendation and they will say theirs is “the best”.  After all, who would go to a sub par doctor (or any professional)?  We may not want to acknowledge it, but everyone can’t be the best – its statistically impossible!  As the punchline says, “What do you call the person who graduated last in their med school class?  Doctor”

How are doctors ranked?

Since there is no medical hall of fame, the first question to ask about a ranking is who is doing the ranking and what perspective are they coming from.  Insurers rank by “cost and efficiency.”  Doctors rank other doctors on reputation, technical skill and experience.  Patients rank us on their own experiences and expectations.

If you are a patient, you can look at multiple online or magazine sources for “Top Doctors” rankings and opinions. But just as I’ve hated movies and restaurants that got great reviews (and vice-versa), if what you need isn’t what the doctor you see provides, it’s not the right fit.

Insurers and Medicare rank doctors on how they perform on cost and utilization – they look for doctors that don’t deviate from the norm – not doing too much or too little.  In other words – those that do average things.

Employers have a different perspective – they want a doctor that fills a need – either specific skills or ability to see patients in a way that improves the reputation and revenues of their system.

How do you research a doctor?

When researching a doctor, you can check basic credentials – license, board certification, medical board sanctions are bare minimums.  Your first question should be – what are you seeing them for?  If you are looking for a diagnostician, such as an Internist, your needs are very different than if you are having heart surgery.  What you need will determine what you are willing to accept.  In your Internist, you want someone who listens to you, is empathetic and helps answer questions about your symptoms.  In a Cardio-thoracic surgeon you may care less about their bedside manner and more about their technical skills.  The length of your relationship is different as well – I’ve known many of my patients for over a decade, whereas an orthopedic surgeon who fixes your knee may only be part of your life for a few months until you are healed.

Most surveys of what patients say make a good doctor have little to do with training, malpractice complaints or cost and efficiency.  It is mostly a subjective assessment – personality, listening, empathy – the things we call bedside manner.  Studies bear this out as well – even when the outcome of care does not end well, doctors with good bedside manner and communication skills are sued less than those who are less liked by their patients.

I like to think I’ve got a good bedside manner – but also recognize that I’d have a lot of empty space in my schedule if I was wrong in 2 out of every 3 diagnoses!  The funny part is listening and using my “soft skills”makes getting the diagnosis right much easier – 90% of diagnoses are made by history.

I don’t expect to see my name on ESPN any time soon, I’m quite content when patients leave the office feeling heard, with a plan to move towards health.

The path to wellness begins with a proper diagnosis

Teachers are another profession without a hall of fame – but what if they had their own network?

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

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
 

Exercise – The Power to Heal Yourself

 

exercise - the power to heal yourself
Visualizations are provided by www.theVisualMD.com

New Year’s is a time of resolution, renewal and rejuvenation.  People resolve to stop smoking, lose weight and exercise.  More gym memberships are sold in January than any other time of the year, and many go unused.  We all have this sense that we should exercise more – but have you ever wondered why that is such a universal sentiment?  What is it about exercise that makes it hard to maintain but remain so high on our wish lists?  What does exercise do for us?

Exercise impacts not only our muscles but almost every body function we have – it changes multiple hormone levels, insulin sensitivity, pain perception, hunger, sex drive and mood.  Exercise gives you the power to heal yourself.  Regular exercise promotes the following changes in the body:
  • increases the development of new blood vessels (can help in heart disease)
  • improves the functioning of multiple immune system aspects
  • decreases anxiety and depression
  • decreases inflammation
  • decreases pain in osteoarthritis
  • improves blood pressure
  • improves cholesterol
  • improves diabetes beyond weight loss
  • decreases the cravings for cigarettes
  • strengthens muscle fibers as well as promotes the development of more muscle tissue
  • improves digestion
  • stimulates the reward centers in the brain with substances called endorphins
  • and many other functions
These effects are separate from and in addition to the usual weight loss that accompanies exercise.

So what is exercise?

Exercise is any activity that maintains or improves physical fitness, health and wellness.  Studies have shown moderate activity will begin to show the benefits of exercise.  Moderate exercise is defined as 150 minutes per week (30 minutes/5 days per week) of brisk walking or similar activity.  The more intense your activity, the less total time you need – 75 minutes per week of intense activity will give similar benefits to the 150 minutes of moderate activity.
recent study in the journal Lancet  showed that in people with a high risk of heart disease and pre-diabetes decreased their risk of a heart attack by 10% just by increasing their walking by 2000 steps per day.   Another study in the British Medical Journal demonstrated that regular exercise was as effective as medication in preventing death from second heart attacks, rehabilitation from a stroke, improving heart failure and preventing diabetes.
The trick is maintaining the activity to continue reaping the benefits – if you don’t use it, you lose it.  Another way of looking at it is stated very well by Jim Rohn, an author and self development coach.  “Motivation is what gets you started, habit is what keeps you going.”

What do I recommend in my practice?

So, should everyone stop their medications if they exercise?  No, and certainly not without discussing your plans with your doctor.  Not every condition can be controlled with exercise, and not every medication can be safely stopped abruptly.  What I try to emphasize with my patients is that medication begins to correct a problem immediately – for example – lowering cardiovascular risk with a statin; adding an exercise program helps manage the long term risk.  We can then decide if immediate action is necessary, and set a goal – say losing a certain amount of weight.  When the goal is reached, stop the medication and reassess the condition.
By re-evaluating your diagnosis the effect of medication and the effect of your actions on your diagnosis can be measured, and your treatment plan revised.  You become an equal partner on your journey to wellness by revising your diagnosis!
Personally, I reconnected with running about 3 years ago. While there have been some ups and downs, I’ve managed to keep about 20 pounds off, and will be running my 7th half marathon next weekend. If you’d like to read about my own story on how I started maintaining a program, see this post – Exercise for a Cause, originally posted on TheVisualMD.com in 2011.

The path to wellness begins with a proper diagnosis