Ten Signs You Are Seeing the Wrong Doctor

December 8th, 2018

By Natan Schleider M.D.

If dustballs in the corner of the doctor’s exam room and bullet proof glass separating your from the receptionist aren’t good enough, here are ten signs that you probably are not seeing the best doctor:

  1. An old expression states if the ink on the diploma is to wet or too dry, seek treatment elsewhere. If the diploma is a pile of dust behind a dingy glass frame, run.
  2. The doctor’s lab coat is dirty. This simple observation reflects the doctor’s hygiene and their respect for medicine. Dirty lab coat, dirty doctor.
  3. Magazines in the waiting room are over 10 year old. This shows the office is not up on the times, that is, if they can’t even update their magazines, what kind of archaic medicine is being practiced.
  4. The doctor spends less than a minute with you and can never remember your name. While I grant many doctors are overworked, they can spare a few minutes and knowing their patient’s names.
  5. The doctor is a social media star who does nothing but tweet, post, take selfies, and promote his brand. While I’m sure these doctors are attractive and interesting, they probably are not practicing as much medicine as the good old fashioned doctor–oh, excuse me for a second, someone just liked my latest post on instagram, just joking.
  6. The appointment is spent talking about the doctor and not about the patient (for example, ‘So you just had a little heart attack, big deal, I get my coronaries rota-rootered every year and since my 8th heart attack and some Lipitor, I eat at the buffet daily).
  7. The doctor cannot make a decision and refers you to a specialist for every problem (IE that splinter in your finger is tiny but just to be safe, let’s have a dermatologist look at it to make sure nothing is being missed).
  8. The doctor’s office frequently cancels your appointment or is late for your appointment.
  9. You arrive on time for your appointment and realize yo have read Was and Peace before being called in to see the doctor.
  10. You are asked to disrobe in the exam room for a talk therapy visit.

I’ve seen variants of all of the above so keep the above in mind before choosing your next doctor.

Natan Schleider MD

Which ADHD Medicine is Right for Me?

by Natan Schleider M.D.

December 7th, 2018

So you think you have attention deficit hyperactiviy disorder (ADHD formerly ADD) and you are considering medicine options. If you are like most patients I see, you’ve already queried friends, family, and the internet so you can tell the doctor what you think is best. I have no issues with educated patients so I’ve put together a list of medicines I use and why.

Note the family of stimulants (IE methylphenidate, Adderall, Vyvanse, and others) are the first recommended treatment in general for patients but that varies by patient and whether they have other medical or mental health issues.

Stimulants can be habit forming so considering a non-controlled medicine (bupropion aka Wellbutrin, Strattera) for ADHD may be a nice option as they are not habit forming although tend to be milder and less strong.

The first question to ask when it comes to stimulants are whether your want a short acting medicine that can be used a few times a day or a long acting medicine taken once a day. This is patient preference as some like flexible dose options with a short acting medicine while others just like to take one pill a day.

So here are your stimulantmedicine options for ADHD:

  1. methylphenidate (best known as Ritalin) which is the oldest and comes as short acting (last 2-4 hours) and long acting (last 6-12 hours for Concerta or Focalin or Vyvanse–I find they last closer to 6 hours in most patients). Note Daytrana is a patch that lasts up to 10 hours
  2. Dextroamphetamine/amphetaime (Adderall) which comes as short acting or long acting (Adderall XR) and super long acting (Mydayis) at up to 12 hours.

 
And here are your non-stimulant medicine options for ADHD:

  1. Atomoxetine (Strattera) which takes about 3 days to kick in and dose can be adjusted from 40 mg to 80 mg (the standard dose) in 3 days.
  2. bupropion (Wellbutrin) is a very activating antidepressant approved for ADHD, tobacco cessation, and depression.

My patients tend to prefer Vyvanse which is the least speedy of the stimulants but every patient breaks the medicines down differently so it may take some trial and error to find the right choice.

When reviewing medicine options with patients I go over the above in detail. While talk therapy helps for most other mental health illneses, it is less effective for ADHD (but no harm in trying it).

If you have any questions or comments please reach out to me on Twiter or Instagram or facebook.

Thanks for reading,

Natan Schleider, M.D.

Herbal Supplements: Helpful, Harmful, or Harmless when using Prescribed Medicines?

Herbal Supplements: Helpful, Harmful, or Harmless when using Prescribed Medicines?

By Natan Schleider M.D.

December 6th, 2018

One of the first things a good doctor does when discussing medical management of an illness is figuring out what treatments the patient is interested in.  Chances are they have already tried cranberry for their urinary tract infections, St.John’s Wort for mood, and a host of other over the counter herbs or supplements which their mother, butcher, or favorite celebrity has recommended.

When these patients come to see me, the melatonin is not really working for sleep and the horny goat weed has not helped libido. These patients may consider trialing a standard medicine when indicated as they feel so bad. Concurrently, they have a strong aversion to taking chemicals bundled into pills that the evil pharmaceutical companies are marketing. After all, if it is natural, it must be better?

When I prescribe a medicine, I need to make sure it will not interact with the herbs that millions of American take so I am writing this blog to weed out (pun intended) the supplements that you can take with other drugs and those that should be avoided or used carefully.

HERBAL DIETARY SUPPLEMENTS WITH LOW RISK OF DRUG INTERACTIONS:  Black cohosh, Cranberry, Gingko, Ginseng (American), Milk thistle, Saw Palmetto, Valerian

HERBAL DIETARY SUPPLEMENTS WITH HIGH RISK OF DRUG INTERACTIONS: Goldenseal, Green Tea Extract, St. John’s Wort

I have not discussed vitamins much and this may lead to a further blog. For example, iron supplements (along with calcium, antacids, and cholesterol drugs) impair absorption of thyroid supplements so take your thyroid medicine 1-2 hours before or after you’ve taken your other medicines and supplements.

I’ve scratched the surface of a major issue but most importantly, tell you doctor and pharmacist what supplements you take so they can tell you how they may or may not interact with your mediation.

Thanks for reading!

Natan Schleider, M.D.

SOURCE: AMERICAN FAMILY PHYSICIAN V.96 No.2 July 15th, 2017

Do I Have Clinical Depression or Am I Just Feeling Badly Because Life Just Dealt Me Crap?

Do I Have Clinical Depression or Am I Just Feeling Badly Because Life Just Dealt Me Crap?

By Natan Schleider, M.D.

November 18th, 2018

So you just broke up with your fiancee, you or a loved one just got diagnosed with a serious illness, or you just started litigation. These are some of the most common reasons patients see me wondering if they are depressed.

So how do doctors and mental health care providers determine if someone is depressed and warrants treatment or is going through a normal grief reaction or ‘adjustment disorder?’

For me it is quite simple–as are the screening guidelines for depression.

A simple 2 questions (called the Patient Health Questionnaire 2 Screening Instrument for Depression or PHQ-2 for short) is all we need to screen for depression:

  1. Over the past 2 weeks, how often have you felt little interest or pleasure in doing things [you normally enjoy]?
  2. Over the past two weeks, how often have you been feeling down, depressed or hopeless?

Not At All=Zero Points, Several Days=1 point, More than half the days=2 points, Most days=3 points.

A score of 3 or more would be a positive screen for depression at which point your health care provider should dig deeper with more detailed questions. I would not give a patient with a score of 2 a slap on the back and a lollipop and say ‘suck it up’ but the PHQ-2 helps catch at least 90 percent of depressed patients.

I am commonly asked: ‘Since I know the cause of my depressed mood, do I really need further evaluation or treatment?’ The answer is: nearly all of my depressed patients know why they are down, if they have clinical criteria for depression such as changes in sleep, interest deficit, guilt (hopelessness, regret, etc), appetite changes/weight changes, psychomotor retardation (trouble coordinating and concentrating), and/or suicidal thoughts or plans treatment is indicated.

That does not mean the patient is committing to a pill for life–a common fear. Talk therapy, herbal medicines like St.John’s Wort, and other non pharmaceutical treatments are available.

If you are feeling down and think you may be depressed, you are not alone–about 8 percent of the US population is depressed.

If you enjoyed this article and have questions, comments, or concerns please let me know via this blog or twitter or facebook or instagram.

Thanks for reading!

Natan Schleider, M.D.

SOURCE: AMERICAN FAMILY PHYSICIAN V.98 NO.8 OCT 15TH, 2018

Ten tips to be sure you have been prescribed the right antidepressant?

Ten Tips to be Sure You Have Been Prescribed the Right Antidepressant

By Natan Schleider, M.D.

October 15th, 2018

‘So my mood is much better,’ said my patient last week, ‘but I can’t get it up.’

Antidepressant medicines (not a great name for what they do since many also treat anxiety without depression, nerve pain, fibromyalgia, etc) come in many families and varieties. Choosing the right one is difficult, espcecially since many share the same common side effects like weight gain and sexual side effects.

If you have been prescribed an antidepressant for any reason, always consider whether possible side effects outweigh potential benefits and ask ‘Am I on the right antidepressant for me?’. Here are some tips on how to do just that:

  1. If you are concerned about weight gain, the Selective Serotonin Reuptake Inhibitor (SSRI) family, the Tricyclic Antidepressant Family TCA), and some other antidepressants like mirtazapine (Remeron) can cause weight gain. I find escitalopram (Lexapro) weight neutral, that is, most of my patients do not gain weight with it althoug it is an SSRI.
  2. Sexual side effects like poor libido or trouble obtaining or maintaining an erection can occur with TCAs and SSRIs
  3. The SSRIs tend to be one of the most common first choices doctors prescribe as they are inexpensive and have a pretty good safety profile; however, they are not all equal in action. Some are more activating and I use these with patients who are depressed, apathetic, oversleeping and overeating. Others are more sedating, good for someone also suffering from poor appetite, and feeling wired or anxious. Here is a list from most activating to least activating (although some patients will react to them differently): fluoxetine, sertraline, paroxetine, escitalopram, citalopram, fluvoxamine (an interesting SSRI not FDA approved for depression but anxiety).
  4. If other symptoms are present that the antidepressant can help with, why not kill too birds with one stone. For example duloxetine (Cymbalta) can be used for depression and/or anxiety and/or nerve pain and/or fibromyalgia.
  5. If you or a first degree relative have had success with a particular antidepressant in the past, that would be a reasonable one to trial
  6. If you are good at remembring to take your pills daily, great. If not, I would avoid venlafexine (Effexor XR) which is broken down quickly in the body and leave you in an uncomfortable withdrawal if not taken at the same time daily.
  7. If you have had side effects from one family of antidepressants, good chance you will have them from all medicines in that family so consider switching to a different family.
  8. If your mood can be managed without a daily medicine, for example talk therapy why not go for that first?
  9. If you are on other mental health medicines, double check there is no interaction between them. Most medicine labels may read do not take your antidepressant with alcohol–this is a common question. textbook answer is ideally don’t drink while on mental health medicines as they can confuse the diagnosis or medicines effect, especially if you like your medicines with a mimosa every morning.
  10. If you have failed the older families of medicines, try some newer antidepressants like vilazodone (Vybrid), Vortioxetine (Trintellix), or levomilnacipran (Fetzima).

Hope that answers some questions! Questions, comments, concerns? Contact me:

Twitter: @DrSchleider

Testosterone Therapy Part I: ‘I’m On an Opiate [buprenorphine, Suboxone, methadone, morphine, etc] and My Mood and/or Libido are blah’

Testosterone Therapy Part I: ‘I’m On an Opiate [buprenorphine, Suboxone, methadone, morphine, etc] and My Mood and/or Libido are blah’

by Natan Schleider, M.D.

August 19th, 2018

While the USA suffers through another opiod use epidemic (yes, we’ve had them before but I’ll give you the history lesson another time), the focus of press and medical/government powers that be are appropriately focused on preventing overdose and death. Far less attention is paid to adverse effects of chronic opiate use.

Whether used for pain management or for Medication Assisted Therapy (MAT) [IE using buprenorphine or methadone to manage Opiod Use Disorder formerly called opiod dependence] here is an important medical fact: if you are taking any opiate, you are at risk for testosterone deficiency. While not life threatening directly, common signs and symptoms of testosterone deficiency are decreased libido, depressed mood, lack of energy, diminished muscle mass/trouble gaining muscle size and strength at the gym, increased body fat, erectile dysfunction, and infertility.

Opiates reduce leuteinizing protein (LH) and follice-stimulating protein (FSH) production at the brain’s pituitary gland. LH and FSH tell the testicles to make testosterone.

In my practice, 50% to 75% of my male patient’s on opiods have low testosterone and half of them have some of the symptoms listed above.

I would argue that suffering the above symptoms poses risk of relapse to illicit opiod use and should be investigated and treated when indicated.

The good news about testosterone supplementation: it can help many of the symptoms above. The bad news: testosterone supplementation increases risk of prostate disease, prostate cancer, blood clots, and possibly heart disease (depending on the study).

Testosterone is broken down/destroyed by the stomach if swallowed so it has to be supplemented via transdermal gel (that goes on the skin daily) or by injection into the muscle (usually the gluteus) weekly to monthly. A few formulations I am not that experienced with as I can rarely get them covered are available: buccal (melts in the mouth) Striant, intransal gel (Natesto) [has to be given 3 times daily–annoying].

Most of my patients prefer the injectable formulations being least expensive and allowing for the patient and I to optimize how frequently to give the shot. I find weekly injections the best as if given less often, testosterone levels tend to peak for several days after the injection and wear off faster than the manufacturer suggests.

I would love to hear your experience or horror stories or opinion about testosterone therapy in opiate users via Twitter.com @DrSchleider or Facebook or Instagram.

Thanks for reading and stay tuned for part II, testosterone supplementation in women and transgender patients.

A Family Doctor’s Visit to See a Cosmetic Dermatologist for Sun Damaged Skin Part I: Poikiloderma of Civatte

A Family Doctor’s Visit to See a Cosmetic Dermatologist for Sun Damaged Skin Part I : Poikiloderma of Civatte

By Natan Schleider, M.D.

Dr. Natan Schleider’s Forehead. Note what appears different color tones which was diagnosed a poikiliderma.

I don’t wear skinny jeans. I wear flip flops whenever I can which apparently are out of style. And while starting to go bald–which I’ve decided to ‘own’ rather than pursue hair plugs or the ever popular toupee, the sun-damaged skin on my forehead has been bothering me (only when I look in the mirror).

Having spoken to my regular dermatologist, Dr. Roy Seidenberg (great, brilliant physician), he suggested a cosmetic dermatology consult for possible laser treatment.

Now I’ve had laser treatment before in my early 30s: laser hair removal on my back and chest. After 18 months of treatment every 6-8 weeks for a total package deal of about $3500, my back and chest were about 60% improved but I learned one valuable lesson: as I aged new hairs began to sprout on my back and chest (not to mention my ears, yikes!). So what I presumed–and is often advertised as a ‘permanent’ fix–not the case with me.

Friends have raved about various laser treatment for skin as the definitive cure while many patients of mine love Retin-A, a prescription cream or gel FDA approved for anti-aging (improving fine lines and sun spots). I tried Retin-A for a few weeks but realized I was soon forgetting to apply it at night (when I was negotiating with my 5 year old daughter Elie on the benefits of tooth brushing, a nightly debate).

Treatment for this would not be ‘one and done’ but would require a ‘series’ of treatments–the doctor would not commit on even a ballpark number but I would surmise 5-10 treatments. lasting ‘minutes’ after a numbing cream was applied. The stronger the laser each session, the better/faster the final results (meaning the more sun-damaged blood vessels are destroyed). If the laser is put on mild, minimal downtime, skin feels slightly sunburned, you can work same day. If laser is put on high power, skin is very red and inflamed and downtime expected to be 1 week. The cosmetic dermatologist suggested an in between setting.oping for a ‘one and done’ laser treatment to leave my forehead smooth and uniform in color, I saw a cosmetic dermatologist yesterday.

I tried to get a price idea on these laser treatments before the consult but found no great source?

Anywho, while I do have a few sun spots medically called solar lentigos, my primary problem in poikiliderma, a benign discoloration of blood vessels brought on by sun exposure underlying the skin leaving colors darker and lighter.

Treatments would occur about once a month and I ultimately got a price of $450 per treatment (which I think is low in the NYC area as it is a small region of skin being zapped as opposed to chest or neck where poikiloderma occurs more commonly.

The staff seemed surprised when I declined treatment at this time. Given this would be a long expensive process with best outcomes (based on my research) about 75% improvement, I paid my $200 consult fee and told them ‘I’d think about it’ which I will do.

The treatment would involve some type of laser which would take ‘a few

Any comments or experiences with cosmetic dermatologic treatments appreciated via Twitter.com or Facebook.com or Instagram.com.

Thanks for reading and I’ll keep you posted if I go back for laser treatment.

 

 

 

Medicine Changes It’s Mind Every 10 Years, Case in Point, Vitamin D Supplements No Longer Advised

Medicine Changes It’s Mind Every 10 Years, Case in Point, Vitamin D Supplements No Longer Advised

By Natan Schleider, M.D.

August 13th, 2018

Having been in practice 13 years now, I’ll let you in on a secret: fifty percent of everything you learn or read about in the news regarding health and medicine will be obsolete or wrong, sometimes even harmful, within 10 years or so. Does that mean I should ask for 50% of my money back from my medical school, hmmmm?

Case in point: In the 2000s, a lot of interest in Vitamin D testing and supplementation ensued with the consensus being, take Vitamin D if you don’t get enough sun, have low levels (my lab says low levels are less than about 30 ng per ml), are elderly and at fall risk, have mood disorder such as depression, are at risk for heart attack…the list went on.

Less than a decade later, recommendations have shifted 180 degrees, that is, studies in recent years show no benefit to taking Vitamin D for all the disorder above unless your levels are below 12-20 ng per ml making you Vitamin D deficient. If you are deficient in Vitamin D or your diet lacks the needed 600-800 IUs recommended daily, take Vitamin D (FYI most multivitamins have about 200-400 IUs of Vitamin D).

I’ve stopped supplementing with Vitamin D and plan on checking my levels in a month or two.

If you have been prescribed Vitamin D but are not in fact deficient and have questions or comments, speak to your doctor or contact me on Twitter. Facebook, Instagram, etc.

SOURCE: AMERICAN FAMILY PHYSICIAN V.97 NO.4 FEB 15th, 2018

What to Bring BEFORE You Go To The Emergency Room to Keep You Sane

What to Bring BEFORE You Go To The Emergency Room to Keep You Sane

By Natan Schleider,  M.D.

July 29th, 2018

One Horse Power Ambulance (Circa 19th Century)

Having gotten a call that my 5 year old daughter had just fallen at the playground in camp and was complaining of right wrist pain, I hustled down to pick her up. While crying inconsolably, the ice pack on her wrist already warm, she said ‘I can’t move my fingers and I want to go to the doctor–but I don’t want a shot.’

The wrist was swollen and very tender to the touch so with nothing but my wallet, smart phone on 40%, and keys, I picked Ellie up and went to the Pediatric Emergency Room directly, panicked, not thinking, unprepared. As doctor who has worked in the emergency room (ER), I should have known better: bring the stuff you need when going to the emergency room as if you were going on a camping trip or off to boot camp.

The ER was packed and we were ushered into a bed outside multiple rooms where the screaming of tormented children rang louder than the ambulances outside.

Long story short, we got there at 1:30 pm and were discharged at 2am and my daughter ultimately left with a cast in a sling having fractured her distal forearm. Hospital staff did not want me leaving my daughter unless I had to use the bathroom because the orthopedist and x ray transport would be here ‘any minute but no promises.’

My personal experience is that the average ER visit lasts 6-12 hours and here is the irony, the less sick you are, the longer you wait for care as heart attacks get prioritized over sore throats in a setting which is almost always understaffed.

While I credit the hospital staff for being polite and professional–they don’t make the rules in the ER nor control how busy it is–I know of no modern emergency room where you are greeted at the door with a handshake or smile, offered a glass of water, or a ‘welcome packet.’

As emergency rooms are losing business to urgent care centers, valet service (at hospitals, not the ER), a coffee machine and crackers, and a single chair for the parent are the latest in luxury amenities.

I was given a computer/tablet about a dozen times to sign consent forms–not to watch Netflix during the prolonged wait (seems like a reasonable idea doesn’t it).

Moving forward when going to the ER, may I suggest/note:

  1. You not go as only 10-30% of the time is it a true medical emergency…get a good doctor who can triage you same day and picks up his/her phone.
  2. Bring snacks, ear plugs, ear buds to listen to music or watch movies or whatever on your mobile device, a good book, a portable phone charger, beverages, a change of clothes, your toiletry kit, a portable chair or cushion, and your medicines.
  3. Learning to meditate because you’re gonna be there at least twice as long as your are initially quoted.

I would love to hear about any emergency room experience or wisdom via Twitter, Instagram, of Facebook!

Over and Out,

Natan Schleider, M.D.

PS–Being a health care provider does NOT afford you any special or speedier care unless you’re on staff in that ER or are a super famous doctor or specialist.

Cosmetic Medicine Part 1: What A Doctor Does for Prevention and Treatment of Sundamaged Skin

Cosmetic Medicine Part 1: What A Doctor Does for Prevention and Treatment of Sundamaged Skin

by Natan Schleider M.D.

July 23rd, 2018

Now that I am 42, those blissful days at the beach when I casually remembered to add SPF sunblock occasionally are catching up. Suddenly my skin in looking like it has some age spots, wrinkles, and my forehead has pigment changes.

I realize I’m no male model but when ‘liver spots’ appear I start worrying that shuffleboard all day and dentures are on the way so let’s nip this in the bud in the most cost effective way possible.

Natan Schleider MD sun-damaged skin on foreheard

Natan Schleider MD sun-damaged skin. Note two dots on back of my hand.

I’ve been using Retin A Micro Gel 0.06% for about a few months and see no results so I’m considering other options.

According to John Hopkins these are my treatment options:

  • Botulinum toxin type A. An injection of botulinum toxin (a complex type of protein) into specific muscles will immobilize those muscles, preventing them from forming wrinkles and furrows. The use of botulinum will also soften existing wrinkles.
  • Chemical peels. Chemical peels are often used to minimize sun-damaged skin, irregular pigment, and superficial scars. The top layer of skin is removed with a chemical application to the skin. By removing the top layer, the skin regenerates, often improving its appearance.
  • Soft tissue augmentation or filler injections. A soft tissue filler is injected beneath the skin to replace the body’s natural collagen that has been lost. There are multiple different kinds of fillers available. Filler is generally used to treat wrinkles, scars, and facial lines.
  • Dermabrasion. Dermabrasion may be used to minimize small scars, minor skin surface irregularities, surgical scars, and acne scars. As the name implies, dermabrasion involves removing the top layers of skin with an electrical machine that abrades the skin. As the skin heals from the procedure, the surface appears smoother and fresher.

    A gentler version of dermabrasion, called microdermabrasion, uses small particles passed through a vacuum tube to remove aging skin and stimulate new skin growth. This procedure works best on mild to moderate skin damage and may require several treatments.

  • Intense pulsed light (IPL) therapy. IPL therapy is different from laser therapy in that it delivers multiple wavelengths of light with each pulse (lasers deliver only one wavelength). IPL is a type of nonablative* therapy.
  • Laser skin resurfacing. Laser skin resurfacing uses high-energy light to burn away damaged skin. Laser resurfacing may be used to minimize wrinkles and fine scars. A newer treatment option is called nonablative* resurfacing, which also uses a laser as well as electrical energy without damaging the top layers of skin.

*Nonablative dermatological procedures do not remove the epidermal (top) layer of the skin. Ablative procedures remove the top layers of skin.

I’m leaning toward the laser because I am inpatient and want fast results but the price in New York City may be $1,000-$2,000 so I may need to go with something else?

I recommend my dermatologist who isa brilliant and has a great bedside manner: Dr.Roy Seidenberg [https://www.laserskinsurgery.com/Dermatologists/Roy-Seidenberg-MD

To be continued after consult…how exciting!

HAVE COMMENTS? PLEASE SEND THE TO MY TWITTER ACCOUNT @DrSchleider or my Instagram!

Thx for reading!