Why Pay Money For a House Call Doctor?

With an urgent care center on every corner and ‘telemedicine’ (that is the fancy word for being able to consult a doctor, nurse, or physician assistant via your smart phone or your computer), this begs the question:

Why Pay Good Money For a House Call Doctor?

1. You are home bound, really sick, and do not want to go to the emergency room. This is one of the most common house call requests I get. A good house call doctor can do all the triage testing that is done in an emergency room like vital signs, an EKG, cardiac enzymes, x-rays, urine,  blood tests, ultrasounds, etc…all in your home. The emergency room would charge thousands of dollars for this testing. Why not have this done in your home and get it reimbursed by your insurance plan?

2. You need a narcotic medication like a pain killer or a benzodiazapene (that is the pharmaceutical term for a medicine in the Valium family like alprazolam aka Xanax). These cannot be prescribed over the phone or by any of those telemedicine companies.

3. You want quality medical care by a Board Certified Medical Doctor. I am sure there are plenty of very nice nurses and physician assistants out there, but if I am really sick or my family is really sick, I want a competent, experienced physician caring for them.

4. You do not want to contract a bunch of germs in a doctor’s office or hospital. Do you know what a nosocomial infection is? Well there are medical journals dedicated to the word ‘nosocomial.” It is the fancy word for hospital-acquired infection. Hospitals and busy doctors offices are the play grounds of nasty bacteria. I don’t care how much antibacterial hand sanitizer is hanging around. [In fact, the hand sanitizers may be predisposing to resistant bacteria but that is another topic].

5. You are busy working and the cost of getting to a doctor, waiting around, seeing the doctor, and returning to work out weighs the cost of the doctor coming to you. Let’s face it, here in Manhattan, my time is money. When I am busy seeing patients in the office, do I call a house call doctor for myself or my daughter when busy? You bet!

“I’m Going to a Developing Country for Vacation, Do I Really Need Travel Vaccines? I Was There Before and I Was Fine.”

“I’m Going to a Developing Country for Vacation, Do I Really Need Any Travel Vaccines? I Was There Before and I Was Fine.”

By Natan Schleider, M.D.

July 2nd, 2017

I get the above question quite often from my patients, often days before they are leaving for Thailand, India, South America, Africa..my patients are world travelers.

Usually the question is followed by a statement like: “I only drink bottled water and will only be in the jungle for a few days.”

The answer to the question is a definitive YES.  Unless of course you like having Typhoid’s bloody diarrhea, Yellow Fever, or Malaria. Sure they may kill you but it will make a hell of a cocktail story 6-12 weeks after your hospitalization. Not to mention you may even get a few people saying: ‘You simply must share your weight loss secrets! You must have dropped 100 pounds darling!”

The Center of Disease Control (www.cdc.gov) has very specific guidelines in the Traveler’s Health section, just chose your destination and figure out what vaccines you need and what medicines you may need (for example Malaria prevention, antibiotics, sunblock, mosquito nets) (https://wwwnc.cdc.gov/travel/destinations/list/)

And I have followed them all! I have literally had every vaccine out there, including Rabies! That’s right! I was bitten by a dog when I was in medical school in Israel and had to have four intramuscular shots (they are not given into the stomach, that is a myth, they are given into the shoulder like a flu shot) weekly for 4 consecutive weeks.

One issue is Travel Vaccines are not covered by most health insurance plans and are not cheap. BUT, they are a lot less expensive than the cost of a private jet flying you to a reputable hospital, that is for sure.

Remember to get the vaccines at least 10 to 14 days BEFORE you leave for your trip to allow your body to build protective antibodies.

You may need a Yellow Vaccine Card if you are getting the Yellow Fever Vaccine (this is almost only needed if you are going to certain regions in Africa). I try to give all my patients this card and email my patients a PDF copy in case they lose the card. Ask you Travel Vaccine Doctor for a Yellow Vaccine card even if you are not getting the Yellow Fever Vaccine. Why? It fits nicely in your passport and is a great way to keep track of adult vaccines.

Look, you just booked a ticket to fly hundreds if not thousands of miles for the trip of a lifetime and I am guessing you spent decent money for the trip.

You may be spending most of your time on a resort. But even those ice cubes in the resort’s five star cocktails can carry viruses and bacteria so do yourself a favor and invest some time in your health and vaccinate.

The vaccines will confer immunity for anywhere from two to ten years so think of them as an investment into your health.

Gone are The Days Where to Build a Medical Practice You Just ‘Hang a Shingle’…

Gone are The Days Where to Build a Medical Practice You Just ‘Hang a Shingle’…

By Natan Schleider, M.D.

July 1st, 2017

“Hang a Shingle?!” What are you talking about? Most young readers are probably unfamiliar with this expression.

To “hang a shingle” refers to a time before the internet (yes, the stone ages) where, when starting a medical practice–or any other small professional business for that matter like a law practice–a young doctor hung a sign  with his or her name engraved (often in front of their home office) to attract new patients.

A shingle here refers to a piece of wood I suppose, not to be confused with the painful rash caused by Varicella Zoster virus yet I digress.

Having just put up a newly revised website, apparently my blogs carry more weight with search engines than my board certifications–so says my online marketing campaign adviser.

Is this why I am writing or should I say blogging? Sure in part.

A bunch of other factors such as how often I tweet on twitter.com and how often my patients “like” my practice on various social media outlets will help get my practice’s website, www.doctorinthefamily.com, highly ranked on Google and other search engines when patients are looking for a doctor.

In other words, I could be a Nobel prize winning, cancer-curing, super nice medical doctor but without the social media buzz, my website would not be highly ranked.

Apparently I’m a dinosaur who has stayed away from the social media limelight for far too long.

Adapt or die.

Follow me on facebook and twitter. Oh, I do not have accounts with them set up yet. And writing that is like nails on a chalkboard.

But if everyone else is glued to their smart phones not interacting with the humans around them, walking into telephone poles as their thumbs busily peck away, I should see what all the hype is about, right?

A Weight Loss Doctor New Year’s Resolution to Lose Weight P.4–Does stretching cause weight loss and get you lean or “ripped?”

Well, it’s 6:27 am and I am a but tired, I am on day 4 of the “30 day gallon water challenge” which I believe I mentioned in a prior post. Whether I make it to my 6:45 am spin class is doubtful as I want to write this blog and have some new stretching to explore and discuss (and perform later with my trainer).

If not, having found no data to support this, apparently celebrity Beyonce drank a gallon of water for a 30 days and noticed her skin was far more radiant and she felt better. This led to a fad water diet trend to which I, a trained physician, have succumbed to. Hey, I’m human, It’s water. Hold on, chug, chug, chug…half a liter down.

So I had my first session with a new trainer,Shawn, yesterday, an experienced personal trainer my age (41) unlike the the younger trainers I have had in years past. Telling him my goal was to lose 40 pounds over the next 40 weeks (or 1 year, I’m in no rush), he focused on showing me how doing certain basic exercises like lateral pull down in one position would isolate one part of the lateral back muscle while simple changing your grip by 45 to 90 degrees would isolate a different part of the same muscle group. The point: a year from now, I am hoping that the definition of my muscles will be equally distributed and I will not look like a big guy that works out a lot (which tends to happen because genetically, I have always been stocky and quickly put on muscle but always had trouble losing fat and getting lean).

I then asked Shawn “Will stretching regularly  lead me to become more lean?” to which he answered unequivocally “Yes.” He explained that regularly stretching out the muscles like a rubber band would ultimately lengthen them in time causing a leaner look.

Shawn has been a trainer for at least 15 years so I will not dispute his personal experience but as a  doctor, I wanted the real data and found it here:

CURRENT CONCEPTS IN MUSCLE STRETCHING FOR EXERCISE AND REHABILITATION. Int J Sports Phys Ther. 2012 Feb; 7(1): 109–119.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3273886/

The study answered my question in one specific section which I will italicize below if you want the bullet point: regular stretching does not increase muscle length, it simply increases ones tolerance to prolonged strecthing of a muscle. So the  rubber band does not get longer, it just gets less stiff.

The effectiveness of stretching is usually reported as an increase in joint ROM (usually passive ROM); for example, knee or hip ROM is used to determine changes in hamstring length. Static stretching often results in increases in joint ROM. Interestingly, the increase in ROM may not be caused by increased length (decreased tension) of the muscle; rather, the subject may simply have an increased tolerance to stretching. Increases in muscle length are measured by “extensibility”, usually where a standardized load is placed on the limb and joint motion is measured. Increased tolerance to stretch is quantified by measuring the joint range of motion with a non-standardized load. This is an important question to consider when interpreting the results of studies: was the improvement based on actual muscle lengthening (ie, increased extensibility) or just an increase in tolerance to stretch?7 Chan and colleagues8 showed that 8 weeks of static stretching increased muscle extensibility; however, most static stretching training studies show an increase in ROM due to an increase in stretch tolerance (ability to withstand more stretching force), not extensibility (increased muscle length).912

That said, Shawn has assigned me home work of stretching for 30 minutes in the AM and PM so I’m gonna buy a yoga mat on Amazon now so I can do my stretching while I watch the evening shows I enoy on Netflix rather than lying on the couch.

A Weight Loss Doctor New Year’s Resolution to Lose Weight P.3

As the cold month of January creeps to an end, I am not immune to the fad diets and the gym promotions that surround this 5’9″ 220 pound medical doctor here in Midtown, Manhattan, New York, City whose goal weight is 177 to 190 pounds over the next year.

Having been in the weight loss business, reviewed the weight loss literature, and watch my own metabolism slow (I  feel for for my cohort of people who now, when completing forms or checking the box on the elliptical trainer, check the 35 to 45 box rather than the 25 to 34 box)., I realize to lose roughly 40 pounds safely and realistically will take a year, needs to be done slow and steady. Slow and steady will win this race.

Something as subtle as eliminating the three cans of V8 vegetable juice which have about 80 calories each which sound and are healthy (minus perhaps the sodium) are 240 calories a day which are more or less what I burn daily in my morning spin class.

Oh yes, incidentally, I joined Crunch gym https://www.crunch.com in New York City.

I do not serve to endorse nor advertise them. I simply liked that their fees were reasonable (for me) at $79 monthly, no annual commitment, cancel anytime. Their approach unlike other high end gyms like Equinox–where everyone seemed “too” good looking with 1% body fat, their skin tight “sports bras” matching their sneakers”–is “come as you are.” Or I might translate, ‘so you are a little chubby, that’s ok, maybe we can get you in better shape.’

They did pitch me hard on 20 personal training sessions which I sigedn up forbut I will credit Fitness Manager Tiran Winston for giving me special attention to diet and nutrition and positive encouragement.

Tiran told me not to weigh myself daily but weekly. I didn’t listen of course having just joined the gym 5 days ago but I have lost 4 pounds since so since joining.

Of additional note, I am doing the 30 Day One Gallon a Day Water Challenge.  More to follow on that…

https://www.thrillist.com/drink/nation/i-drank-a-gallon-of-water-a-day-for-30-days-water-gallon-challenge

http://www.promaxnutrition.com/30-day-water-challenge-worth-it/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770067/http://texas.spoonuniversity.com/live/drinking-gallon-water-day-really-looks-like/

http://livewell.jillianmichaels.com/can-lose-weight-drinking-gallon-water-day-5607.html

http://www.military.com/military-fitness/health/drinking-too-much-water

A Weight Loss Doctor New Years Resolution to Lose Weight P.2

January 15th, 2017

by Natan Schleider, M.D.

So as a 41 year old male standing 5 feet 9 inches and weighing 220 pounds (I weighed about 180 in college, always been fairly stocky genetically but even I am not immune to desiring all the Hollywood actors incredible physiques my age or older), I calculated my BMR or Basal Metabolic Rate on line.

The BMR formula also called the Harris Benedict Equation can be calculated at these websites and tells you roughly how many calories you burn each day based on height, weight, gender, lifestyle, and age:

http://www.bmi-calculator.net/bmr-calculator/harris-benedict-equation/

http://manytools.org/handy/bmr-calculator/

Once you know this, you can calculate how much of a calorie deficit you need to lose weight daily. For example, my BMR is guesstimates that if I lie in bed all day and do nothing, I burn 2441 calories to maintain my weight. Frankly that sounds high because I have been eating rather healthy (no sweets, pizza, french fries, etc) but have lost no weight in months (since I started paying attention at age 40).

Knowing that one pound of fat is 3500 calories, if I cut my calorie intake by 500 calories daily (or burn 500 more calories daily exercising), I should lose one pound a week if my diet remains unchanged. Alternatively, I reduce my calorie intake by 500 calories daily and should get the same result.

Note that after age 30, our metabolic rate slows by about 5-10 percent per decade (it feels like a lot slower personally so I’m with you if you are middle age and been eating and exercising on some level and not losing weight as you did in your 20s or 30s).

I plan on going to the gym for mostly weight lifting which I enjoy at least 15 minutes daily, cutting my daily calories by 500, and am currently trialing two medicines with data showing they promote weight loss, bupropion/naltrexone (Belviq) and will soon be adding on toprimate (Topamax).

I wish I could have the weight off in a few weeks but that is not realistic and “good things come to those who weight [pun intended].”

If anybody is reading this and wants to know how I am doing–or has any advice–I am all ears.

If I write a part 3 to this segment of my blog, I will research anti-aging medicine supplements to promote muscle mass and fat loss.

 

A Weight Loss Doctor’s New Years Resolution to Lose Weight

A Weight Loss Doctor’s New Years Resolution to Lose Weight

by Natan Schleider, M.D.

January 12th, 2017

Before starting New York House Call Physicians, I had a few temporary part time doctor jobs that honestly tough me a lot. I worked in a small emergency room. I worked for an urgenct care center chain. And I worked for a diet doctor practice.

While working as a “diet doctor,” I was 29, ran 6-10 miles every morning like a machine, and really watched my diet, namely caloric intake. If you want to lose weight simply put, put if fewer calories than you burn. As a chubby 8 year old, my grandfather whom I miss dearly–an attorney who hated his job weeding out the “fakers” who claimed disability at the insurance company he worked for, was an avid handball player in Brooklyn, NY and regular at the YMCA and bowling lanes.

Visiting him and my grandmother in Florida in their Jewish retirement community, Century Village, he pinched my love handles firmly and simply said: “What is this?”

Minutes later, he was showing me how to do leg raises and said I was to do 200 a day.

Not the first to “tease” me on my weight, by age 15 I had given up high school baseball for the gym and 10 years later, was an avid runner and “gym rat”, an athletic 175  pounds standing 5 feet 10 inches. I counted every calorie. Cocktails were always mixed with a diet beverage or club soda. No carbs were eaten after 2 pm. I took a rest day maybe once every 2 to 3 weeks. If my weight peaked 180 pounds, I would starve myself the next day. So it weant for years.

Now that I am 41, having spent my 30s building a medical practice and raising a daughter, I am 5’9″ and 220 pounds. I am obese based on my Body Mass Index. Me, obese, a former diet doctor! What happened?

Clearly my metabolism has slowed although comprehensive lab tests I collected on myself show I am in the normal range.

In recent weeks and months I have dropped my calorie intake to 1500 calories daily without weight loss. I have not had a cookie, a sweet, or ice cream in months. I have been in the gym 3-5 days weekly for at least 20-30 minutes breaking a sweat–not the ironman of workouts but something is better than nothing.

I consulted a bariatric surgeon, was signed up to have a $16,000 lap band put around my stomach. But after reviewing the data and speaking to half a dozen friends and patients who had the procedure, I cancelled the surgery. Most studies show patients regain their weight within a few years.

I have been on Belviq (bupropion plus naltrexone) which is a relatively new non-controlled non-stimulant weight loss drug for 6 weeks and my weight is unchanged.

Am I frustrated, yes! Have I given up my “skinny jeans” I wore 10 years ago, not yet.

Am I ready to starve myself for months to get back to 180 pounds? Not really.

Am I ready to dive back into the gym or start running again, given that it seems I would need to put in twice the time and energy to maintain my goal weight of 180 pounds, maybe.

I see these hollywood stars my age with terrific physiques and know if they can do it, so can I.

My current plan: drop my calorie intake to 800 to 1200 calories daily, double my time in the gym, speak to my doctor about Topamax which is a non-controlled medicine which also shows efficacy for weight loss. I will not take the stimulant weight loss medicines like phentermine or Vyvanse, they work but are habit forming and tolerance can easily occur within weeks to months if used daily.

My scale and I will keep you posted.

Alcohol Abuse, Love, and Frostbite

With the New Year ushering in, many of us will usher out for “celebration.” I won’t be one of them as most recent new years, being on call, I’ve managed cases of acute alcohol abuse, frostbite, and love.

Cliche dictates we brave the cold for a magical New Year’s kiss, for love essentially.

We brave the New York City street and Time Square, generally under-dressed: who wants to pay the extra money for the coat check, mess up their hair with a hat, sport boots in cocktail dresses? I don’t.

The US National Library of Medicine specifies alcohol as an independent risk factor for frostbite, here is the link if you don’t believe me: https://medlineplus.gov/ency/article/000057.htm.

Should love be added to the list of risk factors, displaying all of the aberrant behaviors of disease, the sleepless nights, the obsessions and compulsions of checking our Tinder and Facebook accounts, the mood fluctuations from elation to depression, I could go on.

I write as a physician wishing you a happy and healthy holiday. And as I query a recent question posed to me: Are you a “hopeless romantic?” I would answer “If it meant me risking frost bite for “true love” I suppose I am.

An aspirin a day keeps the heart attack (and colon cancer) away.

Aspirin, also known as acetylsalicylic acid (ASA), is a medication used to treat pain, fever, and inflammation and is an NSAID (Non-Steroidal Anti-Inflammatory Drug). It is often not grouped with other NSAIDs because of it’s blood thinning effect by binding platelets.

It went into mas production in 1899, sold by Bayer, and was a blockbuster, the Viagra of its day (and that’s an understatement).

Unlike it’s more commonly used competitors in the NSAID family like ibuprofen (Advil) or naproxen (Allve), aspirin 81 mg daily REDUCES THE RISK OF HEART ATTACK AND STROKE AND COLON CANCER in patients that have ANY risk factors for these conditions like high blood pressure, diabetes, obesity, male gender, the list goes on. [We can talk about the less discussed fact that most other NSAIDs like Advil and Alleve increase the risk of heart attack and stroke later, seems like some pharmaceutical companies don’t want this advertised, remember Bextra and Vioxx, I do].

Based on the United States Preventive Task Force a baby aspirin daily which is 81 mg is recommended ” for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.” [https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer].

I turned 41 this past November and I take a baby aspirin daily. It is dirt cheap. Does not bother my stomach. And, depending on the study, can reduce risk of a heart attack or stroke or colon cancer (and possibly breast cancer, endometrial cancer, and prostate cancer) by up to 10%, maybe more, maybe less, it is all about how much risk you have for developing those diseases.

There is a lot of data coming out about the benefits and risks of aspirin despite the fact that it was around two centuries ago–you’d think they would have come up with something conclusive by now, right?

Anywho, if I’m your doctor or you want to play doctor as many patients do by educating themselves on the internet, tell me your thoughts.

How to verify a patient’s insurance information is accurate, especially on Christmas Day?

5:30 am in a dark New York City, four days after the winter solstice, I guess Santa is making his final rounds for all the good children but what about all the good doctors?

Would it not be nice if, because it’s Christmas, if the Health Insurance Fairy left a health insurance company’s fee schedule under my pilliow?

Being an out-of-network physician–meaning I have no contractual relationship with any third party insurance companies including Medicaid and Medicare–I am constantly forced to guesstimate what I will be paid for my medical procedures and time.

To make matters worse–as medical schools do not offer any significant classes in medical billing–I am self-taught, having learned the mumbo jumbo language of CPT codes, ICD-10 coes. modifier codes, all sorts of weird numbers and letter that change often that I put on a “1500 claim form” and send in to my patient’s insurance company. (If you don’t know what any of this stuff is and your a doctor considering private practice, start studying my friend or contact me with questions, as if there is anyone reading this?).

Dropping that form in the mail is like a Hail Mary in football, except I will not find out the compensation (if any) for the doctor services provided.

I get back what is called an explanation of benefits (commonly called an EOB) from SOME insurance companies, not all. That is, in the last year, a few insurance companies like BCBS only send paperwork to the patient, not the doctor, so you have no idea if and when you’ve been paid unless you bug the patient to have them check their male and send you the EOB.

A few health insurance companies have even requested a HIPPA medical release for my office to determine claims and eligibility of a patient’s insurance plaa which is obviously ludicrous since the patient is not yet an established patient.

I can rant and rave for a while but this Christmas, my wish, some transparency from the insurance company “Matrix” unless there is a Neo out there?

So how to verify a patient’s insurance information is accurate, especially on Christmas Day? Would anyone reading this care to offer advice (and I know there are some automated systems that provide claims and eligibility but at least 50 percent of the time, in my experience, I need to speak to a human to get answers, yes, a human).