A Succinct Review of the Top Medical Research Studies of 2018 for Family Physicians

By Natan Schleider, M.D.

May 19th 2019

SOURCE: AMERICAN FAMILY PHYSICIAN V.99 # 9 MAY 2019 P.565-573

Every year I try to some up the most important easy to understand studies for my patients, doing my best in eliminating fancy medical mumbo jumbo.

Here are the important points for 2018:

  1. Home blood pressures are more accurate than doctor’s office blood pressures. Sooo, if your blood pressure is high at the hospital or doctor’s office (which it should be unless you are super zen), check your blood pressure at home with any machine that measures above the elbow OR ask a friend who knows how to check blood pressure. If you find yourself surrounded by machines as in the above photo, you are doing something wrong…that photo is actually an old ECG machine.
  2. Lower blood pressures are almost always better EXCEPT in elderly patients 85 or older.
  3. Shorter courses of antibiotics are almost always as effective and have fewer side effects than longer courses. So, for example, if a Zpack usually helps your bronchitis or ear infection or sore throat, opt for the 3 day Zpack rather than the 5 day.
  4. For women who suffer from 3 or more UTIs annually, drinking an additional 1.5 liters of water daily reduces risk of future UTI by 50%.
  5. Several studies show that non-opiod pain medicines are as effective for relieving acute injury of arm or leg pain in the emergency room compared to opiods.
  6. Patients who exercise (at least 150 hours per week or more) have lower risk of depression.
  7. For patients being medically treated with anxiety who then stop their medicines, 1/3rd will have a relapse and require medication again. 1/6th of all patients with anxiety will have worsening anxiety despite treatment.
  8. Stool testing for colon cancer screening using DNA found in stool (called Fecal Immunochemical Tests or FIT) is better than standard stool testing for blood and an optional substitute for colon cancer screening other than colonoscopy.
  9. Type II diabetics should shoot for a HbA1c of 7-8 percent (and not lower as previously advised).
  10. If you are 60 or older, a blood pressure of 150/90 or lower is ok presuming you do not have other serious medical issues. Below 60 lower than 140/90 is ok.

Please contact me with any questions or comments.

Thx,

Natan Schleider, M.D.

Turning 50? Get ready for a battery of tests…here is what is recommended.

‘Some men just can’t seem to grow old gracefully.’

By Natan Schleider, M.D.

January 14th 2019

I’ll be turning 50 soon and I can tell. I wake up 4 times nightly to pee )so my prostate is growing.’ My hair is thinning. Joints hurt. I shrunk from 5’9″ to 5’8″ based on my last physical. While I am researching anti-aging medicine, I am preparing for the slew of tests indicated at age 50.

In no particular order if you are 50 or older you should have these tests:

  • Screening colonoscopy for colon cancer every 10 years for those at normal risk of colon cancer. Alternate options which I am considering is Cologuard which is a stool based DNA non invasive test with 95% accuracy done every 3 years instead of colonoscopy (unless of course the test is positive in which case you need colonoscopy).
  • Screening Chset CT Scan (age 55 to 77) if you have ever smoked 30 packs of cigarettes in your life or have smoked any cigarettes in last 15 years.
  • Prostate testing in men annually–debatable, talk to your doctor.
  • Checking your weight, cholesterol, and blood sugar annually
  • Pap smear every 5 years in women
  • Mammogram annually for women
  • Annual skin exam by skin doctor
  • Make sure vaccines are up to date–these get confusing and probably warrant another blog/article–most common is tetanus booster with pertussis every 10 years

If anyone knows a good anti-aging doctor, let me know!

Natan Schleider, M.D.

‘Dear Blue Cross Blue Shield, Thanks for raising my fees because I know the 1+Billion Profit You Made in 2018 Will Go Straight to the Sick and Infirm!’

By Natan Schleider, M.D.

January 12th, 2019

First let me say if you are reading this blog and comment or follow me on social media and are a new patient with no health insurance, I’ll provide you free medical care for 3-6 months within the scope of my specialty. Why? Quite simply if I can afford to run a medical practice with zero income from some new patients, perhaps large insurance companies can do the same?

Anthem made 1.1 Billion Dollars in 2018 while dropping 888 thousand clients. Way to trim the fat.

If health care providers provide medical care and patients receive medical care why do the middle men–health insurance companies–make all the money? This complex question which seemed innocent in 1917 has snowballed to the point I pay over $2000 dollars a month for health insurance for me and my daughter which we sometimes use. But not $2000 a month! We are healthy fortunately.

So my proposal to Empire Blue Cross Blue Shield, the biggest insurance company in New York City: For every free patient I treat, you treat a free patient like a 9/11 victim, a pregnant mom, anyone warranting care.

If we both lose a 100 million dollars monthly then we regroup but if everything goes smoothly, become a nonprofit that gives out smoothies!

Hope to see some new patients soon as well as people commenting on my blog.

Natan Schleider, M.D>

So Your Doctor Says You Have High Cholesterol: How To Read Your Cholesterol Report

December 22nd, 2018

By Natan Schleider, M.D.

Dr. Schleider Cholesterol Report

So you had a physical and your doctor told you you have ‘high cholesterol’ but what does this really mean?

Historically, labs could only test ‘Total Cholesterol’ so alevel above 200 was considered high and below 200 was considered normal. This is a vast oversimplification to the point that in the 21st Century, Total Cholesterol tells doctors very little as it includes both Good (HDL) and Bad (LDL) cholesterol. So, for example, if your LDL cholesterol in 90 (which is quite low) and your HDL cholesterol is 120 (which is quite high but that’s good, the higher the better) your Total Cholesterol would be above 200 and you would have enviable cholesterol.

I included my own cholesterol test results above. This is a fancier panel which some insurance companies will not cover but it is detailed and a good teaching tool.

The common cholesterol test (aka lipid test panel) your doctor performs includes the following which I will help you to interpret (so you can decide whether to skip the bacon cheeseburger and/or exercise more and/or add a medicine for cholesterol.

Cholesterol Tests:

  1. LDL (Low Densiy Lipoprotein)–If you remeber anything, the LDL is THE MOST IMPORTANT NUMBER ON YOUR CHOLESTEROL TESTING. Commonly called bad cholesterol, LDL is the stuff that sticks to and clogs arteries anywhere in the body cauisng heart attacks and strokes and peripheral vascular disease. [Note different sub-types of cholesterol are sometimes called ‘particles’ and the smaller the particle the more likely it is to clog arteries. You will note my test has a ‘Lipoprotein Particle Evaluation’ which for our purposes is too complex to review and not that relevant for most patients]. As a general rule, if your LDL is above 160 treatment is immediately indicated, generally with a medicine. This does not mean you are committed to Lipitor for life but if your cannot keep you cholesterol below 160 you may need medicine indefinitely. Note I take Lipitor 40 mg daily for prevention reasons as current USPTF guidelines show that artifically lowering your cholesterol from normal to low reduces risk of artery clogging, heart attack, and stroke. If LDL is below 100 you are in the clear (unless you have high risk factors for artery clogging like diabetes, tobacco smoking, or perosnal history of heart attack or stroke) in which case LDL should be below 70. If your LDL is between 100 and 160 there is some debate but as a general rule, if you have zero risk factors for artery clogging try to get LDL to 130 or less without medicine. If you have some risk factors for artery clogging like obesity or high blood pressure try to get LDL to 100 or lower.
  2. HDL or Good Cholesterol–This should be above 40 ideally but the higher the better. While some new injectable medicines can raise HDL, as of 2018 these are not commonly used in primary care. Only regular exercise brings up good cholesterol although statin medicines like Lipitor may help a bit.
  3. Triglycerides–These are a type of fat that do not stick to arteris very well so I won’t say they are not important but will say try to keep levels below 150 with diet and exercise and consider a medicine if they run above 150.
  4. Total Cholesterol–As mentioned before, no real information here, the devil is in the details of the other tests.

So that covers the basics on cholesterol. I know I am seeing an educated intelligent patient when they say “Tell me about my LDL and HDL, the total cholesterol doesn’t matter much.’

Thanks for reading,

Natan Schleider, M.D.

Weight Loss & Lifestyle Tips to A Lean Healthy Physique: Dr. Natan Schleider Shares His Medical Secrets (Shhh Don’t Tell)

ARE YOU TOO FAT. Vintage weight loss advertisement circa 1900

By Natan Schleider, M.D.

December 12th, 2018

Gone are the days where I could simply skip desert and stay rather lean and toned. Having just turned 43, I literally feel my metabolism slowing and all I need to do is look at carbs and they go straight to my gut by osmosis. 

I weighed about 175 pounds (standing 5’9″) into my late 30s but after a recent physical I weighed in at 220 pounds and have shrunk to 5’8″. At this rate I’d be a walking doughnut with a head so I left my doctors office determined to get lean using every bit of advice I could find in the world of medicine, science, and technology.

Its been two weeks and I am down to 205 pounds. I could say I feel great but I’d be lying. My internal barometer seems to want me obese which I qualify for using a Body Mass Index Calculator. I’m tired as I don’t sleep well when I’m hungry. I’m cranky but fortunately I get a lot of telemarketing calls which allow me to toy with people trying to sign me up for ‘limited time offers’ on credit cards, business loans, and Nigerian Gold Mines.

I presume my mood and body will get used to my goal weight which is 180 to 190 pounds if I can get there. 

So here is what has been working to get the weight off…

  1. I go to the gym at least 5 days a week and workout with a trainer. This is my life one big luxury but I am so lazy if I didn’t pay the trainer I would barely work out. The trainer doesn’t let me skimp on those last few squats that leave me dizzy and gets a good laugh when I fall on my face doing box jumps. Bottom line: if you can afford a trainer or have a motivated work out partner that really helps. That said, weight loss is about 80 percent diet so if you cannot afford a trainer and hate the gym most of success lies in meticulous eating.
  2. I started using a My Fitness Pal app which is a real pain because it takes about 5 minutes to enter calories for every meal depending on the number of ingredients. The simpler the meal the faster I can enter and count calories. I’m aiming for 1500 calories daily, a few hundred more if the workout has been strenuous. Some of the things I snacked on like a slice of American Cheese or Prosuciutto have way more calories than I thought so the app has been educational. Even cucumbers have calories and if you are going to lose weight, you need to be rather meticulous in your calculations
  3. I’ve stopped eating out or ordering take out as I cannot count these calories–plus I like to cook so not a biggie for me.
  4. I have prepared healthy meals ready to be cooked or simply heated. I have a great healthy tomato bisque recipe–if anyone is interested let me know.
  5. I have my ‘skinny jeans’ front and center in my closet and try to put them on every few days. They obviously don’t fit (yet) and this negative reinforcement pisses me off, re-motivating me to stick to the diet exercise plan.
  6. Studies show drinking diet beverages can actually cause weight gain and other issues but when I have a sweet craving, I’ll go for a Diet Cherry Coke which is better than Cherry Garcia.
  7. I bough a food scale for about 10 dollars and while I think anyone weighing their tomato wedges is nuts, it is the only way for me to know exactly how many calories I am eating (because the common advice ‘just portion control’ means instead of eating an entire pizza pie, I eat half for dinner and half for dessert).

Some of the above I am sure you’ve read while other may seem somewhere between fanatical and disciplined but if I am serious about weight loss, this is a discipline which takes time and I just hope I can stick with it to the point it becomes routine.

Anyway, thanks for reading!

Natan Schleider, M.D.

Humorism: Why Modern Medicine is Still an Infant or Maybe a Young Toddler

December 11th, 2018

By Natan Schleider, M.D.

‘The Four Humors’ by Granger Drawing Circa 1574

So its the 21st century, you had a physical, and the doctor collected body fluids like blood and urine for ‘sophisticated’ testing. Ah the marvels of modern medicine.

But wait, doctors have been doing this for thousands of years. I would have been one impressed Gladiator in Ancient Rome if my doctor tasted my urine and explained I was feeling weak and urinating a lot because I had too much sugar in my blood. And doctors did just that. No glucose strips or little battery powered devices. Diabetes mellitus was diagnosed with a simple taste test, not blood test. 

Perhaps that doctor sends me to a specialist in Gladiators (who had the status and value of today’s NBA and NFL stars when Rome ruled the world) who likely would do a blood test. Sounds perfectly reasonable. Who wouldn’t want to know if their four humors (black bile, yellow bile, phlegm, and blood) were out of whack.

Today, we honor those four humors and their inventor, a physician known as Hippocrates (460-370 BC):

  1. Doctors take the Hippocratic Oath
  2. We take humors like phlegm and blood of out peoples bodies to test (IE for infection or anemia) and treat them (IE for Polycythemia)
  3. Doctors keep their patients humors in balance by reducing phlegm if they have too much of it so they can breathe

Around the 1500s doctors realized that there may be more to medicine than the four humors but that didn’t stop doctors from bleeding patients therapeutically for virtually any ailments into the early 1900s. Did you know George Washington died of being bled by his doctors for a throat infection. Seriously!

The greatest advances in medicine in the last few centuries include soap (probably saved more lives than all the antibiotics ever created), antiseptic surgical technique, and Viagra (not necessarily written in order of importance).

Sure we have fancy breathing machines, pictures that let us see inside our bodies, and robotic surgery. 

I’m no surgeon but I have to wonder about the bedside manner of robots, I mean, after fixing my heart valve will they reassuringly rest their arm on my shoulder and take a sip of my urine to confirm my diabetes is under control?

Thanks for reading!

Natan Schleider M.D.

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.

While discussing stimulants, let me add that I am often asked ‘Can’t I just drink a lot of caffeine for my ADHD?’ Caffeine is a unique molecule and while it keeps most people awake and is activating, it does NOT help ADHD symptoms.

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.
  3. Dexedrine and Dexedrine Spansules are popular amongst a handful of my patients althugh they re hard to find at pharmacies.

 
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.

Top 20 Medical Studies of 2017 Reveal that LESS IS MORE

Top 20 Medical Studies of 2017 Reveal that LESS IS MORE

By Natan Schleider, M.D.

June 3rd, 2018

The Doctor, by Jan van Staveren after Gerrit Dou, 1650-69, Dutch painting, oil on copper. Doctor holding a bottle against light to examine a patient’s urine.

As long as I’ve wanted to be a doctor (some 30 years now) it was a veritable fact that Type II diabetics not on insulin should routinely check their blood sugar at home.

Wrong! Or so says the recent American Family Physician of May 1st, 2018 Vol 97, No.9 P.584. A 1 year study showed patients were less happy checking blood sugars at home nor did they have any improved HbA1c levels (a long term marker of blood sugar). They did not get more low blood sugar. And doctors ‘did not seem to respond’ to the home blood sugar tests patients brought in. Get rid of the test strips and painful fingersticks and if you (or your doctor) tell want to monitor home blood sugars, might as well just taste your urine (or rather have your doctor taste it. Seriously. When blood sugar rises above 180-200, the urine tastes sweet and you may be getting into trouble. See how much modern medicine has learned! I bet the diabetes testing companies are bummed out.

Medicine notoriously changes its mind every 10 years or so but some of these studies are real shockers and made me laugh:

  • Sterile gloves do not lower risk of infection for minor procedures like suturing skin lacerations or removing small lumps and bumps. Hand washing and irrigating the wound with regular tap water work just as well.
  • Cortisone injections for arthritis of the knee are not beneficial and may be harmful-don’t do them-plus they hurt like hell in the wrong hands.
  • When discussing cancer screening with older patients, doctors should use the right lingo. Don’t say since you’re probably gonna die soon, you don’t need this screening cancer test, skip the mammogram and go take you grandkids for ice cream. Better to say ‘This test will not help you live longer.’

Something I have been advocating for years is using a statin like Lipitor for primary prevention of heart attacks, strokes, and artery clogging. So if you are 40 or over and have any significant risk factor like smoking, diabetes, high blood pressure, etc, take a statin. I take atorvastatin 80 mg daily and have hypertension and my LDL (bad) cholesterol is great in the 70s!

Conversely, another study found that if you are 65 or older and have no cardiovascular disease, a statin will not be helpful and after age 75, may be harmful. Bottom line: take a stating from age 40-65 to keep arteries clear and then you can stop them if you have not had a heart attack, stroke, peripheral vascular disease, etc.

The American College of Physicians discerned that taking any medicine for back pain is more harmful than helpful. Good for them. When my low back hurts I am still going for Tylenol or Advil–call me weak, I have a low pain threshold.

These are some highlights from the academic world of medicine in 2017. In 10 years medicine will likely change it’s mind when these studies are repeated. but for now as a basic rule in medicine as my mentor told me: ‘Patients get better 95% of the time despite what the doctor recommends.’

If you have any questions or comments, please let me know on Twitter (@DrSchleider) or find me on facebook.

 

Thanks for reading!

Dr. Natan Schleider, M.D.

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!