Concierge Medicine – My 15th Anniversary

I practiced general internal medicine from June 1979 until November 2003. Immediately after training I became an employed physician of an older internist covering my employer’s patients and building my practice for two years before embarking on my own.

I saw 20 or more patients per day in addition to providing hospital care and visiting patients as they recovered in nursing homes. As managed care made its clout felt by kidnapping our patient’s and trying to sell them back to us at 50 cents on the dollar, I helped form a 44 doctor multi-specialty group with its own lab, imaging center and after hours walk-in center. The hope was that a large group might have some negotiating leverage with insurers allowing us to take more time with our patients for more reasonable fees. They laughed at us.

Three years later, my associate and I went to the bank, took out a big personal loan and started our concierge practice. We did this primarily to be comfortable providing excellent care to patients. The system was broken and no medical leader, insurer, employer or politician was going to fix the broken system.

Year after year as our patient’s survived and grew older and more complicated, private insurers including CMS (Medicare) asked us to see them quicker, in shorter visits, but be more comprehensive. The insurers essentially wanted us to place a square peg in a round hole. Switching to a Concierge practice meant I would be caring for a small group of patient’s well at the cost of finding a new medical home for 2,200 existing patients. Switching to Concierge Medicine was our response to a broken system being pushed in a direction of more money and profits for administrators and insurers at the expense of patients and doctors.

In retrospect, I should have made this change five years sooner. The financial rewards are not very different – caring for a small patient panel that pay a membership fee as compared to an enormous panel of patients. The rewards to the patients’ and the doctor for doing a job well done are priceless.

We increased our visit time to 45 minutes from 10 minutes. We set aside 90 minutes for new patient visits. We made a point of continuing to care for our hospitalized patients while all our colleagues were turning that over to hospital employed physicians with no office practices. We provided same day visits and access to the doctor 24 hours a day, seven day a week with accessibility by phone or email. We had the time to advocate for our patient’s as they weaved their way through a bureaucratic mind numbing health care system that made filling a prescription as difficult as the science of launching a rocket into space.

The results of the change are striking. There are very few emergency admissions to the hospital. Falls and trauma, which are mostly not preventable, replaced heart attacks, strokes and abdominal catastrophes as reasons for hospitalizations. There are many fewer hospitalizations. There are fewer crises because we learn about the problems immediately and see the patient’s quickly. If necessary, we help them get access to specialty services.

We have the time and staff now to battle with insurers and third party administrators to get our patient’s what they need to regain their health and independence. When they need specialty care we get them the best; the people we go to ourselves both locally and nationally. We send them equipped with all the information and questions they need to ask about their health problem.

Concierge Medicine has additionally given us the time to teach future doctors. While this stewardship of the profession and launching of future physicians is immensely satisfying, it also makes us stay current and on top of the latest literature and advances.

I look forward to this coming celebration of my 15th year in concierge medicine. I see Direct Pay Practices developing which deliver concierge services to the masses for lower fees. It is a spin-off of “boutique “medicine” or Concierge Lite” as my advisor calls it. It is an attempt by young physicians to reestablish the doctor patient relationship and deliver care in a broken health system.

I am thankful to my patients, who took a chance and came on this journey with me. I look forward to caring for them for years to come.

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Prostate Cancer, Digital Rectal Exams, PSA and Screening

The PSA blood test, to detect prostate cancer, clearly has saved lives according to numerous studies. The United States Preventive Task Force (USPTF) recognizes this but has decided that screening for prostate cancer is not a great idea in men aged 55-69. They point out the PSA can be elevated from an enlarged prostate, an inflamed or infected prostate, a recent orgasm while having sex and other causes.

Elevated PSAs led to trans-rectal ultrasound views of the prostate and biopsies of the prostate. These biopsies were uncomfortable, even painful, and often followed by inflammation and infection of the prostate. Many times the prostate biopsy was benign with no cancer detected. The USPTF felt the cost, worry, and potential side effects were a risk far outweighing the benefits of screening. They consequently came out against screening men in this age group.  Naturally this position produced a tidal wave of criticism from urologists and other.

So, the USPTF has produced new recommendations calling for patient education and making a shared decision whether or not to obtain a PSA measurement before you send it out. This is a bit confusing because we always discuss the pros and cons of a PSA before we draw it. Adult men are entitled to hear the pros and cons so they can make their own informed decision.

To complicate matters, a study out of McMaster University in Canada reveals physicians are poorly trained in performing a digital rectal exam. They cite the lack of experience coming out of school and going into training and cite numerous research studies showing a rectal exam is a low yield way to detect prostate cancer. They do not recommend performing digital rectal exams for prostate cancer screening.

This received much media hype and the blur between the efficiency of detecting prostate cancer via a rectal exam and the use of the rectal exam to detect rectal and colon disease has been lost. We perform digital rectal exams to detect prostate cancer and look at the perirectal area for disease. We test the strength and performance of the anal sphincter muscle. We feel for rectal polyps and growths and, in certain situations, test the stool for the presence of blood.

During my internal medicine training my teachers always required a digital rectal exam, stool blood test and slide of the stool as part of the exam. As trainees, we realized the invasiveness of the exam and did our best to be polite, gentle and caring. I always asked for permission first, and still do. How can you tell if something is abnormal if you haven’t performed normal exams?

Last but not least, Finesteride, a medicine used to shrink an enlarged prostate by inhibiting male hormones, has finally been shown to be protective against developing prostate cancer. A study published in the journal of the National Cancer Institute found that men taking it for 16 years had a 21 % lower incidence of prostate cancer.

Artificially Sweetened Beverages, Stroke and Dementia Risk

An observational study in the Journal “ Stroke, A Journal of Cerebral Circulation” examined the question of whether there is an a relationship between consuming “ diet” beverages with artificial sweeteners and the development of a stroke or dementia using data from the Framingham Heart Study Offspring Cohort. They looked at 2888 individuals older than 45 years of age for the development of strokes and 1484 participants over age 60 for the development of dementia. They followed the group for ten years and were able to gauge their intake of artificially sweetened beverages from food questionnaires filled out at exams. After making adjustments for age, sex, education, caloric intake, diet quality, physical activity, and smoking they found that higher consumption of artificially sweetened beverages was associated with a higher risk of strokes and dementia. This was not seen in individuals drinking sugar sweetened beverages.

In a comment section, the author acknowledged that diabetic patients had a higher risk of stroke and dementia than the general public and they consumed more artificially sweetened beverages than others. While the study did not show cause and effect it does leave us wondering just how safe these diet drinks are?

Allergies Worsening Due to Climate Change

The American Academy of Allergy, Asthma and Immunology and the World Asthma Organization just concluded their joint congress in Orlando, Florida. One of the topics of concern is how climate change is making everyone’s allergy symptoms much worse.

We read about more powerful hurricanes and cyclones, seasonal tornadoes occurring out of season, horrible beach erosion and flooding due to large volume rains, lack of rain causing poor harvests leading to waves of migration for survival for animals and humans. Climate change also exacerbates allergy symptoms. Nelson A. Rosario, MD, PhD, professor of pediatrics at Federal University of Parana (Brazil) discussed longer pollen season and increased allergens caused by fallen trees and ripped up plants, mold growing following flooding and irritants in the air due to wildfires. An international survey in 2015 found that 80% of rhinitis patients blamed their symptom exacerbations on climate change items. Pollen seasons have more than doubled in some areas.

The argument should not be about whether climate change is due to cyclical planetary changes or man-made pollutants. It should be about what we can do as a society to maintain economic growth while limiting man made contribution to adverse climate changes. The health and survival consequences of not addressing this issue will ultimately involve our survival as a species.

Does Curcumin Use Help with Cognitive Dysfunction?

Recently, more and more patients have been adding curcumin or turmeric to their cooking to help with their memory. Curcumin is a metabolite of Turmeric and has been available in health food stores for years.

A study a few years back on Alzheimer’s patients published by J. Ringman and Associates showed no benefit in slowing the development of symptoms and no improvement in symptoms when supplied with curcumin. When they looked closely at their study, and analyzed the participant’s blood, they found that curcumin was not absorbed and never really entered the bloodstream.

Last month a study was published in the American Journal of Geriatric Psychiatry by Dr. Gary Small and colleagues. They looked at 40 patients with mild memory complaints aged 50 – 90.  Some were administered a placebo and others were administered nanoparticles of curcumin in a product called “Theracumin”. The participants were randomized and blinded to the product they were testing. The study designers felt the nanoparticles would be absorbed better than other products and would actually test whether this substance was helpful or not. At 18 months, memory improved in patients taking the nanoparticles of curcumin and they had less amyloid deposition in areas it usually found relating to Alzheimers Disease.

Robert Isaacson MD, the director of the Alzheimer’s Prevention Clinic at Weil Cornell Medicine and New York- Presbyterian, has been suggesting his patients cook with curcumin for years. Until the development of the Theracumin nanoparticles, cooking with curcumin was the best way to have it absorbed after ingestion. There is now some evidence to suggest that curcumin, in this specific nanoparticle form, may play a role in both the risk reduction and potential therapeutic management of Alzheimers Disease.

Can My Relative, the Physician, Review My Hospital Chart?

I practice in a community, Boca Raton, with a multitude of seasonal visitors. Many of these “snowbirds” have long term relationships with physicians “back home” and a developing relationship with their local physicians. When they become ill enough to be admitted to the hospital, I often get a request to allow a family member to review their medical chart. I have never objected to transparency, especially if it allows the patient and family to feel more comfortable with the caregivers and plan we are following.

When we used a paper chart the process was simple and involved writing an order in the chart to allow that family member to read the chart. I usually spoke with the patient’s nurse and the floor charge nurse to inform them of my permission. The family member simply sat in the patient room or at the nursing station with the complete medical record and reviewed it.

The switch to paperless charts has made it far more complicated. Giving patients’ relatives access to the chart now involves granting them access to the hospital computer record system. It now involves asking medical records to get involved and either devote time and cost of supplies (printing out records) or labor time – asking an employee to sit down with the family member and give them access. It is far more difficult than it once was.

I still grant them access but it must be through the hospital’s information technology and medical records department and protocol. This week I was asked by the physician son of a patient for permission to review his parent’s chart. I had no objection to this request as long as the son went through the medical records department protocol. This was poorly received by the son who saw my actions as an obstruction rather than a necessary process.

If anyone should be understanding regarding these protocols it should be that of a fellow physician.

Fitness Lowers Your Risk of Dementia

Over the years I have read and passed on to my patients the benefits of exercise on quality of life and healthy aging. This hypothesis was supported by a recent publication in the journal “Primary Care” by Peter Lin, MD, CCFP. Dr Lin and colleagues followed a group of woman aged 38 to 60 years for 44 years to determine the relationship between fitness and development of dementia. They chose to follow 191 women from a group of 1462 patients and selected a balanced number of patients in each age group up to age 60. They performed a physical fitness test on the women in 1968 and then grouped them into high fitness category, intermediate fitness category and low fitness category based on their performance in the physical fitness test. The women then received neuropsychiatric evaluations in 1974, 1980, 1992, 2000, 2005 and 2009.

The patients within the high fitness group showed an 88% reduction in dementia rate compared to those with medium fitness. Those in the lowest fitness group had a 41% increase d risk of dementia compared to the medium fitness group. Those patients in the high fitness group who developed dementia showed symptoms 9.5 years later on average than the patients in the medium fitness group.

The message for young adults is simple. Stay fit at a high level doing something you enjoy and you may reduce your risk of developing dementia by up to 90%.