Executive Physical Exam in Your Apartment

There has been much debate over primary care for everyone raising the cost of health care. The main reason is because in the traditional medical model testing begets more testing. This is the reason executive physicals are so expensive and often times inconclusive.

The problem with many of these tests is there has not been a clinical utility demonstrated with many of the findings. Also, many of the tests reveal things that have no treatment. The idea of testing for something without having a workable plan in mind from the outset is bad medicine. Often findings on these extensive and expensive tests reveal things that may never progress to a disease state. These tests also allow the doctor to give up on critically thinking about you as an individual and often times sets off a cascade of red herrings.

The hype in the media of course does nothing to help this rush for massive testing. The Bio-Physical 250 or the latest manufacturer of CT scanners hyping the benefits of a total body scan as the gold standard in disease prevention is does nothing to decrease mortality. There is a rhetorical comment in medicine that refers to CT scanners as the diagnosis machine. This comment is made tongue-in-cheek. Just because something abnormal appears on the scan does not mean that it is what is causing the current problem. Another problem with unwarranted scanning and testing is the fear that becomes inspired in many patients.

Is there any benefit to the advances of modern science and medical testing? The plus side of testing is that sometimes these findings may motivate patients to do major healthy lifestyle changes. This assumes those changes will have an effect on the abnormal finding.

Is there an executive physical that can actually motivate behavior change and not cost thousands of dollars? Yes. The way this is done would be by a health care provider that takes the time to get to know you. One whom you establish a relationship with. It is very important for your primary care provider to get to know you in the context of your daily life. This yields a far better picture of your health rather than a one time snap shot that leaves us all guessing at how you got to this point. The best executive physical should focus on current lifestyle habits and state of health. Patients should complete a detailed history which includes a screening for alcohol abuse, domestic violence and sexual history. Also included should be a depression screening, anxiety screening, and quality of sleep screening. Finally no health review would be complete without an extensive nutritional and diet review. Ideally a 3 day diet recall/ journal should be kept in advance of the actual meeting with the health care provider.

Another important component of an executive physical which is often overlooked is a health education session in which patients learn how to navigate the health care system with respect to their current and future health problems. Patients should be taught how to speak to health care providers to get the answers and the care they need.
In an effort to perform a better physical exam and health survey a new trend has started emerging in the New York City area. Patients are being seen in their homes. The comprehensive physical exam consists of the health surveys previously discussed. This is becoming particularly attractive to men who state the main reason they do not go to the doctor is because of time wasted. Another advantage to being seen in your own home is the less likely chance of catching a infection in a standard medical office or hospital. How many times have you gone in for a physical and then three days later gotten sick?

Conducting a physical exam in the patients home consists of the following measures that yield the most informative data:

waist measurement
height on a door jam
blood pressure in both arms in 3 positions
screening men for testicular cancer (and teaching them how to do this on their own)
as well as digital rectal exam for prostate cancer.

These test combined with a through skin exam and review of the major systems can yield far more useful data than a whole body CT Scan that picks up obscure findings that have no clinical correlation. The home based executive physical exam also allows for a look in the refrigerator, bathroom, and common living area for quality of food, hygiene, and potential hazards.

What about testing?
Blood tests should be done with a plan of what you hope to do with the results in mind. Random and massive testing can have some very serious and expensive consequences.
This is a list of tests that will yield the most useful data that can actually be addressed without causing further harm or alarm:

* complete blood count (CBC)
* comprehensive metabolic panel (CMP)
* Lipids
* cardio-CRP
* homocystine
* HgbA1C
* Serum Insulin
* thyroid profile
* urine analysis and micro albumin
* Hep A and B antibodies
* Varicella and MMR titers
* Syphilis titer (RPR), Herpes titers and HIV

These test give insight to the major body organs and systems as well as highlighting risk of infectious diseases. The results can be greatly improved with lifestyle modifications. Other tests can be added on if clinically indicated.

What about imaging?

In an effort to spare patients needless radiation and to maintain biggest bang for the buck much of the imaging should done by ultrasound. This adds no radiation and allows for a sufficient evaluation of blood flow. Insufficient blood flow is typically what kills most people.

* Carotid dopplers (for stroke risk)
* 2-D Echo (heart function)
* Renal Ultrasound (kidney function and early high blood pressure)
* Abdominal including hepato-billiary (aneurysms, liver size and function)
* PA/Lat chest X-ray and 12 lead EKG (shape of lungs, sub-clinical chronic diseases, and electrical function)

This exam including the tests can be done in a patients home. Insurance sometimes picks up the cost of the tests, if something is revealed during the non-invasive portion of the exam that would have warranted the test. E.g. High Blood pressure or a heart murmur would probably justify many of the tests listed above.

What should patients do once they get all theses results?

Since the primary motivation in conducting an executive physical was to motivate a health behavior change patients are encouraged to follow-up with the provider for health behavior counseling at least a year. Meeting quarterly to discuss goals and ways to achieve them helps provide the needed psycho-educational support along the way. Some practices conduct these sessions by web-cam to ease the burden of traveling to the doctors office for frequent appointments. The focus of these meetings is to see what modifications are working and what is not, and why?

The reason these tests and screening tools are recommended is because the patient can actually do something with the results. Depending on the type of health care provider you see your annual physical exam can be futile. Many physicians have said the annual physical is really not worth a whole lot in the way of catching and treating illness. If you happen to see a Nurse Practitioner the annual physical exam is an opportunity to spend time teaching patients about their individual health. This is the time to ask all your questions and review any concerns you may have had through out the year.

Are executive physicals cost effective? No, not as they are currently being done, but if they are done by your primary care provider, and it is used as a spring board to motivating a healthy lifestyle change; then without a doubt they can be very cost effective and beneficial.

Raymond Zakhari, MS, NP http://MetroMedicalDirect.com Board Certified

Metro Medical Direct The first web-based primary care medical house calls practice in NYC that takes the hassles out of going to the doctor. Care is provided by a board certified nurse practitioner who examines you at your home, office or hotel.

Secure patient portal offering the home-based executive physical exam, email consultations, web-cam appointments, texting and secure messaging, access to your test results.

Back Pain: Alternative Treatments

One of the most common chronic pain conditions is low back pain. This condition affects almost 35 million people in the United States. Treatment of this condition can be very challenging. In order to effectively treat the pain it is essential to uncover what is causing the back pain in order to treat the underlying cause.

Causes of back pain can fall into one of three categories. The most common cause of back pain is muscle and ligament strain or weakness. The difficulty in diagnosing these conditions is often times no objective test findings are able to identify an organic cause. The reason imaging studies like x-rays and MRIs are often ordered for these conditions is to rule out the most serious conditions. The diagnosis Musculoskeletal back pain with out a visible cause is made by excluding other potential causative factors. Some common findings on x-rays and MRIs include scoliosis, and subluxations (joints out of place).

Another common cause of back pain includes improper body mechanics. Working at awkward angles, lifting things and twisting, working on surfaces and inappropriate heights can all be environmental factors that cause musculoskeletal back pain. These environmental factors that can cause back pain are also called ergonomic related injuries. Uneven hip heights, or shoulder heights, no wrist or arm rests in your work area or desk chair, sitting on a wallet in your back pocket all can be modifiable environmental factors that can alleviate or cure back pain.

The third condition that can cause back pain is disc disease. This is the most commonly sought after medical diagnosis for back pain in western medicine. This condition often causes weakness and or a decrease or loss of function in the foot or hand. The severity of pain and the degree of functional loss often times are the determining factor in deciding the course of treatment. Disc disease can also be caused by arthritis but the same principles apply toward treatment. Beginning from conservative to most aggressive depending on pain, function and the other conditions the patient may have that make various treatments more risky than others.

Treatment
In most cases of back pain multiple factors are responsible for the symptoms that are occurring. Usually a combination of treatments can be very effective.As with any treatment Lifestyle modification must be addressed. This is especially true if lifestyle was the primary cause of the problem.

Some basic guidelines to keep in mind with respect to lifestyle modification in treating back pain symptoms include:
• If it hurts do not do it.
• Lift with the legs (never bend at the waist, squat with the knees like you are sitting in a chair and hug the object as close to your body as possible).
• Consider using warm most heat and massage.
• Consider getting a medium firmness mattress, and sleeping with a pillow between your thighs when sleeping on your side or placing a pillow under your knees while sleeping on your back.
• Core strengthening exercises and stretches are also very effective in building up supporting muscles.

Other treatment measures include:
Physical therapy combined use of electrical stimulation, ultrasound, soft tissue massage, myofacial release, acupressure, acupuncture and osteopathic manipulative treatments may all help to reduce or eliminate back pain. In addition some over the counter and prescription anti-inflammatory medications and topical applications may also be effective in the short term use to break the initial pain cycle and to allow you to do the therapeutic exercises. On rare occasion narcotics and muscle relaxers may be used for very short-term use. Prolonged use of narcotics and muscle relaxers can lead to dependence and addiction and may become ineffective over time in treating any other pain conditions. For this reason they should be used with the utmost caution and supervision.

Another lesser-known treatment option that is available only through a health care provider is an intravenous nutrient infusion (sometimes called the Myer's Cocktail) that contains magnesium. Magnesium serves as a muscle relaxer and B complex vitamins can help with neuropathic nerve pain. No official studies have been done to test the effectiveness of this infusion, but some patients have reported significant pain relief. This therapy would be classified as not harmful and possibly helpful in patients without any contraindications. A weekly infusion for 6 weeks can provide lasting pain relief in combination with some above listed therapies.

Back pain is a common problem that affects many people at one time or another. It is important that the underlying cause be determined before an appropriate treatment can be utilized. For this reason patients are advised to seek the advise of a qualified healthcare provider to ensure that a more serious condition is not being missed.

Raymond Zakhari, MS, NP http://MetroMedicalDirect.com
Board Certified

Who’s who in health care « The Informed Patient

Who’s who in health care « The Informed Patient

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स्माल बिज़नस ओव्नेर्स आप्शन फॉर हैल्थ केयर इन नीक

There is a new primary care practice in New York City takes the hassles out of going to the doctor. Small business owners know how difficult it is to take a day off for illness, much less for an annual check up. Who has time to wait on hold for an appointment in 2-3 weeks, and then travel to the appointment, and wait almost an hour before your are seen for a 10 minute appointment. Metro Medical Direct It is a web-based primary care medical house calls practice. Patients can avoid the usual hassles associated with going to an appointment because the exam room is delivered to your NYC home, office, or hotel.

Patients simply log in to a secure patient portal available at MetroMedicalDirect.com. There they can request appointments, ask questions, request refills, request referrals to a specialist, complete your health forms, send attachments, and other secure communications. And If you travel for business of pleasure you have the option for an e-mail consultation and web-cam appointment. The practice also uses electronic prescriptions so that you don't have to wait at the pharmacy, and offers some weekend and evening appointments. Patients can even get a wide range of diagnostic tests delivered including x-rays, ultrasound, EKG, and phlebotomy services for added convenience.

The practice participates as an out-of-network provider for all 3rd party payers, but you can receive a coded receipt of payment that can be submitted for reimbursement. The initial visit is $160, and subsequent visits with in 1 year $100. The email and web-cam visits are $60 (available only to patients that have been physically seen twice). Also, if you have a Health Savings Account or Flex Spending account this service would be an allowable expense.

Since your time is valuable and you cannot afford to get sick or neglect your health. Check out MetroMedicalDirect.com or call 917-484-2709 to request an appointment. Also, feel free to bookmark the patient education library as a useful resource for future reference. The practice offers a free phone consultation for new patients to discuss a current health concern.

Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD) « The Informed Patient

Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD) « The Informed Patient

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Obama administration condones discrimination against Mental Illness

The Obama Administration put a moratorium on all federal regulations that were in the pipeline at the time President Bush went out of office. This means that the Final Regulations the DOJ promulgated pursuant to the Americans with Disabilities Act were put on hold indefinitely. New Final Regulations may be forthcoming at some point in the future but the Disability Rights Section at DOJ has made no formal announcements. That said, the remarks made by DOJ in its Notice of Proposed Rulemaking published in June 2008 in the Federal Register still stand. Importantly, DOJ made a distinction in this document between "doing work" and "performing tasks" saying that a lot of Psychiatric Service Dogs "do work". They gave as an example a person with Dissociative Identity Disorder who uses a PSD to remain grounded (oriented) in time and place. "Doing work" is often a passive form of assistance whereas "performing tasks" is usually an active form of assistance. "Doing work" is also the act of incorporating one's PSD into a cognitive intervention such as hallucination discernment whereby a handler leverages her dog's natural response to its immediate environment in order to figure out whether what she is hearing or seeing is really there, or not. In the same document, DOJ explicitly endorsed the legitimacy of PSD so let there be no doubt that PSD are recognized under the law.

On other regulatory fronts, the egregiously discriminating final regulations under the Air Carrier Access Act went into effect on May 13, 2009. These rules make clear that no airlines personnel may demand paperwork for Service Animals as a condition of boarding the plane with the animal, EXCEPT if the handler uses a PSD. In which case, the handler must provide a letter on mental healthcare provider stationary (dated within one year) that discloses that the patient is mentally ill and needs the animal during the flight or at his/her destination. The provider must include his/her license number, state, and date of issue on the letter. Furthermore, PSD handlers must provide this letter to the airlines at least 48 hours in advance of air travel so that its authenticity may be verified. In response to these rules, PSDS assembled a coalition of advocacy groups and participated in a conference call with U.S. Department of Transportation officials and the White House in early May 2009. Despite having been briefed on the discriminatory nature of these new rules, the White House allowed the rules to go into effect.

Basic EKG

EKGs seem to cause stress. Let this help solve the problem

Basic EKG

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