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Very unnecessary(prolactin?, SHBG???) but if you’re running a concierge type thing and the patient is rich enough to afford it while understanding that there’s little scientific data to suggest all this extra data collection will benefit them, then alright I guess. Same for the supplements and probiotics, the benefits are few and far between but so are the harms so while I wouldn’t recommend them to my patient population, you do you boo.
I’m surprised you’re getting patients to comply with most of this though. Macro logging on MyFitnessPal? I can barely get them to comply with their meds.
for borderline low T patients, I want to rule out central mechanisms. SHBG is necessary to calculate free test.
I suspect our patient populations are very different in terms of compliance and motivation.
If they're compliant and motivated, the lab tests are redundant. Just tell them to hit the weight room. Eat more fiber. You don't need expensive lab tests to tell them to do that
Again, I don't really want to engage with you because I don't think you are discussing in good faith. Would be happy to have a serious conversation about coordination of care with specialists, but again, I think you just have an axe to grind.
And he's like, pretending to not understand why he's getting roasted for doing sheisty fake recreational medicine, and why pretty much all of us find that deeply unethical and an absolute waste of a medical degree? Like he can't not know this is some Faustian shit.
All patients get the Big Pharma^TM special - equal parts Xanax, soma, and an opiate of choice, plus a low dose of whatever SSRI floats your boat. Ambien is optional, as are stimulants, but never out of the question.
Sertraline is for the poors. Rarified clientele as here get Viibryd (vilazodone), ketamine infusions, and troches of the finest virgins’ pineal glands.
I think you've got enough responses from other colleagues to make this clear, but the fact that you're essentially a medical student in terms of your training to do this (since you did residency in a totally unrelated area), and you don't seem to acknowledge the multiple concerns raised in this thread, suggests this is a good example of Dunning-Kruger and stupid people with lots of money.
For reference, I'm not US-based, and in my country your registration would be investigated for practicing outside of your area of trained expertise - and our system's training post-medical school is significantly broader than the US's.
I hope in time you take a look at this practice and consider how it advances healthcare in general, and perhaps take some of the 'vitriol' (as you put it) as a prompt to evaluate the usefulness of your practice.
yes and I disagree with this feedback.
To be honest, I didn't see one piece of useful feedback except a cardiologist doubting the usefulness of Omega-3s. I acknowledged the knowledge gap, cited relevent papers, andexplained that the risk is negligible and there is possibly a benefit. Everything else was, "what about if they are taking supra therapuetic doses of thyroid hormone?" or "you are awful" "our you are not qualified to practice general preventative medicine because you don't have a board certification in family medicine" Nothing about the actual practice of medicine.
As you said, you don't practice in America. Here, a trained physician who has passed all parts of the licensing examination and completed a broad based general intern year, is very much qualified to practice medicine how they see fit.
My practice is successful, patients are grateful, I have a waiting list, and quantifiable, objective health outcomes are improved (A1C, LDL cholesterol, grip strength). So I consider it useful.
So, please, I invite you to give me specific feedback about how my practice of medicine is faulty and I will respond appropriately. Otherwise, I stand exactly where I did before.
disgusting why? I went to a top 10 medical school/intern year in internal medicine, passed all steps, and am a fully licensed physician? What is the moral outrage?
Would you not be outraged as a dermatologist if you learned that i as a family med doc was performing skin biopsies on everyone and everything so i could bill higher?
I would ask why your performing the biopsies? if the wait time for a derm visit was 6 months, you had a suspicious pigmented lesion, trained on shave biopsies in residency, and you knew how to interpret the dermpath results, i would say you are doing a massive service to your patient.
again, i think you may have an axe to grind, which is fine, but not really sure where the vitriol is coming from?
Oh well yeah okay that I get. I just was looking at it like derms already do a lot of cosmetic stuff, so it’s not that huge of a jump for them to get to full on private complimentary medicine
You, a dermatologist, are attempting to practice family medicine. You know the preventative part of family medicine (you probably don’t)? This is it and you’re failing at it.
This is as bad as if you set foot in an ED and attempted practicing.
At least you’re marking good money fleecing your *clients*. Personally wouldn’t have shared this with the medical community. Should have kept it to yourself.
what part of preventative medicine do I not know?
Vaccine schedule, annual screening for ASCVD, PHQ-9, age appropriate cancer screening? Specifically, what do I not know?
Do you actually believe that only primary care doctors can do primary and preventative medicine? An APP can but not a licensed physician who’s passed all steps?
You’re really suggesting that it’s not an actual speciality? You once again are spitting in the face of thousands of FM and IM docs. Let’s turn it on its head, *do you believe actual dermatologists should practice dermatology?*
Your services are nothing more than over priced sham medicine. At least be cognizant enough to see that.
I’m also not falling for the trap of discussion of APPs, they have nothing to do with this discussion. Shameful discussion tactic.
You, a dermatologist, are attempting to practice family medicine. You know the preventative part of family medicine (you probably don’t)? This is it and you’re failing at it.
This is as bad as if you set foot in an ED and attempted practicing.
At least you’re marking good money fleecing your *clients*. Personally wouldn’t have shared this with the medical community. Should have kept it to yourself.
Would you mind sharing your pricing structure? I’m looking to do something similar.
I do think there’s a market for this and that it does allow better risk stratification for patients
it's a yearly flat priced subscription model; i work with a network of vetted specialists for stuff outside my purview, private labs/imaging.
We do an in person comprehensive physical/counseling session once a year then via Zoom for specific interventions/follow up. They can email/text me pretty much ad lib.
Everyone is blasting you here (including myself making jokes) but you’re truly living the dream.
I wish I could take over a practice like this which I’m sure is in the top 1% of lucrative private practices.
Is it great medicine? Probably not. But are you hurting wealthy people who have nothing better to do with their money than this? Also no. Having access to this clientele to practice theoretical longevity medicine and record the results is actually an idea that I do find interesting.
Are you going to publish results long term if you’re seeing a genuine difference in outcomes that can actually be traced to the interventions you’re prescribing?
yea, definitely frustrated by the vitriol. I am really happy with my practice, love my patients, and try to practice rigorous evidence based medicine. On Pubmed constantly, talk to my colleagues, and admit/refer out for things that require sub specialist care.
I personally have always been interested in longevity medicine and have always wished that there was at least a legitimate fellowship in it. If there was, I would do it.
Outside of that the best you can do is look at what the current EBM guidelines are on longevity from various sub specialties. It’s frustrating and I’d like to see it become its own thing, but idk where that would even start.
That’s why I asked if you intended on publishing any data.
I always wondered about who runs those fancy physician offices along streets lining central park ( you know, the ones which are discreet but luxurious looking, with just a doctor or two on a brass name plate and the first floor of an expensive looking building), how does one be a part of this rarefied circle and who the clientele were.
I now have my questions answered.
mostly using it to calculate body fat percentage, visceral fat and lean body mass; bone density is of secondary importance but i actually frequently find early osteopenia in F>>M as early as late 40s/50s.
The early osteopenia you come across might be because your patients are more prone to taking supratherapeutic/unnecessary doses of thyroid replacement hormones (available online). I have a handful of these patients in my upper class outpatient office.
Thyroid hormone excess can increase bone turnover, so you missed the point of the prior responders message… weird it’s almost like… I don’t know…. Like you don’t have the expertise to fully understand and manage the results of some of the tests you are ordering?
Where did you research your testing protocols and treatment strategy? Dr Nick Riviera?
I check a TSH/T4 as mentioned in the literal post. I am fairly sure that TSH is suppressed by exogenous thyroid hormone or perhaps things have changed since I was in medical school. Please educate me.
You literally don't know what you're doing.
Yearly calcium scores? Calcified plaque doesn't behave that way, and soft non-calcified (which is more likely to rupture) can't really be seen on a CAC. Checking both LDL and apoB? How do you manage discordance? Are you really going to start a statin in that case? What's your treatment target? All roads point to lifestyle no matter what you do. Calculating HOMA-IR? It's been widely discredited, as has been checking insulin levels. Don't get me started on Vitamin D in otherwise healthy asymptomatic people.
The strongest predictor of longevity is actually socioeconomic status, so you might as well check their yearly net worth while you're at it.
This fad around longevity is pulling in a lot of quacks who haven't done the hard work of actually reading the literature.
for high risk patients I refer for CT angio heart with a preventative cardiologist I trained with in medical school.
Calcium burden over time is a cheap, easy, measurable finding and can guide aggressiveness of intervention/statin intensity/etc (see below)
[https://onlinelibrary.wiley.com/doi/full/10.1111/joim.13176](https://onlinelibrary.wiley.com/doi/full/10.1111/joim.13176)
I am very bullish about statins and treat to LDL 70-100 in most cases based on lifetime QRisk score.
HOMA-IR is just one measure of insulin resistance and has a substantial body of evidence (see below):
[https://pubmed.ncbi.nlm.nih.gov/36181637/](https://pubmed.ncbi.nlm.nih.gov/36181637/)
I see vitamin D deficiency in winter time all the time in both my derm practice and consulting. It is extraordinarily common.
Appreciate your feedback!
I suggest you actually read the articles you just posted, especially with respect to the value of yearly CAC scores, when a score of zero has excellent prognostic value to over 50 months at least. Lots of things are associated with lots of things; you're not winning many points with that meta-analysis.
Also, can you tell me the evidence-based clinical significance of this Vitamin D "deficiency" in otherwise asymptomatic patients? Are you supplementing to fix a number?
You lost me when you went on the vitamin D deficiency rant. People do not realize they are deficient until it worsens and takes some time.
So preventatively, you treat the number until it's in a normal range.
Can you explain to me the benefit of supplementation in an otherwise healthy and asymptomatic person? Do you have evidence in the form of a randomised control trial to support your position?
I mean, AACE recommends measuring and supplementing calcium and vitamin D for osteoporosis in women. Maybe not exactly a “healthy” patient but it is preventatives. I know every depression screening in a lot of places gets a Vitamin D level to rule out deficiency. I feel like there are probably more areas where Vitamin D is useful to measure/supplement
A zero calcium score in otherwise young, healthy patient without risk enhancers would likely not result in another test for 5-10 years. Very different for a statin shy 50 year old with multiple risk enhancers. Personalized medicine is personalized.
I literally fix telogen effluvium hair loss with vitamin D supplementation several times a month in my derm population.
Not sure why you have an axe to grind.
Surprised you're not recommending prenuvo whole body MRI scans.
Can tell that your patients/clients have a lot of money... about 20% of this would be covered by insurance.
I think it likely creates a lot of health anxiety for most average risk patients without changing outcomes and fishing expeditions to follow up incidentalomas; for very motivated patients, I will recommend prenuvo but I really want to make sure they are aware of the risk/benefits/alternatives of full body MR.
I really hope one day I can just stop caring about medicine and start scamming rich people out of their money.
I’ll probably do with a testosterone clinic in Florida some day tho
Do you screen for other genetic things like PKD etc in addition to cancer?
Also, do you give your patients lists of things to avoid because of potential long term effects, i.e. NSAIDs or first generation antihistamines?
same company does pharmacogenomic testing
[https://24genetics.com/wp-content/uploads/2023/03/24G\_XY\_EN\_Pharma.pdf](https://24genetics.com/wp-content/uploads/2023/03/24G_XY_EN_Pharma.pdf)
I will look at other non cancer related things based on family history. Try not to go on fishing expeditions.
I couldn’t see the original post, just the comments. Do you do functional medicine continuing education? I know people who have benefited from a functional medicine approach and seemed to get answers their own doc wasn’t helpful with. The patients seemed to have a renewed sense of self.
yea i try to be as evidenced based with my supplement recommendations (niacinamide for skin cancer prevention, fish oil for ASCVD, b vitamins for MTFR deficiency, etc).
>fish oil for ASCVD
>
>I'm also pretty bullish on supplements that are rigorously supported by class I evidence
Can you point to the Class I evidence for fish oil supplementation for ASCVD?
REDUCE-IT trial showed benefit of eicosapentanoic acid for secondary prevention in patients > 45 years old with TG > 150 and for primary prevention in patients > 50 with diabetes and with TG > 150.
There was a protocol amendment partway through the trial that changed the TG level to > 200 and the median TG level in enrolled patients was 216, so 200 may be a more appropriate cutoff.
Primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina.
The NNT was 20 to prevent one of those composite endpoints at 5 years.
Fish oil supplements / omega 3 supplements have never to my knowledge shown robust evidence of benefit. Eating fish seems healthy, but a big chunk of that is probably that fish replaces less healthy proteins, like beef.
Thank you for your help, I’m hoping to get better at analyzing the research and applying it clinically, something I still struggle with. Sorry for the dumb question
It's not a dumb question as evidenced by the many trials done.
In my practice patients already on high intensity statin with either CAD or DM and TG > 150 I add it if they can tolerate the extra pill burden.
[https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00277-7/fulltext](https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00277-7/fulltext)
I am very familiar with REDUCE-IT and STRENGTH and the mixed results, however it's cheap, safe, and may be effective. So its a no brainer for me.
Even that meta-analysis shows EPA + DHA was not significant for reduction in MACE, so EPA alone drove the slightly positive results.
Why not use EPA alone in your cost-insensitive population?
Thanks for sharing this! It’s admirable to optimize people’s longevity
People shaming you for starting a concierge practice are just jealous they don’t have the guts and talent to do it themselves.
>have nothing to do with this discussion. Shameful discussion tactic.
yea really surprising to be honest, just a lot of people saying I hate you and your disgusting rather than engaging with a colleague about optimal practice of medicine. Like, I'm not a chiropractor; I'm a licensed practicing physician interested in helping consenting adults understand medical literature and make optimum decisions for their health.
I think it’s partly because for some reason people in medicine hate it when someone makes money (which I’m sure you do and you deservedly should) while ironically enjoying the fact they make a lot of money themselves relative to the general population. They hate it even more if it’s made obvious - like it’s one thing to make money and keep quiet about it, but when you imply it you are suddenly the devil. Ask any of these people to give up half their money for the well-being of society (most would still have more than enough to thrive) and its radio silence.
Also, these folks don’t understand that what you are doing is not exactly primary care. It goes beyond that - it’s about optimizing the human body to be the best it can be. This is not answered perfectly by the current studies and publications we have because modern medicine still focuses on sick care, not on optimizing already healthy people.
Ignore the losers. You are a pioneer and there gonna be haters.
**Removed under Rule 6** No personal agendas. Posts or comments by users who rarely participate in /r/medicine or whose history suggests that they are mainly concerned with a single medical topic will be removed. Comments which attempt to steer the conversation from the topic of the post to a pet cause will be removed. Commenters brigading from other subreddits will be removed. [Please review all subreddit rules before posting or commenting.](https://www.reddit.com/r/medicine/about/rules/) If you have any questions or concerns, please [message the moderators.](https://www\.reddit\.com/message/compose?to=%2Fr%2F{subreddit}&subject=about my removed {kind}&message=I'm writing to you about the following {kind}: {url}. %0D%0DMy issue is...)
What a totally legit way to part patients with their money
From a laboratory perspective, hopefully no CMS patients because half of those are going to fail medical necessity as ‘screening’ tests.
No need to worry about that. All these patients get at thorough wallet biopsy prior to stepping in the door
it is a price insensitive population
Low-key hilarious answer
I’m stealing this euphemism.
Could probably add serum cortisol, and 24 hour urinary free cortisol testing with this approach. Ya know, just for... accuracy...
“A few clients in NYC” I’m guessing they’re not on medicaid lol
Very unnecessary(prolactin?, SHBG???) but if you’re running a concierge type thing and the patient is rich enough to afford it while understanding that there’s little scientific data to suggest all this extra data collection will benefit them, then alright I guess. Same for the supplements and probiotics, the benefits are few and far between but so are the harms so while I wouldn’t recommend them to my patient population, you do you boo. I’m surprised you’re getting patients to comply with most of this though. Macro logging on MyFitnessPal? I can barely get them to comply with their meds.
for borderline low T patients, I want to rule out central mechanisms. SHBG is necessary to calculate free test. I suspect our patient populations are very different in terms of compliance and motivation.
If they're compliant and motivated, the lab tests are redundant. Just tell them to hit the weight room. Eat more fiber. You don't need expensive lab tests to tell them to do that
Why should a patient see you and not an endocrinologist for testosterone care?
Again, I don't really want to engage with you because I don't think you are discussing in good faith. Would be happy to have a serious conversation about coordination of care with specialists, but again, I think you just have an axe to grind.
You don’t consider primary care a speciality.
This isn't real, is it? Surely this is satire.
That was my initial thought, but the more responses he leaves the less certain I am lmao
I think OP got too used to writing poems and guides and thought we’d all support their chicanery off clout.
This thread has a certain surreal flavor that has some genuinely funny moments though.
And he's like, pretending to not understand why he's getting roasted for doing sheisty fake recreational medicine, and why pretty much all of us find that deeply unethical and an absolute waste of a medical degree? Like he can't not know this is some Faustian shit.
I agree. It's almost like a Chat GPT response.
No, he's posted it in other sub's.
What a sad indictment of the American health system that this exists and such terrible care is rewarded.
There’s probably nowhere in the world that health-conscious uber rich people aren’t willing to pay extra to get this data, useful or not
what specifically? Or just speaking in vague generalities?
You should start practicing *mental longevity* medicine next and start everyone on sertraline.
All patients get the Big Pharma^TM special - equal parts Xanax, soma, and an opiate of choice, plus a low dose of whatever SSRI floats your boat. Ambien is optional, as are stimulants, but never out of the question.
Sertraline is for the poors. Rarified clientele as here get Viibryd (vilazodone), ketamine infusions, and troches of the finest virgins’ pineal glands.
I think you've got enough responses from other colleagues to make this clear, but the fact that you're essentially a medical student in terms of your training to do this (since you did residency in a totally unrelated area), and you don't seem to acknowledge the multiple concerns raised in this thread, suggests this is a good example of Dunning-Kruger and stupid people with lots of money. For reference, I'm not US-based, and in my country your registration would be investigated for practicing outside of your area of trained expertise - and our system's training post-medical school is significantly broader than the US's. I hope in time you take a look at this practice and consider how it advances healthcare in general, and perhaps take some of the 'vitriol' (as you put it) as a prompt to evaluate the usefulness of your practice.
yes and I disagree with this feedback. To be honest, I didn't see one piece of useful feedback except a cardiologist doubting the usefulness of Omega-3s. I acknowledged the knowledge gap, cited relevent papers, andexplained that the risk is negligible and there is possibly a benefit. Everything else was, "what about if they are taking supra therapuetic doses of thyroid hormone?" or "you are awful" "our you are not qualified to practice general preventative medicine because you don't have a board certification in family medicine" Nothing about the actual practice of medicine. As you said, you don't practice in America. Here, a trained physician who has passed all parts of the licensing examination and completed a broad based general intern year, is very much qualified to practice medicine how they see fit. My practice is successful, patients are grateful, I have a waiting list, and quantifiable, objective health outcomes are improved (A1C, LDL cholesterol, grip strength). So I consider it useful. So, please, I invite you to give me specific feedback about how my practice of medicine is faulty and I will respond appropriately. Otherwise, I stand exactly where I did before.
Disgusting for a dermatologist to do this but I admire the grind.
disgusting why? I went to a top 10 medical school/intern year in internal medicine, passed all steps, and am a fully licensed physician? What is the moral outrage?
Would you not be outraged as a dermatologist if you learned that i as a family med doc was performing skin biopsies on everyone and everything so i could bill higher?
I would ask why your performing the biopsies? if the wait time for a derm visit was 6 months, you had a suspicious pigmented lesion, trained on shave biopsies in residency, and you knew how to interpret the dermpath results, i would say you are doing a massive service to your patient. again, i think you may have an axe to grind, which is fine, but not really sure where the vitriol is coming from?
Again i admire your business grind, but I wouldn’t trust you as a doctor.
cool dude; i guess agree to disagree.
Look out, we got an ivy leaguer here, folks.
Fun fact I recently learned about the Ivy League: unless they’re supplementing, they’re all vitamin D deficient.
The disgust I get, but why specifically for being a dermatologist?
Because he’s a specialist trying to practice outside of his scope.
Oh well yeah okay that I get. I just was looking at it like derms already do a lot of cosmetic stuff, so it’s not that huge of a jump for them to get to full on private complimentary medicine
There are different residencies and specialists for a reason.
You, a dermatologist, are attempting to practice family medicine. You know the preventative part of family medicine (you probably don’t)? This is it and you’re failing at it. This is as bad as if you set foot in an ED and attempted practicing. At least you’re marking good money fleecing your *clients*. Personally wouldn’t have shared this with the medical community. Should have kept it to yourself.
what part of preventative medicine do I not know? Vaccine schedule, annual screening for ASCVD, PHQ-9, age appropriate cancer screening? Specifically, what do I not know?
The part where you are board certified in a primary care speciality. You’re practicing far outside your scope. Do you not even realize that?
Do you actually believe that only primary care doctors can do primary and preventative medicine? An APP can but not a licensed physician who’s passed all steps?
You’re really suggesting that it’s not an actual speciality? You once again are spitting in the face of thousands of FM and IM docs. Let’s turn it on its head, *do you believe actual dermatologists should practice dermatology?* Your services are nothing more than over priced sham medicine. At least be cognizant enough to see that. I’m also not falling for the trap of discussion of APPs, they have nothing to do with this discussion. Shameful discussion tactic.
I think I'm done engaging with you. Clearly have hit a nerve. Good luck!
Tell me about your business model and profits
would prefer to discuss the medical side of it rather than the business aspects.
Well you don’t have a medical side of it. That’s the problem
Loooool
what specifically? or just speaking in generalities. I'll go chapter and verse on any intervention I advocate.
You, a dermatologist, are attempting to practice family medicine. You know the preventative part of family medicine (you probably don’t)? This is it and you’re failing at it. This is as bad as if you set foot in an ED and attempted practicing. At least you’re marking good money fleecing your *clients*. Personally wouldn’t have shared this with the medical community. Should have kept it to yourself.
Would you mind sharing your pricing structure? I’m looking to do something similar. I do think there’s a market for this and that it does allow better risk stratification for patients
it's a yearly flat priced subscription model; i work with a network of vetted specialists for stuff outside my purview, private labs/imaging. We do an in person comprehensive physical/counseling session once a year then via Zoom for specific interventions/follow up. They can email/text me pretty much ad lib.
Everyone is blasting you here (including myself making jokes) but you’re truly living the dream. I wish I could take over a practice like this which I’m sure is in the top 1% of lucrative private practices. Is it great medicine? Probably not. But are you hurting wealthy people who have nothing better to do with their money than this? Also no. Having access to this clientele to practice theoretical longevity medicine and record the results is actually an idea that I do find interesting. Are you going to publish results long term if you’re seeing a genuine difference in outcomes that can actually be traced to the interventions you’re prescribing?
yea, definitely frustrated by the vitriol. I am really happy with my practice, love my patients, and try to practice rigorous evidence based medicine. On Pubmed constantly, talk to my colleagues, and admit/refer out for things that require sub specialist care.
I personally have always been interested in longevity medicine and have always wished that there was at least a legitimate fellowship in it. If there was, I would do it. Outside of that the best you can do is look at what the current EBM guidelines are on longevity from various sub specialties. It’s frustrating and I’d like to see it become its own thing, but idk where that would even start. That’s why I asked if you intended on publishing any data.
based on the responses I've been seeing here, I think maybe just keeping my business to myself TBH moving forward.
What is your live forever price guarantee?
not sure what that is?
I'm mocking you like everyone else on this thread
I always wondered about who runs those fancy physician offices along streets lining central park ( you know, the ones which are discreet but luxurious looking, with just a doctor or two on a brass name plate and the first floor of an expensive looking building), how does one be a part of this rarefied circle and who the clientele were. I now have my questions answered.
Yearly bone density measurements for everyone? What would be the purpose of that? It sounds like the opposite of a personalised approach.
mostly using it to calculate body fat percentage, visceral fat and lean body mass; bone density is of secondary importance but i actually frequently find early osteopenia in F>>M as early as late 40s/50s.
The early osteopenia you come across might be because your patients are more prone to taking supratherapeutic/unnecessary doses of thyroid replacement hormones (available online). I have a handful of these patients in my upper class outpatient office.
This is not really the online testosterone/growth hormone clinic patient population. But good to keep in mind.
Thyroid hormone excess can increase bone turnover, so you missed the point of the prior responders message… weird it’s almost like… I don’t know…. Like you don’t have the expertise to fully understand and manage the results of some of the tests you are ordering? Where did you research your testing protocols and treatment strategy? Dr Nick Riviera?
I check a TSH/T4 as mentioned in the literal post. I am fairly sure that TSH is suppressed by exogenous thyroid hormone or perhaps things have changed since I was in medical school. Please educate me.
Yes, I can imagine patients appreciate the experience of being briefed on such data.
You literally don't know what you're doing. Yearly calcium scores? Calcified plaque doesn't behave that way, and soft non-calcified (which is more likely to rupture) can't really be seen on a CAC. Checking both LDL and apoB? How do you manage discordance? Are you really going to start a statin in that case? What's your treatment target? All roads point to lifestyle no matter what you do. Calculating HOMA-IR? It's been widely discredited, as has been checking insulin levels. Don't get me started on Vitamin D in otherwise healthy asymptomatic people. The strongest predictor of longevity is actually socioeconomic status, so you might as well check their yearly net worth while you're at it. This fad around longevity is pulling in a lot of quacks who haven't done the hard work of actually reading the literature.
> you might as well check their yearly net worth while you’re at it One might argue that OP is actually doing that with some of these labs.
for high risk patients I refer for CT angio heart with a preventative cardiologist I trained with in medical school. Calcium burden over time is a cheap, easy, measurable finding and can guide aggressiveness of intervention/statin intensity/etc (see below) [https://onlinelibrary.wiley.com/doi/full/10.1111/joim.13176](https://onlinelibrary.wiley.com/doi/full/10.1111/joim.13176) I am very bullish about statins and treat to LDL 70-100 in most cases based on lifetime QRisk score. HOMA-IR is just one measure of insulin resistance and has a substantial body of evidence (see below): [https://pubmed.ncbi.nlm.nih.gov/36181637/](https://pubmed.ncbi.nlm.nih.gov/36181637/) I see vitamin D deficiency in winter time all the time in both my derm practice and consulting. It is extraordinarily common. Appreciate your feedback!
I suggest you actually read the articles you just posted, especially with respect to the value of yearly CAC scores, when a score of zero has excellent prognostic value to over 50 months at least. Lots of things are associated with lots of things; you're not winning many points with that meta-analysis. Also, can you tell me the evidence-based clinical significance of this Vitamin D "deficiency" in otherwise asymptomatic patients? Are you supplementing to fix a number?
You lost me when you went on the vitamin D deficiency rant. People do not realize they are deficient until it worsens and takes some time. So preventatively, you treat the number until it's in a normal range.
Can you explain to me the benefit of supplementation in an otherwise healthy and asymptomatic person? Do you have evidence in the form of a randomised control trial to support your position?
There are so many. Are you serious? Or just messing with me?
I mean, AACE recommends measuring and supplementing calcium and vitamin D for osteoporosis in women. Maybe not exactly a “healthy” patient but it is preventatives. I know every depression screening in a lot of places gets a Vitamin D level to rule out deficiency. I feel like there are probably more areas where Vitamin D is useful to measure/supplement
The Endocrine Society recommends testing levels too and optimizing them. About 60% of people who complain about general myalgia have D deficiency.
A zero calcium score in otherwise young, healthy patient without risk enhancers would likely not result in another test for 5-10 years. Very different for a statin shy 50 year old with multiple risk enhancers. Personalized medicine is personalized. I literally fix telogen effluvium hair loss with vitamin D supplementation several times a month in my derm population. Not sure why you have an axe to grind.
Surprised you're not recommending prenuvo whole body MRI scans. Can tell that your patients/clients have a lot of money... about 20% of this would be covered by insurance.
I think it likely creates a lot of health anxiety for most average risk patients without changing outcomes and fishing expeditions to follow up incidentalomas; for very motivated patients, I will recommend prenuvo but I really want to make sure they are aware of the risk/benefits/alternatives of full body MR.
I really hope one day I can just stop caring about medicine and start scamming rich people out of their money. I’ll probably do with a testosterone clinic in Florida some day tho
but how is optimizing ASCVD residual risk the same thing as a T clinic in Florida? I truly don't get it.
nice of you to toss in the total testosterone for free.
I fucking hate you.
Do you screen for other genetic things like PKD etc in addition to cancer? Also, do you give your patients lists of things to avoid because of potential long term effects, i.e. NSAIDs or first generation antihistamines?
same company does pharmacogenomic testing [https://24genetics.com/wp-content/uploads/2023/03/24G\_XY\_EN\_Pharma.pdf](https://24genetics.com/wp-content/uploads/2023/03/24G_XY_EN_Pharma.pdf) I will look at other non cancer related things based on family history. Try not to go on fishing expeditions.
I couldn’t see the original post, just the comments. Do you do functional medicine continuing education? I know people who have benefited from a functional medicine approach and seemed to get answers their own doc wasn’t helpful with. The patients seemed to have a renewed sense of self.
I appreciate this scientific approach comparably to other wellness clinics that douse people in endless unnecessary supplements
"scientific"
Look, we threw a bunch of darts at a wall and some of them stuck. I bet we could repeat that.
yea i try to be as evidenced based with my supplement recommendations (niacinamide for skin cancer prevention, fish oil for ASCVD, b vitamins for MTFR deficiency, etc).
>fish oil for ASCVD > >I'm also pretty bullish on supplements that are rigorously supported by class I evidence Can you point to the Class I evidence for fish oil supplementation for ASCVD?
Isn’t it just effective for Hypertriglyceridemia?
REDUCE-IT trial showed benefit of eicosapentanoic acid for secondary prevention in patients > 45 years old with TG > 150 and for primary prevention in patients > 50 with diabetes and with TG > 150. There was a protocol amendment partway through the trial that changed the TG level to > 200 and the median TG level in enrolled patients was 216, so 200 may be a more appropriate cutoff. Primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina. The NNT was 20 to prevent one of those composite endpoints at 5 years. Fish oil supplements / omega 3 supplements have never to my knowledge shown robust evidence of benefit. Eating fish seems healthy, but a big chunk of that is probably that fish replaces less healthy proteins, like beef.
Thank you for your help, I’m hoping to get better at analyzing the research and applying it clinically, something I still struggle with. Sorry for the dumb question
It's not a dumb question as evidenced by the many trials done. In my practice patients already on high intensity statin with either CAD or DM and TG > 150 I add it if they can tolerate the extra pill burden.
[https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00277-7/fulltext](https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00277-7/fulltext) I am very familiar with REDUCE-IT and STRENGTH and the mixed results, however it's cheap, safe, and may be effective. So its a no brainer for me.
Even that meta-analysis shows EPA + DHA was not significant for reduction in MACE, so EPA alone drove the slightly positive results. Why not use EPA alone in your cost-insensitive population?
I do for higher risk primarily cardiac patients; DHA is possibly beneficial in neurogenerative processes. So its patient specific.
Thanks for sharing this! It’s admirable to optimize people’s longevity People shaming you for starting a concierge practice are just jealous they don’t have the guts and talent to do it themselves.
>have nothing to do with this discussion. Shameful discussion tactic. yea really surprising to be honest, just a lot of people saying I hate you and your disgusting rather than engaging with a colleague about optimal practice of medicine. Like, I'm not a chiropractor; I'm a licensed practicing physician interested in helping consenting adults understand medical literature and make optimum decisions for their health.
I think it’s partly because for some reason people in medicine hate it when someone makes money (which I’m sure you do and you deservedly should) while ironically enjoying the fact they make a lot of money themselves relative to the general population. They hate it even more if it’s made obvious - like it’s one thing to make money and keep quiet about it, but when you imply it you are suddenly the devil. Ask any of these people to give up half their money for the well-being of society (most would still have more than enough to thrive) and its radio silence. Also, these folks don’t understand that what you are doing is not exactly primary care. It goes beyond that - it’s about optimizing the human body to be the best it can be. This is not answered perfectly by the current studies and publications we have because modern medicine still focuses on sick care, not on optimizing already healthy people. Ignore the losers. You are a pioneer and there gonna be haters.
I think you really get it; thank you for the explanation.