My Search for the Best Annual Physical: An interview with Dr. David Fein

In my search for the best annual physical, I recently had an in-depth discussion with Dr. David Fein. Dr. Fein is the Founder and CEO of Princeton Longevity Center (PLC). Since it’s foundation in 2002, PLC has become widely recognized in the field of executive wellness. Dr. Fein seeks to incorporate the latest technologies for not just early detection, but with a goal to predict risk for important diseases over the next 10-20 years. His program goes far beyond the routine annual assessment and seeks to develop personalized programs to assist patients in making important lifestyle changes and monitoring their improvement. “Preventive medicine” according to Dr. Fein, is like “financial planning…. It’s a lifetime commitment, not a one shot deal”.

In our interview Dr. Fein describes a variety of innovative ways in which the 64 slice CT scanner is being used at PLC. 64 slice CT scanners are typically used for coronary artery disease screening with coronary artery calcium and coronary angiography. PLC however also uses this important diagnostic tool to evaluate all of the major blood vessels as well as visceral fat which is significantly related to metabolic syndrome risk. The scanner is also used for virtual colonoscopy which may replace standard colonoscopy someday.

As for the future, Dr. Fein sees a greater use of inflammatory blood based biomarkers as well as genetic markers to greater personalize a patient’s risk and response to therapy.

The entire interview is available as a pod cast.

My Search for the Best Annual Physical: An interview with Dr. David Fein - Podcast

Dr. R:  I’m here with Dr. David Fein who is the founder of the Princeton Longevity Center.  Dr. Fein has  truly been a pioneer in prevention over the last decade and has really contributed a great deal to what we know about the optimal way to perform wellness evaluations.  Dr. Fein, could you just tell me a little bit about Princeton Longevity Center. 

Dr. F:  Sure George.  Basically Princeton Longevity Center was founded in about 2002 and seeks to incorporate the latest in technologies for not just early detection of disease, but really to aim at being predictive about what diseases you might be at risk for in the next 10, 15, 20 or even more years than that.  On top of that, we also aim to provide our clients with the tools that they need in order to be able to try to modify that future.  The typical annual physical leaves most people with advice pretty much turned them out to “you need to lose some weight and exercise more”.  While those are important components for most people, the problem still remains in how do I do that?  How do I come up with something that I can fit into my lifestyle, something that is going to be doable for me that is actually going to change my risk of what’s coming down the road?

Dr. R:  Right.

Dr. F:  Basically, that’s really our major goal is to not just tell you what you might be at risk for down the road but also how we can help you to change that future in ways that are going to be doable for you.

Dr. R:  Excellent.  That’s a very important part of it.  So it’s not just a one shot deal, it’s really more of a process or a program.

Dr. F:  Exactly.  Really, this kind of preventive medicine has to be thought of more almost as being analogous to financial planning. 

Dr. R:  That’s a great metaphor for this. 

Dr. F:  It’s really not something you can do as a one shot deal.  It’s basically a lifetime commitment to deciding what your goals are and how are you going to get from where you are now to reaching those goals down the road.

Dr. R:  Right.  Now, if you could just explain to me and to our listeners, what would be the major components of a comprehensive evaluation?  Let’s consider an individual whom you’ve never seen before, what would those components be?

Dr. F:  First, we start off with a very very in depth medical history.  The history and the physical exam still remain the cornerstone of what we’re doing.  We bring in all sorts of additional technology but unless you really have the time to sit down with somebody and find out not only what are their current aches and pains and complaints, but also really what are all the medical problems they’ve had in the past.  What’s all the issues and family history, their social history, etc. you can’t really get a good sense of where they are now and where they are going.  We also utilize 64 slide CT scanner that gives us the ability to look at the vasculature, we can see actually if there is any coronary artery disease or atherosclerosis that is starting up.  It also gives us a tremendous tool for doing cancer screening.  We can pick up many tumors at a very very early stage before they have become symptomatic, before they have spread, before they might be detectable on other tests.  We do a treadmill stress test which not only helps us to further evaluate cardiovascular status, but also gives us a good handle on aerobic fitness levels.  We can do body mass testing that includes being able to determine not only how much muscle mass and body fat you have, but also in combination with the CT scan, allows us to even look at how much of that is visceral fat which is the fat inside the abdomen as opposed to the fat under the skin.  That’s something that’s increasingly being recognized now as a very important predictor of not only cardiovascular risk but also diabetes, high blood pressure risk down the road.  We do a complete fitness assessment looking at everything from joint mobility and individual muscle group strains to poor stability and individualized exercise prescriptions.  We do a full nutritional assessment that includes a multi day food diary that the client fills out before they come in and then we can fine tune what are the nutritional recommendations, not just in general but really specifically geared to what are the individual problems that we find in the rest of your testing.  We do a complete set of blood tests.  We do pulmonary function testing, hearing, vision screening, EKG, etc.  All the things that would otherwise be a typical component in an annual physical.

Dr. R:  That really is very comprehensive.  Would the great majority of that be accomplished in one visit? 

Dr. F:  Absolutely.  In fact the goal is to get everything done in one day and in one location.  We also can even offer too as part of that such things as virtual colonoscopy to do colon cancer screening.  We can do a CT angiography which allows us to get essentially the same data as one might get from a cardiac catheterization.  So we can really get very detailed and in depth here, but the goal is to try to make it as convenient as possible for the client, but also the point is that way all of our various professionals, the physicians, the nurses, the exercise psychologists, the dietician, have this tremendous amount of data that we can synthesize all at once and really be able to put together an individualized plan based on all of these different findings. 

Dr. R:  That is fantastic.  So the patient would have this evaluation done in one day and at the end of the day it’s all sort of pulled together by the physician and they leave with a program, a prescription for better health?

Dr. F:  Exactly.  We sit down with these patients at the end of the day.  The physician will spend about an hour or so going over all of the various results from that day’s testing.  Not only explaining what those results mean, but then also trying to put it together into an overall coherent package here that says, “Here’s where you’re at now.  Here’s where we think you’re going to be 10 years or 20 years from now.  These are the things that are great and here are the things that might potentially be a problem.  Here’s what we think you ought to do about it”.  Now they end up leaving our center with a pretty thick book almost about an inch thick with all of their test results.  All of the various reports and recommendations that they can take home with them and start working on it that very night.  I think that’s really a very important point in any kind of executive exam like this is that we find that most people when they leave our center are really pretty charged up and pretty enthusiastic about getting to work on making some changes.  They have often found it a very illuminating day and leave here with a sense that they really understand now why certain things might benefit them if they change them.  If you don’t give them those tools to start working on that day, you lose a terrific opportunity.  Sending people their results a month later, by that point, the enthusiasm often has waned and the results tend to sit in an envelope unopened on the kitchen table for 3 months.  We think it is very important to give you all of this information to start working on that night. 

Dr. R:  It’s that teachable moment when it all is brought together.  Right?

Dr. F:  Exactly.

Dr. R:  Tell me about the role of genetics testing or genomics, that’s been in the news a lot, where do you see that fitting into a wellness evaluation? 

Dr. F:  It’s a fascinating field and one that’s moving along very very rapidly and certainly is getting some attention lately.  I think there is really going to be two ways that it ends up fitting into this kind of preventive medicine.  On the one hand as a predictive tool for being able to look at genetic mutations and variations to be able to say, “You have the gene and you are at risk, for example, for diabetes or for hypertension or for atherosclerosis or a number of other diseases that we can modify and try to prevent, osteoporosis, for example.  I think the other role that is very likely to emerge with this is being able to individually tailor treatment.  For example, with statin therapy.  Giving people cholesterol lowering drugs to modify the progression of atherosclerosis.  We know that we don’t get 100% protection.  We definitely see a significant reduction in risk but some people seem to respond to it better than others.  It is very possible in the not to distant future we may be able to start looking at genetic markers that will tell us whether you are likely to respond to that treatment or to a different treatment and allow us to really optimize your therapy in advance rather than waiting to see did it help or didn’t it.

Dr. R:  Right.  So it really is delivering on this promise of personalized medicine.

Dr. F:  Exactly.  I think also it’s going to ultimately end up having some very interesting promise in terms of being able to look back.  Once we start doing genetic screening like this, then we now start collecting data over a period of years with people and then can go back and look at what else we could have predicted might be going on with you.  I think what we’re going to see is an explosion over the next few years, an increasingly wide spectrum of ways to utilize this kind of data to individually customize your medical care.

Dr. R:  Right.  Exactly.  I wanted to follow up on something that you mentioned with your imaging about vascular imaging because a lot of centers just focus on the heart, the coronaries, that’s basically it.  What you’re doing with imaging is really very innovative – vascular imaging, visceral fat imaging and so on.  If you could just elaborate just a little bit more on the vascular imaging, abdominal, visceral, fat imaging, I would be very interested in that. 

Dr. F:  The visceral fat is particularly interesting.  Basically for those who are not terribly familiar with the concept.  While the fat under the skin, the subcutaneous fat is generally considered to be relatively metabolically inactive and therefore is not really associated with all of the increased health risks that we worry about from being over weight.  The visceral fat, the fat inside the abdomen does seem to be strongly linked with the risk of diabetes, heart disease even certain types of cancers because it is metabolically a very active form of fat.  With the CT scan we can actually measure exactly how much of that fat is present and that’s something that you can’t tell simply from getting on a scale or from measuring even things like percent body fat and body composition.  Whether you’re 200 pounds and it’s all under your skin and subcutaneous or whether all present is visceral fat, either way you are 200 pounds.

Dr. R:  Right

Dr. F:  The only way that you can really measure this is by doing the scan.  Then we can actually measure the volume of visceral fat that is present and that allows us then to really go back and tailor what recommendations we are giving you.  If we have somebody who has a high level of visceral fat, they are very likely to be at risk for diabetes to have problems with insulin resistance.  That is somebody who we are likely to counsel them that low carb diets and specific exercise recommendations are going to be very healthful.  There are even some nutritional supplements that we would recommend that are all designed to overcome the insulin resistance that visceral fat indicates is starting to develop.  That’s one of several different things that we use.  For example, trying to decide if you are better off on a low carb or a low fat type of diet.  It really has some tremendous utility in individualizing what we do with the patient.  As far as the vascular aspect of this, what we find is that in a number of patients they may not yet have any significant evidence of coronary artery disease.  Their stress tests are fine.  They have no symptoms and even their heart scan does not show any significant amounts of atherosclerosis in the coronary arteries.  But very often you’ll see that they are already starting to develop atherosclerosis down in the lower portion of the aorta, in the iliac arteries, the arteries down in the pelvis and while that in and of itself may not present tremendous short term risk, it is still an indicator that they have started that process of making significant atherosclerosis.  We know that that means in the not too distant future it’s very likely that it’s going to start showing up in the coronary arteries.  That gives us an even further advanced warning of what is starting to develop and allows us to institute treatment even that much earlier and hopefully prevent it from ever even getting to the coronary arteries or to the carotid arteries and that way keeping heart attack and stroke risks from getting to a level where it is already become significant before we treat it.

Dr. R:  Right.  That early treatment is really a great opportunity and besides as you mentioned, atherosclerosis is a systemic problem.  It’s not just in the coronaries; it’s in all the vasculature. 

Dr. F:  That’s exactly right.  The problem is that everybody is so focussed on treating their coronary arteries they are missing the boat here and missing the fact that it really is a systemic disease.  So putting a stent in a coronary artery treats one problem but it hasn’t treated the whole problem.

Dr. R:  Right.  Exactly.  What about the role of more expansive or comprehensive blood testing.  Where do you see that going?

Dr. F:  I think that’s also going to be something that’s increasingly important as we move forward.  Not only in terms of the ability to predict future problems, but also I think we are finding that our ability to aim earlier and earlier in the disease process for our detection point is also going to be evolving.  All of the new markers that people are working on looking for various cancer markers for example, can we find these diseases rather than imaging techniques, are there blood tests that will allow us to detect these things earlier on.  Looking at inflammatory markers as ways of further stratifying our cardiovascular risks.  Can we try to determine if there is a patient who even though they don’t look like they have extensive coronary artery disease.  We have seen patients with relatively little disease on their heart scans, but yet they have still gone on to have heart attacks or other cardiovascular events.  These tests looking at particularly things like inflammation may end up being helpful for us in deciding – even though you don’t have what would otherwise be considered to be very elevated risk, these tests indicate you might benefit from more aggressive treatment. 

Dr. R:  Right.

Dr. F:  Same thing also in the other direction.  We see a lot of patients who are out there being aggressively treated.  They are on statin therapy and other drugs and yet it turns out they are not really at very very high risk and we may be able to simply treat those people with lifestyle changes instead.  I think it’s going to be useful in both directions.

Dr. R:  Right.  Exactly.  Again, maybe it will help us in that promise of a more personalized medicine approach.  One final question.  If you could look into your crystal ball and give us sort of a vision of the future of health and wellness screening.

Dr. F:  The biggest problem we run into with crystal balls is that I can tell you where I think things will be 5 years from now or 10 years from now.  I think it’s going to turn out that we dramatically underestimated how much things are going to change in a relatively short period of time.  The things that we are seeing coming right over the horizon at this point are already absolutely fascinating and amazing.  Whether it’s the ability to do more advanced screening with various blood tests and markers of disease processes or the genetic components of being able to individualize therapy and predict where you’re going to be at down the road.  But even know we are currently talking to some groups that are interested in starting to look at doing stem cell harvesting because of the field of regenerative medicine that’s coming in the next few years to.  The ability to start the growing of new body parts in the event that something starts to go wrong.  I think what we are going to find is that 10 years from now, our ability to not only predict what is going to happen to you down the road, but also to prevent that from happening.  We’re really going to start seeing some really traumatic changes in not only in life expectancy but I think in terms of the ability to remain active and functional and enjoying your life as you get in the later years is really going to be phenomenal. 

Dr. R:  That really is exciting.  I just got into my 50’s and I hope that all of that is going to come together soon enough. 

Dr. F:  I’m sure for our kids it’s going to be terrific.  I so would like to think that you and I are both young enough that we’re going to be able to still take advantage of those things.  I really think the key is then for the next 5-10 years we have to work really hard at staying in good shape so that as these things come down the road we can really take full advantage of them. 

Dr. R:  This has been a wonderful opportunity to delve into some important topics and I really appreciate your sharing your thoughts with us.  Dr. Fein you’ve really been a leader in this area and I wish you the best going forward.

Dr. F:  Thanks a lot George.  It’s been my pleasure.

Dr. R: Thanks a lot.

Mammography

Some people just like to complain, and mammography has its share of detractors because of the radiation exposure and the high incidence of false positives. We don’t find the first complaint compelling.  The radiation dose of standard film mammography is already low but with the continuous refinement of digital mammography systems and their ability to potentially lower radiation exposure, this should really be a non-issue. 

The “false-positive” issue is a different story. 
Consider the numbers:  1000 women get a mammogram

• 100 women are called for a follow-up because of an abnormal finding
• 10 of these women are biopsied
• 2.5 have cancer

That’s a 97.5% false positive rate. 

My security system has a false positive rate worse than that, and I still turn it on every night.

To me, the only number that is worth paying attention to comes from Robert A. Smith, director of cancer screening for the American Cancer Society.  He found in a study that mammography screening reduced breast cancer deaths by 63%.  End of story.  Get a mammogram.