An Interview with Dan Cosgrove of Wellmax

I recently had the opportunity to talk to Dr. Dan Cosgrove who founded Wellmax Center for Preventive Medicine in 1997. Dr. Cosgrove described his background in Internal Medicine and later Emergency Medicine. It was his dissatisfaction with the rapid, superficial symptom- driven evaluation that characterizes Emergency Medicine that led to his creation of a model comprehensive prevention at Wellmax.

The patient’s Personalized Health Portfolio is the center of care at Wellmax. Dr. Cosgrove and his staff work diligently with the patient to create the health portfolio which ultimately becomes the living story of their health. Past events are noted but the document is updated by a careful medical history and exam followed by a comprehensive array of structural, functional, and biochemical tests. This organized and comprehensive approach allows Dr. Cosgrove and his staff to gain special insight into that patient’s risks and presymptomatic conditions. Dr. Cosgrove and his staff work on a roadmap or plan of next steps and lifestyle improvement for the patient. This process is supported by a psychologist, exercise physiologist, and nutritionists to help sustain positive change. The flow of information and creation of a network of care providers is what lies in the future.

The entire interview is available as a pod cast.

An Interview with Dr. Dan Cosgrove of Wellmax - podcast

Dr. R: I’m here with Dr. Dan Cosgrove who is the founder of Wellmax Center for Preventive Medicine at the LaQuinta Resort and Club in La Quinta, California. Dr. Cosgrove has really been a pioneer in the integration of imaging, human performance and genetic and protein biomarkers. It’s truly a pleasure to have Dr. Cosgrove with us today. Dan, if you could just share with us how you came up with the concept of Wellmax and what led to developing your center.

Dr. C: My background is internal medicine. Then I got boarded in emergency medicine for a while when I was young. I liked the excitement of the fast pace as well as getting to see problems across the spectrum from pediatrics to gynecology to older people with heart disease. You just see everything – musculoskeletal problems, whatever it is, but you also get people raw off the street. In doing that our ER group was set up as I think a lot of doctor’s internal medicine practices are set up if they are working for a big company, that we were graded or evaluated on how many patients we saw per hour, how many dollars we charged per patient and then how many dollars we charged per hour. They would set up this curve every month and, of course, 50% of us would be below the curve and those people would then try harder to basically move the meat faster and see more people more quickly. Ultimately what you end up with is doing as little as possible for as many people as possible.

Dr. R: Yes.

Dr. C: And I think that after a few years of that I needed a kind of personal redemption to really have the joy of doing it right and not feeling like I’m cutting corners and moving too fast. Secondly a kind of professional approach where I could really apply the technology and the knowledge that’s out there. We are now in this information age, and I think there is a completely different ability to respond to complaints of patients and to do proactive care than there was when I was in medical school in the early 80’s. It was all these big text books that come out every few years. Now there’s a tremendous amount of information and ability to retrieve the information that wasn’t there before and I wanted to have the opportunity to embrace that and to apply that to individual patients.

Dr. R: Great. So this was a huge transition for you to go from emergency medicine where everything is very abbreviated and real time to what you’re doing now with a very comprehensive prevention approach. When did this happen? What year did you found Wellmax?

Dr. C: 1997. So it’s been over 10 years now. There were two kinds of patients that I would see that I realized were not getting their needs met. One of them and the obvious one that people in preventive medicine always are aware of is the guy who just turns up yellow because he’s got jaundice because he’s got colon cancer metastases to his liver or the person that turns up with the sudden unexpected heart attack and its unexpected because nobody was measuring anything other than symptoms so that until the day that he got chest pain, he was deemed well. I think the second kind of patient is the person whose sort of the walking wounded where – I just saw a guy today. He said on a scale from 1 to 10, he would put his energy at a four. Well, it used to be nine and just in the last couple of years it kind of went down to four but he looks good. He’s still active and he did see his doctor in another state and the guy did a CBC and a Chem. 7 and did a cursory physical exam, listened to his heart and lungs and said, “Well, I think you’re okay. You’re just working hard”. I realized that in the ER, those patients were getting short shrift and what we would say to them was “well, if its been going on for several month or a year that you’ve been weak, that’s not an emergency problem” so we charge for the visit and we send them to the internal medicine guy on call and that guy is seeing 40 people a day or something and he gives them a few minutes and they don’t have the opportunity to do more. So it occurred to me a lot of this is driven by the economics, that you get a fixed fee for seeing a patient whether you spend 15 minutes or an hour for the most part.

Dr. R: Right.

Dr. C: So what the system has driven people to do is use EMRs that make it appear that they did a comprehensive exam where they get 8 out of 12 review of systems thing and get it done in 15 minutes. I asked myself, “would patients pay more for somebody to take more time and to do tests even if those tests were not covered by insurance or considered to be deemed “medically necessary”?” and it turns out that they will. It’s not necessarily a high percentage of patients on a given street or block, but throughout the population a lot of people have the discretionary income, they have the need and the desire to pay for more and truly receive more, and have a doctor spend more time. And of course for a doctor it’s a dream job because I get to – instead of seeing how quickly I can get him out the door, I sit at the table and think, “before I get up here, what else can I do for this patient?” It’s really a pleasure to practice medicine that way.

Dr. R: It really is a paradigm shift. I agree. I think so often it’s sort of like that conveyor belt medicine - try to do as little as possible to handle the situation just putting a patch on something and rarely having the opportunity to really delve into the root of what is the underlying problem for that patient. Now you have the opportunity to be as thorough as you need to be and I think that is a wonderful paradigm shift. Was it difficult making that transition, connecting with those patients that really value this approach? Was it a difficult transition to go from as fast as you can do it to this more comprehensive approach?

Dr. C: It certainly was difficult in terms of cash flow because I went from making good money to going negative where I was spending more than I was making with the overhead of the clinic. The first patient came in and she was about 50 years old and asked me about hormones and menopause and should she take Premarin and Provera or not and I’d read a little bit about it but I had to go do a lot of homework. Even in doing that I discovered that there is no one overall 100% consensus answer and those were the days before the Women’s Health Initiative. Now, as you probably know just in the past few months there have been a slew of articles talking about the benefits of estrogen. As we might have predicted, the pendulum is now going to move back the other way. It’s just an enormous amount of knowledge just to address that one problem well. So in a kind of holistic primary care setting there is a whole spectrum of problems. In a way it was almost like I had to get educated in a new specialty. I was already boarded in internal medicine and then studied for emergency medicine boards, but it was far, far more work to become where I felt confident in this personalized medicine. It’s still an ongoing challenge unlike certain kinds of specialties where you’re kind of a one trick pony and you just do a couple of things and learn those and that’s what you do. This is far more intellectually challenging -

Dr. R: Absolutely.

Dr. C: In addition, even though I’m seeing fewer patients, I think in many ways it has more liability because the buck stops here.

Dr. R: Right, exactly. Now if you could just explain what would be the components of your standard approach now in terms of history and physical, imaging tests, blood tests, human performance testing? So if you’re seeing somebody for the first time, what would be the basic approach for the typical middle-aged man?

Dr. C: To me, my approach is to build a health portfolio and the reason I’m doing that is to have a methodical approach, to have a place for everything and everything in its place. The reason I’m doing that is I’m really looking for modifiable risks for aging. It’s early detection for existing disease but its also early detection of processes of disease where we might not call it disease. For example, a person whose coronary calcium score is elevated such that 90% of people have less than they have, but its still a very low score let’s say if they are 40 years old, any calcium for a man at 40 probably puts them in the top half at least and whether or not that is cardiovascular “disease” or arteriosclerosis, still, he is maybe on a track that is being caused by a modifiable risk factor that can be addressed, it can be changed so we can actually change the course of where they are going. Heart disease, I think, is one of the easier ones to visualize, but maybe they are poorly absorbing iron or B12 and these kinds of things might have minimal or no symptoms and still, if caught early, can make a huge difference in their life and makes the evaluation a priceless one.

Dr. R: Absolutely.

Dr. C: So what we do specifically is to create a health portfolio. This is really just a series of check lists. There are structural tests which include the imaging ones. For example, DEXA density is a structural test. I just had a guy who had very low bone density and then it led to us doing a 24-hour urine calcium and it turns out he’s losing calcium, he’s kind of peeing out his calcium. It would be many years before that would be caught. It would never have been discovered without us being alerted to the problem through this structural measure even though the structural measure per se didn’t cause any problems in his life. And then the other imaging or structural tests would be lung CT. It’s been demonstrated that there is valid cause for doing a lung CT and getting early detection of lung cancer. For heart, there is coronary calcium and we often do the CT angiogram as well. Of course colonoscopy is a kind of structural test to see what’s there. Then there are all the functional tests which start with blood pressure and pulse. A cardiac treadmill is checking the heart by seeing how does the EKG change and we like to do a VO2 max there and see what is the person’s cardiovascular fitness.

Dr. R: Right.

Dr. C: In selected cases get an echocardiogram which combines structural and functional aspects of the heart. We also methodically evaluate patient’s symptoms. I think one of the most important is to just sit and listen to the patient. Then after they’re done sharing what’s important to them, we could methodically go through and ask them lots of questions, including how many bowel movements a week do you have. It’s amazing how many people will say, “per week” and it comes out to be 40 bowel movements a week or 3 and they didn’t mention that as constipation or diarrhea because they’d had it for a while and it didn’t occur to them to be a big problem. Anyway, so there are symptoms like that and then, of course, signs presented on physical exam. Melanoma is probably the most obvious of those or a heart murmur or something.

Dr. R: Then based on those initial findings you might tailor the rest of the evaluation, right?

Dr. C: Now, we aren’t doing echocardiogram as a part of the standard health portfolio. I have it on the list of the health portfolio so that after I build it I can sort of look at it and agree with the patient, “okay, your last echocardiogram was never and we’re comfortable with that because your other structural and functional tests are okay and you have no murmur on the exam and you’re doing well”, but a case could be made even for them to still do one and, of course, if they have a murmur or other findings, or they have some rhythm problems on the treadmill, then that would lead us to do additional tests that would then have an even greater predictive value.

Dr. R: Right. Then in terms of blood tests, what kind of genetic screening or biomarker screening do you recommend? Do you have a standard approach or is it very much individualized?

Dr. C: We definitely have a standard approach, because we want to complete the health portfolio of information gathering on all patients. But in doing so, we collect so much data from different sources — such as lab, imaging, personal symptoms, and so forth — that we can then build algorithms that become highly individualized. Our approach should be methodical but also be providing personalized medicine and individualized medicine. For example, a spot on the lung in a person who smokes. There was a guy we just saw this week, he had two packs a day for 40 years so he’s got an 80 pack year history of smoking and he had two 5mm spots. Now these spots, if they were found on a 40 year old nonsmoker, would have a very different likelihood of being cancer. And we can even further add to that. We start with some knowledge or information just from the data from the lung CT, but we’ve built it up by adding the data of their background, that they’re a smoker. Then I think we can do even more so with the genetic data. I know Navigenics has a model, I know it’s at least 20% of people who turn up with heart disease don’t have any of the principal risk factors like smoking, diabetes, hypertension. They were showing that with certain not uncommon gene variants that can be easily detected, a person’s risk can exceed that for the traditional risk factors. You can see then that by combining these that you have a tremendous amount of information. But what I was going to say is I think an argument can also be made to just kind of shotgun and the Biophysical is a great example of that. It’s got 250 blood tests and a lot of the blood tests I might not think we need immediately in seeing the patient. But we get the data and then I think anybody who has done a lot of Biophysicals discovers important issues that could not have been anticipated. For example, there was recently a patient whose serum B12 level was 200 and we wouldn’t have guessed that. They weren’t complaining overtly of neurologic symptoms and everybody feels a little forgetful compared to how they should be, but for that person… for us to pick that up and give them B12 for decades that may have been missing, for that one person, this simple discovery could be priceless. Another example is ferritin, you know, iron. There are people who are iron overloaded and people who have too little. Celiac disease is another important disease to screen for. Then there are a lot of tumor markers, and a lot of these are tests that are in the Biophysical that help provide really early detection, because issues can be discovered before there are any symptoms. The fact that there are no symptoms doesn’t mean that it’s any less important or valid.

Dr. R: Right, exactly. Now, do you try to accomplish the history, the physical, the human performance, the imaging in a one day period? How does it work for an individual who is from out of town?

Dr. C: I’ve actually been kind of evolving in that because there’s a guy with an imaging place in LaJolla and his background is gynecology and so he is very comfortable with women’s issues and women’s hormones, but not so much with a lot of other things. We can actually use a combination of a questionnaire and lab and the imaging that he does there to start building a substantial part of a health portfolio and with the questionnaire you know and then a phone interview you can really get up to speed on the symptoms. The physical exam I think should not be neglected but in reality when you have everything else, you know if I think maybe they have a big liver, the first thing I do is go look at their CT and ultrasound and see you know, how big is it?

Dr. R: Right.

Dr. C: If I think their prostate is a little big, what I really want to know is what is their post void residual, how much urine is left in their bladder after they empty it which we get routinely on ultrasound and I want to know how big is the prostate and what’s their PSA and other lab values that are relevant. So anyway, I guess what I’m saying is we have an executive physical program, but really we’re just trying to make the process pleasant and easy to get all this information. So this week we have some people that are all from out of state and have come a pretty long ways and we’re based at a resort so it’s kind of fun for them to just check in to the hotel and the hotel likes us because we put heads on beds for weeknights. Our patients tend to check in on Sunday night when everybody else is leaving and then we start first thing Monday morning often with obtaining the fasting blood work and then getting the history and physical. When they start getting tired in the afternoon, they can lie down and get all the ultrasounds and the DEXA. We do send them out for the lung CT and CT angiogram. Then we can do the fitness stuff here. It’s a lot to pack into one day, but the fact is I could spread it out over a couple of weeks or I could have a lot of it actually outsourced and get the vast majority without ever seeing them. I’m actually intrigued by this idea of building the health portfolio and then looking at the whole as greater than sum of the parts. So for example, if a patient complained of some bloating and some irregular bowel habits and then we look at that in light of their celiac antibodies and stuff like that. To see one thing in light of another gives greater meaning to both.

Dr. R: Oh yeah, absolutely. Then is there a moment during this evaluation when there is sort of a comprehensive wrap up? Where you say okay we’ve got everything in and we’ve explored the things that we needed to explore based on your questionnaire or the other findings and here it is in one comprehensive wrap up?

Dr. C: Well, we do it in two stages. When they finish, just before they leave I try to go over all the information that I have. Just before this interview a man was here for 2 or 3 days, his plane was leaving and I was able to show him just using these worksheets from the ultrasound a couple of important findings and to go over some things. Another guy that’s here, he was just on his way to get his lung CT and his coronary calcium, but his NMP, his urine test was positive so I called and asked them to continue the CT and get the kidneys and the urinary track and everything. NMP is a screening test for bladder cancer, and like a lot of these tests it may have a “false positive”, but as you pointed out with your nice essay in your blog about mammograms, we shouldn’t be mislead about false positives because its an opportunity to pick something up early.

Dr. R: Right.

Dr. C: Our ultrasound didn’t show anything on his kidneys but I thought we’d get an even better view so we called and quickly added kidney imaging to his CT evaluation. Then the Biophysical takes a couple of weeks to come back and so does the Navigenics [genetic panel]. We are currently using the Navigenics and they do provide a lot of genetic information but it takes a couple of weeks to get that stuff back so we set an appointment for the person 3 or 4 weeks later….

Dr. R: …To do a wrap up on the phone just as a follow up?

Dr. C: Yeah. So 2-4 weeks after their initial evaluation, when all the tests have returned, we have another interview or “consultation” that is included in their program, and this can be done in person or by telephone, usually as a “WebEx.” They also receive a personalized but methodical letter from me at that time, so we’re reviewing a document together that the patient can read again or share with other health providers. That additional time after their medical evaluation here also gives me time to kind of look at it all and say, what does that mean? What does that mean in light of this, and it’s nice for me to have that extra time because a lot of times it’s not that obvious or that easy to make recommendations. Many times the recommendation has to be a kind of list of alternatives. It becomes almost philosophical what the patient might want to do about a given finding. They might want to just recheck it again in 6 months or they might want to take immediate action to work it up further and I want to provide them the best information I can to help them make that personal decision.

Dr. R: Right. For those who are out of town, do you try to stay in touch with them or do they have a way of contacting you so that they can sort of stay on the program. I mean if you outline here is the steps to achieving better health, how do you keep them on track especially those that are out of town?

Dr. C: We have a combination of things. We can offer full “concierge medicine” with 24/7 access and comprehensive ongoing healthcare. Alternatively, many patients choose for us to maintain their Personal Health Portfolio, and keep in touch, although they’re ongoing medical care is provide elsewhere by others. We have what we call Patient Wellness Advocates and these are people who are clinically savvy, often nurses and they don’t even necessarily have to have an RN, but they call and follow up and we actually invest a lot of time for these people. A lot of times a person will go and have a subsequent test or just a test based on some new symptom or something that they get in another city, another place, another doctor. We just quickly get that information and add it to their health portfolio. We monitor their health portfolio, stay up with it and then we are staying up with the patient and saying, for example, “what did you ever do about this?” or “did those symptoms resolve by following up?” I think it’s pretty well known that all patients just love a call from the doctor a few days later saying how are you feeling now? We were trying to leverage that benefit and value through these wellness advocates. Then we also have a lady who has a PhD in psychology. She’s a psychologist or health coach and she calls and often works out other issues with them and then we have a psychiatrist and he’s comfortable doing ongoing phone things for those people who need it. Our fitness and nutrition person likes to do it because they are kind of contracted in a way so if they can get the patient to be comfortable with telephone stuff and they get paid for it, then they will do it. Some of the complexity has been in a tracking system. To be honest I just paid for a big EMR that they promised all kinds of stuff it turns out it doesn’t have. We’re actually using ACT, a contact management system, because unlike the EMR, you can attach to the patient’s note whatever the follow up is, whatever we’re going to do. For example, we agree to check back with them in 6 weeks again about some symptoms or maybe they promise to get a breast MRI and we write for it or a lab test. Well, it’s easy for them to kind of just disappear off the radar screen. It’s earmarked to call them again and it comes up on the calendar even if we’re not thinking of that individual patient on that day. In addition, we can look up that individual patient at any time and it’ll be on there. Then thirdly, the task is on a list for certain individuals here (Patient Wellness
Advocates) that are assigned those tasks to follow up so it’s on their list as well. So it’s in three different places that all link so that way we actually can do a lot of health care long distance because it’s really about information and data management. If this, then that, and fill in the blanks, and making sure that you take action. Applying this approach using healthcare employees purposely chosen in part because they are “big hearted” can create tremendous value for each individual patient.

Dr. R: Well it sounds like a wonderful program and I really like how you’ve integrated nutrition and exercise physiology as well as behavioral change. We all know that that’s sometimes the hardest thing to get people to change the way they go about their lifestyle. I think that’s really cool that you have professionals that are really trained in behavioral medicine to help you with that.

Dr. C: I’ve got to tell you, we don’t make any money on that. As a business or whatever, that’s a very tough business. The easiest thing to do is the high end quick apparent comprehensive snap shot executive physical and then send them out and say, “Go see your doctor. I’m not going to take care of you. I can’t write a prescription because I’m just doing these snap shots. There is no ongoing care.” There is no ongoing taking responsibility for the patient’s health and there is no measure of how you change their life over time because it’s just a snap shot. The fact is the most fundamental stuff is trying to get their head on straight and not eat when they’re stressed or smoke or bad behavioral things and sometimes those behavioral things have scientific/medical issues like calorie density but more often it has to do with psychological and social things. It’s hard to even break even on doing that kind of stuff. I think by adding it in over time it really makes a tremendous difference in people’s lives. It makes a difference to us because we want one of our measures of success to be, “how did the patient change over time?” rather than “how happy were they after one day?” because everybody’s happy when they first leave here because we’re at a resort and we make it pretty fun. They usually feel good unless we tell them some pretty terrible news. They feel good when they leave, but I think that’s a too easy of a measure of our success.

Dr. R: Well I think putting it all together as you have, Dan, creates that overall great value. And I think that’s really one of the many reasons Wellmax has such an outstanding national reputation for quality. I think it’s really all of those elements working together to improve the lives of the patients you care for. I wanted to ask you, we’ve just returned from the Aspen conference, the Aspen Summit on preventive medicine and it certainly opened my eyes to what’s out there, but I wanted to ask you Dan, how do you see things changing in the near future with regards to what you’re doing at Wellmax?

Dr. C: You mean how do I see the direction of preventive –

Dr. R: Right, as you look into your crystal ball,

Dr. C: At Wellmax specifically?

Dr. R: Both in general and also maybe even some things that you might even be incorporating in the near future at WellMax.

Dr. C: Well, I think that what I’m seeing is that there have been kind of two parallel tracks that need to work together better. One is the preventive medical “snapshot,” often called the “executive physical” and the other track is high quality ongoing medical care, sometimes provided as “concierge care.”

Executive physical programs often take a snapshot of the patients’ health, and then send them back to their own doctor. This is especially practical for patients that live out of state. But if their own doctor in the first place wasn’t taking the time for them and wasn’t doing the tests that may have been necessary, then, although I think it has value to do the annual snap shot, I think the more complicated but much higher value thing is to continue to advocate and continue to help the person maintain and utilize a health portfolio to improve their wellness. Too often, a problem is identified that won’t receive proper attention when the patient returns to his or her doctor. For example, if a man’s testosterone level were discovered to be really low. Now a days testosterone has become more mainstream, but there was a long time there where if a person’s testosterone is really low you had a choice of prescribing testosterone to a guy who lives out of state or sending him back home empty-handed for “local follow-up,” knowing that he doesn’t have a doctor or his doctor is not going to do anything, and say he’s fine. Then there are also some of the health, nutrition and fitness things and so I think finding community based resources and then networking these and then using the power that we have with the information age to share with the local doctor, “here’s what I found and here’s what you could do”, but still not cutting him out of the loop. I envision more collaboration so that we inform and empower the local doctor, making sure he or she is still the primary provider so that we become kind of catalyst in the complicated and often labor-intensive job of information management. I see that as being a role that we at WellMax could play. When I was in Aspen, there were a lot of doctors attending there that really struck me as good hearted, well meaning doctors. They expressed the same frustration and dissatisfaction I felt 10 years ago, where they are uncomfortable just doing a limited amount of tests that insurance approves and they know that they have patients that are willing to pay for more and now they need to find their way in combining the two tracks I described above, this sort of emerging specialty of early detection medicine, and secondly, providing more aggressive ongoing medical care: doing more for each patient but shifting the costs to the patient and then allowing this consumer driven medicine to kind of take care of itself and pursue quality. I think there is a whole role for that. Those doctors that came to the conference are looking for ways that they can network with us. So the ideal future would be for us to help support them with information and algorithms. I envision a future in which many like-minded doctors, working together and networking, that we can begin to create a new level of medical care with different standards, built not upon most cost effective, or most efficient in caring for large numbers of people, but rather, creating standards about providing the best medical care. We could establish suggested standards or lists of stuff about what else can we do and what should we measure. For example, I was saying that we don’t do echocardiograms. There’s people who have told us that we should do an echo as a baseline or do a brain MRI as a baseline and I think that we’re going to start seeing more forums now where we can kind of argue these things out and that we’ll all learn more and allow us all to be better practitioners and the patients are the ones that are going to profit the most from it.

Dr. R: I think that’s a wonderful vision of where we are and where we need to go. I particularly like the idea of creating virtual networks with other physicians with your center acting as a catalyst and giving a road map perhaps to the local physician so that they can be there to support the patient as they are making these important changes in their lives. I think it’s a wonderful vision Dan. I really appreciate you joining us today and sharing with us all the experience that you’ve had for now over a decade at Wellmax. You have created an outstanding center and truly been a leader in this field. I look forward to following your career at Wellmax for years to come.

Dr. C: Thanks George. It’s an honor to be interviewed by a guy who was managing a huge cardiology practice and then saw the value of these biomarkers and early detection tools and now working with Biophysical and doing this blog with the pod cast. You’ve really become a leader in this whole field.

Dr. R: Thank you very much Dan. I think we share the same passion in prevention. I look forward to working with you for years to come.