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.

Biophysical250

The Biophysical250 is the nearest thing to a “Wiki” you can find in the world of medicine. It aggregates hundreds of different blood tests that have been recommended by leading specialists in the fields of cardiology, rheumatology, gastroenterology, infectious disease, endocrinology, etc. into a single product that provides the most comprehensive overview of your health available anywhere. And it does all this with just 2 tablespoons of blood! The Biophysical250 is also constantly being revised and refined as the rapidly evolving field of biomarker research uncovers new tests that can detect disease presymptomatically. That is the main use for a test like this. The biochemical changes that appear in the blood are often the first sign that a disease is beginning to develop. However, the test has also found many believers among the people who have been living with a medical condition that has not been easy to classify by conventional medical approaches. By looking at the biomarkers associated with almost every system in your body, the Biophysical250 is sometimes able to quickly identify problems that might take months or years to unravel as one is passed from one specialist to another.

Everyone should do this test at least once after the age of 45.

An Optimal Annual Physical: An interview with Dr. Jim Ehrlich

In my search for the best annual physical, I recently had an in depth discussion with Dr. Jim Ehrlich.  Dr. Ehrlich has truly been a pioneer in the field of prevention and comprehensive assessment.  Dr. Ehrlich stated that unfortunately “most people who present to their physician with a life threatening illness are already too late”.  This certainly sets the case of trying to build a better program.  In the early 1990’s Dr. Ehrlich established Colorado Heart and Body Imaging and  introduced electron beam computer tomography for coronary calcium scanning to the Denver area.   Using this tool he could identify patients at higher risk for heart attack.  Over the next decade and a half, he gradually added other imaging modalities such as virtual colonoscopy (Viatronics 3D).  He introduced lung scanning to identify early lung cancer.  He then added bone scanning for early detection and quantification of risk for osteoporosis.  Later Dr. Ehrlich introduced a new type of breast scanning called Sentinal Breast Scanning which uses infrared imaging to identify early breast cancer.  A unique skin imaging called Solar Scan was added to the armamentarium to more thoroughly evaluate and survey an individual’s skin for melanoma.  Dr. Ehrlich’s emphasis has been on imaging technology, but he has also added certain physiologic parameters such as screening for sleep apnea and vascular reactivity which can be altered by atherosclerosis.

 

In our discussion, Dr. Ehrlich suggested developing packages for patients with a certain risk or interest.  These would be heart and vascular package or a stroke prevention package.  He also stated that it is important to combine imaging with important blood biomarkers.  This approach has led to Dr. Ehrlich’s interest in advanced lipid analysis.  Dr. Ehrlich is now the medical director for Atherotech which is a national leader in advanced lipid testing. 

 

According to Dr. Ehrlich the core of an annual assessment will build upon a careful history and physical conducted by the physician and incorporate comprehensive imaging as well as blood biomarker analysis.  For the typical middle-aged adult, Dr. Ehrlich felt that it was important to emphasize screening for coronary artery disease and common cancers such as colon, breast, lung, prostate and skin.  The trend for the future is to expand biomarkers especially those reflecting inflammation (and to incorporate genetic markers as well). 

 

The entire interview is available as a pod cast.

An Optimal Annual Physical: An interview with Dr. Jim Ehrlich - Podcast

Transcript:

Dr. R – I’m here with Dr. Jim Ehrlich and I wanted to tell all of our listeners that Dr. Ehrlich has truly been a pioneer in the field of prevention and we are really honored to have him here with us. He has been in this field for over 15 years. Jim, if you would just tell me about how you got into this area and how you started your center in Denver.

Dr. E – Well my interest over the last 15-18 years has been in what I call “high tech prevention”. From my point of view that’s comprised of new biomarkers, psychologic tests and preventive imaging procedures to give us a clue about the early onset of disease and what we term presymptomatic or sub clinical disease. So my interest started as I was an anesthesiologist and I had really been enamored with prevention and high tech generally. What occurred to me quite early is that most people who present to their physicians with a life threatening illness are already too late. They are providing symptoms to a doctor and the doctor then reacts and our managed care system rewards doctors to intervene when there is a clear diagnosis of problems. But that particular viewpoint fails to serve a very large percentage of people whose first manifestation of a problem might be sudden death or disease that irreversible. For example, more than 50% of people present their first manifestation of heart disease as irreversible either an MI or sudden death. And my interest with a family history of heart disease and noticing friends and family members developing problems very late in the course of disease was to see if we could provide for the public and for physicians ways to identify problems years or decades before they become symptomatic. That drove me to explore methods to detect heart disease subclinically. At the time and this was in the early 90s there was some very promising literature on the value of coronary calcium imaging, atherosclerosis imaging to detect early heart disease and this is being performed at a few centers using electron beam tomography. I basically decided that this was something that I wanted to bring to Denver and then subsequently go involved in centers in three other cities where we provided coronary calcium quantification by EBCT and eventually expanded to other uses of EBCT like virtual colonoscopy and lung scanning for the early detection of Stage 1 lung cancer and eventually added other modalities, things like new techniques for sleep apnea detection, osteoporosis, breast imaging, techniques for measuring vascular compliance and then new blood tests. Everything from bladder cancer to tests that could help determine early biomarkers in cancer. That’s how my interest developed and eventually most recently I became involved with a company that makes a very advanced cholesterol profiling test called the VAP test.

Dr. G. - Wow. So Jim you were really a pioneer in this. I mean the early 90s in coronary artery imaging is really early on. So you started your center in Denver and initially you were pretty much focussed on coronary issues and atherosclerosis is that right?

Dr. E - That’s right. At first we made available to physicians for risk stratification and for the public for screening our EBTC scanner for coronary calcium imaging. Very quickly afterwards we added lung imaging and very selective use of total body scanning recognizing that it had to be used very responsibly and under a physician’s supervision so we allowed individuals to come in either self referred or by physician referral initially for heart scans and then soon afterwards lung scans and total body scans. Then about 2 years after inception, we began to offer CT colonography otherwise known as virtual colonoscopy and we were perhaps the earliest adopter of a technique that has subsequently been shown in multiple articles to be at least as accurate as regular colonoscopy. That’s called the Viatronix 3D technique. By 2005 Colorado Heart and Body Imaging had the nation’s most expensive private center experience with virtual colonoscopy using this very accurate technique. We started added a few other novel technologies. The Sentinal Breast Scan from Stoneybrook, Long Island which is a digital infrared scanning for breast cancer detection, FDA approved for woman 18 and older. We got very interested in new techniques for osteoporosis and sleep apnea termination and melanoma detection using a very unique technology from the Sydney Melanoma Unit in Australia called the Solar Scan.

Dr. R – Tell me a little bit about that. How does that work? Does it have some kind of scoring system for the characteristics of the skin lesion or how does that work?

Dr. E – Yes. It’s essentially a video camera that looks at any pigmented lesion and extracts by multi varied analysis. The 18 characteristics, most of which are not readily apparent to a clinician – the 18 characteristics of a melanoma with a known probability and then is able to weigh all those characteristics mathematically and compare them to a data base to 4,000 pathology proven melanomas and non melanotic pigmented lesions. The computer is able to come up with a score that tells the clinician whether this has a high enough likelihood to be serious that needs immediate excision, whether lesion can be monitored and the technology can detect a 2%-3% change in any characteristic so one of the characteristics of melanoma is a change in the characteristics, but the average physician or any physician could not really monitor and keep track of these characteristics by memory. Also, it’s able to show which lesions can be very comfortably dismissed as non cancerous. So it’s exciting technology proven in the archives of dermatology to be more accurate than any dermatologist who is specially trained in examining these kind of lesions.

Dr. R – So this is really exciting and you know with this battery of high tech tests, really cutting edge stuff, just off the top of your head can you remember any home runs that you hit with this. I mean some great finds that really changed people’s lives?

Dr. E – I think the most common dramatic circumstances have been with imaging and particularly the ultrafast low radiation CT scanner and in our case Electron Beam CT whereas we believe that we have lowered the risk for thousands of people. From a dramatic point of view it’s the instances where somebody comes in for virtual colonoscopy and we find an aortic aneurism or an early renal cell carcinoma these things are not rare and are readily detected because in the case of a virtual colonoscopy, the radiologist is obliged to look at the rest of the abdomen. So I think patients who come in to look at their heart and we find either a lung tumor or a big thoracic aortic aneurism, those kind of things are more dramatic and result in a quick trip to the operating room. There are many, many cases of that kind of thing.

Dr. R – Oh sure.

Dr. E – Having said that, one of the areas that we are concerned about obviously is making sure that people do not believe, for example, that a body scan is a substitute for a good physical exam and they recognize the limitations that some of the things that we find will turn out to be nocuous or not medically significant and that’s the downside and really the reality of any very sensitive screening tests, there will be some aspects of exam that could turn out to be false positives.

Dr. R – Right. Now, the way that this would work at Colorado Heart and Body Imaging, would people come to get as many of your tests as possible in sort of a package to get the sort of overall view of everything or would they just select a few of the tests that they were interested in or their doctor was interested in? How would that work?

Dr. E – We tried to develop programs that combined relevant tests for the purposes of the program. For example, a stroke prevention program would include a coronary calcium image looking for the calcium score to determine the person’s underlying coronary vascular risk. It would include carotid ultrasound particularly looking at the intimal medial thickness and quantifying that. It would include an advanced lipid test looking for risk factors, a review of blood pressure including the stigma corp device from Australia. This is a device that looks at aortic augmentation pressure and arterial compliance and is a direct risk factor for stroke and then also the lipoprotein, LP PLA 2 plaque blood test, a specific marker of vascular inflammation that’s FDA approved as a risk factor for stroke. So an individual interested in stroke prevention might be encouraged to have some or all of those tests within a program. Then others come in just for heart scans or lung scans and then physicians in somewhat of a concierge’s type of set up sometimes will take advantage of 8 or 10 procedures that we have in concert with their own executive physical. So they may choose an ultrasound of the neck, plus a virtual colonoscopy and a heart scan to compliment their office space physical exam.

Dr. R – I see. Now tell me just a little bit about how biomarkers would fit into this kind of a comprehensive plan and by biomarkers I mean blood tests, looking at proteins and molecules and not genomics we’ll talk about that in a little bit.

Dr. E – The way I look at it is that the physician in a sense becomes a detective and is gathering data to get an overall assessment of any clues to early disease. In this respect, serum biomarkers can be very valuable. So for example, an individual who might otherwise to be low risk for heart disease could get advanced lipid test, the plaque test which is the LP PLA 2 vascular inflammation biomarker and maybe in combination with a physiologic test to look for hidden risk factors. So somebody who came in with a family history of premature heart disease, we would want to know do they have coronary disease so they’d get an EBCT heart scan, but I’d also want to know if they had an inherited biomarker of protein like lipoprotein(a), a very atherogenic particle that’s not only pro atherogenic but pro thrombotic certainly runs in families and would signify the need to lower LDL by another 30%. So this is a kind of investigation that we find useful. Then in the field of cancer there are some emerging biomarkers of interest and certainly the concept of multiplexing which I know Biophysical has aluminated, this idea that sometimes looking at multiple biomarkers can help give an idea of whether somebody’s developing a pattern of disease.

Dr. R – Well, great. We’re going to need to take a short break and be back in just a minute.

Dr. R – We’re back with Dr. Jim Ehrlich who has been a pioneer in the field of prevention and started Colorado Heart and Body Imaging back in the early 90s and has continued with that and is now the medical director for Atherotech which has a great new specialized lipid test called the VAP. Jim, I was going to ask you about the role of genetic testing or genomics. I guess in 2000 we finished the project of mapping the entire genome of Craig Vetter and the promise was that knowing what was going on from a genomics standpoint, we could protect every disease someone was going to encounter. What do you see the role of genomics and genetic testing in prevention?

Dr. E – I think it’s going to be a very valuable part of our armamentarium. Especially in selecting and individualizing care. For example, about 40% of diabetics have what’s called a haptoglobin 22 phenotype. Those particular diabetics as revealed by two large studies are extremely responsive to Vitamin E lowering their risk of about 50% of macrovascular events and are very responsive to tight control of their diabetes including statins. So with the controversy about how tightly we should control diabetics because of the recent ACORD trial, physicians are going to be confused and certainly by some of the data that shows that Vitamin E overall may not confer much of a benefit at all for prevention of heart disease. It would be useful to be able to select out those individuals in a setting who could best benefit from our therapies and where the risk benefit ratio would be favorable. That’s an example as what I see as a coming trend. The individualized therapy. Another example might be if a person has a low HDL, a low level of good cholesterol, one person might respond very well based on their genetics to Niacin, another might respond to alcohol and exercise and the future might be that physicians will individualize decisions somewhat based on genetic susceptibility tests and genetic profiling. I see a role in pharmaco genetics. I see a role in counseling patients as far as their future risks and ways of lowering environmental stresses by having the data. It’s certainly very early in the game and there are not a whole lot of circumstances right now that physicians are comfortable doing genetic profiling.

Dr. G – Right. So that’s very interesting. So this would be sort of like delivering on that promise of personalized medicine.

Dr. E – That’s exactly right. A good example is that there are individuals that have a particular type of genetics where estrogen therapy would greatly reduce their risk of cardiovascular disease. This would help again in this area of deciding with all the controversies from the HERS trial and other trials which people would best benefit from either short term or life long therapy based on their genetic predisposition and could help counsel people on the best risk factor reduction strategies.

Dr. R – Okay. Great. So Jim, I’m a middle-aged man and describe for me what would be the components of the ideal comprehensive annual assessment. I won’t call it a physical because I don’t want to limit ourselves to a physical exam, but what would be the components of the optimal evaluation and let’s just put money aside. Let’s just say, what would be the best?

Dr. E – I think it would obviously certainly as a based component it would be a careful history and physical exam. But my feeling is that that’s inadequate including routine blood testing to protect the average individual from likely disorders like heart disease and cancer. Especially based on the family history, we would tend to focus on the major killer which would be cardiovascular disease and also the major cancer killers, lung cancer being # 1 and colon cancer being #2 and for a man obviously prostate cancer is very important. If the individual was 50 years old and otherwise healthy, in addition to the history and physical, coronary calcium imaging I think should be done. There is some controversy of whether this should be done routinely, but considering that we routinely do colon cancer screening to detect the 6% life time risk of colon cancer and we routinely do mammography knowing that only 4% of women will develop breast cancer, why not screen for a disorder that will effect at least 45% of men which is cardiovascular disease. So I think coronary calcium imaging and perhaps carotid imaging to look for evidence of a vasculopathy somewhere is a very good first step. This would help determine future LDL goals. Now we want to characterize the person’s risk further. Instead of stopping with a coronary calcium scan, we then could justify advanced lipid testing which can be acquired very inexpensively and will look for hidden risk factors for heart disease but also fully characterize the risk. Maybe the person has insulin resistance or metabolic syndrome. This may be the first clue to think about the contribution of metabolic syndrome just from a lab test. I also want to have some index of inflammation. If a peson has a positive coronary calcium score, I want to know is it likely that some of that plaque is vulnerable to rupture or unstable and the plaque test LP PLA 2 blood test from Diadexsis has been very useful for us to know how seriously we should take somebody who has let’s say even an average coronary calcium score. So if somebody has an inflammatory situation, I’m more concerned than somebody who has coronary plaque that appears to be quiescent. Then as far as blood pressure measurement we very quickly consider more advanced blood pressure testing either 24 hour blood pressure ambulatory monitoring to decide on if a person really does have hypertension we consider sleep apnea very very seriously and commonly in any person who has hypertension. About 50% of diabetics, for example, have sleep apnea and these are conditions that can be identified early. We like a particular ambulatory device from Israel called the Watch Pad 100 which gives all the information that a sleep specialist would need from a patient’s home worn one night on their forearm, antihypnotic index, oxygen desaturation index, percentage of realm sleep. So it effectively replaces the need for sleep labs in people who have a moderate risk for sleep apnea. So those kinds of things are important from a cardiovascular point of view. Then from cancer prevention, obviously we would give the individual a choice of regular colonoscopy or CT colonography and the American Cancer Society now endorses both of these as front line screening options. Fecal cult blood testing would be added to this and then of course besides a digital exam, certainly a PSA would be the minimum and we’re hoping for better biomarkers for prostate cancer. I think that would be the kind of high tech supplementation to an executive physical on a 50 year old.

Dr. R – That’s fantastic. We’re going to have to take just a quick break and we’ll get right back.

Dr. R – We’re back with Dr. Jim Ehrlich and we’re talking about some really outstanding stuff regarding wellness screening and prevention. One final question, Jim. Looking into your crystal ball, what do you see as the future trends for wellness screening and prevention?

Dr. E – I see that there will be more emphasis generally on blood tests, advanced lipids, measurements of inflammation, a few new biomarkers, hopefully an ovarian and prostate cancer and I think there will be greater acceptance generally of the value of supplementing the history and physical with physiologic and imaging tests. There have been restrictions on this. Certainly insurance companies have largely determined the distribution of prevention by not generally covering some of the more advanced screening tests so this affects who will actually elect to have these tests. I think there will be greater acceptance of some of these tests and many of these will be brought into the physician’s office. For example, endothelial function testing is generally done on a research level. It’s available at certain research centers and now there are two companies that have developed very nice office space for endothelial function test that are accurate and could be available to the clinician to get an ideal of their vascular health and monitor the effects of therapy. So an individual, let’s say metabolic syndrome and whose on statins and other medications could get a measurement in the physician’s office of their vascular health and then be followed along to get an additional indication besides advanced lipid testing of the effect of the lipid lowering regime. These are things that I think are part of the future.

Dr. R – That’s great. Jim, I can’t thank you enough for being a part of this segment and you truly have been a pioneer and a leader in this field and it’s really an honor to hear your comments.

Dr. E – Thank you very much. It was a pleasure.