Gone are The Days Where to Build a Medical Practice You Just ‘Hang a Shingle’…

Gone are The Days Where to Build a Medical Practice You Just ‘Hang a Shingle’…

By Natan Schleider, M.D.

July 1st, 2017

“Hang a Shingle?!” What are you talking about? Most young readers are probably unfamiliar with this expression.

To “hang a shingle” refers to a time before the internet (yes, the stone ages) where, when starting a medical practice–or any other small professional business for that matter like a law practice–a young doctor hung a sign  with his or her name engraved (often in front of their home office) to attract new patients.

A shingle here refers to a piece of wood I suppose, not to be confused with the painful rash caused by Varicella Zoster virus yet I digress.

Having just put up a newly revised website, apparently my blogs carry more weight with search engines than my board certifications–so says my online marketing campaign adviser.

Is this why I am writing or should I say blogging? Sure in part.

A bunch of other factors such as how often I tweet on twitter.com and how often my patients “like” my practice on various social media outlets will help get my practice’s website, www.doctorinthefamily.com, highly ranked on Google and other search engines when patients are looking for a doctor.

In other words, I could be a Nobel prize winning, cancer-curing, super nice medical doctor but without the social media buzz, my website would not be highly ranked.

Apparently I’m a dinosaur who has stayed away from the social media limelight for far too long.

Adapt or die.

Follow me on facebook and twitter. Oh, I do not have accounts with them set up yet. And writing that is like nails on a chalkboard.

But if everyone else is glued to their smart phones not interacting with the humans around them, walking into telephone poles as their thumbs busily peck away, I should see what all the hype is about, right?

A Weight Loss Doctor New Year’s Resolution to Lose Weight P.4–Does stretching cause weight loss and get you lean or “ripped?”

Well, it’s 6:27 am and I am a but tired, I am on day 4 of the “30 day gallon water challenge” which I believe I mentioned in a prior post. Whether I make it to my 6:45 am spin class is doubtful as I want to write this blog and have some new stretching to explore and discuss (and perform later with my trainer).

If not, having found no data to support this, apparently celebrity Beyonce drank a gallon of water for a 30 days and noticed her skin was far more radiant and she felt better. This led to a fad water diet trend to which I, a trained physician, have succumbed to. Hey, I’m human, It’s water. Hold on, chug, chug, chug…half a liter down.

So I had my first session with a new trainer,Shawn, yesterday, an experienced personal trainer my age (41) unlike the the younger trainers I have had in years past. Telling him my goal was to lose 40 pounds over the next 40 weeks (or 1 year, I’m in no rush), he focused on showing me how doing certain basic exercises like lateral pull down in one position would isolate one part of the lateral back muscle while simple changing your grip by 45 to 90 degrees would isolate a different part of the same muscle group. The point: a year from now, I am hoping that the definition of my muscles will be equally distributed and I will not look like a big guy that works out a lot (which tends to happen because genetically, I have always been stocky and quickly put on muscle but always had trouble losing fat and getting lean).

I then asked Shawn “Will stretching regularly  lead me to become more lean?” to which he answered unequivocally “Yes.” He explained that regularly stretching out the muscles like a rubber band would ultimately lengthen them in time causing a leaner look.

Shawn has been a trainer for at least 15 years so I will not dispute his personal experience but as a  doctor, I wanted the real data and found it here:



The study answered my question in one specific section which I will italicize below if you want the bullet point: regular stretching does not increase muscle length, it simply increases ones tolerance to prolonged strecthing of a muscle. So the  rubber band does not get longer, it just gets less stiff.

The effectiveness of stretching is usually reported as an increase in joint ROM (usually passive ROM); for example, knee or hip ROM is used to determine changes in hamstring length. Static stretching often results in increases in joint ROM. Interestingly, the increase in ROM may not be caused by increased length (decreased tension) of the muscle; rather, the subject may simply have an increased tolerance to stretching. Increases in muscle length are measured by “extensibility”, usually where a standardized load is placed on the limb and joint motion is measured. Increased tolerance to stretch is quantified by measuring the joint range of motion with a non-standardized load. This is an important question to consider when interpreting the results of studies: was the improvement based on actual muscle lengthening (ie, increased extensibility) or just an increase in tolerance to stretch?7 Chan and colleagues8 showed that 8 weeks of static stretching increased muscle extensibility; however, most static stretching training studies show an increase in ROM due to an increase in stretch tolerance (ability to withstand more stretching force), not extensibility (increased muscle length).912

That said, Shawn has assigned me home work of stretching for 30 minutes in the AM and PM so I’m gonna buy a yoga mat on Amazon now so I can do my stretching while I watch the evening shows I enoy on Netflix rather than lying on the couch.

A Weight Loss Doctor New Year’s Resolution to Lose Weight P.3

As the cold month of January creeps to an end, I am not immune to the fad diets and the gym promotions that surround this 5’9″ 220 pound medical doctor here in Midtown, Manhattan, New York, City whose goal weight is 177 to 190 pounds over the next year.

Having been in the weight loss business, reviewed the weight loss literature, and watch my own metabolism slow (I  feel for for my cohort of people who now, when completing forms or checking the box on the elliptical trainer, check the 35 to 45 box rather than the 25 to 34 box)., I realize to lose roughly 40 pounds safely and realistically will take a year, needs to be done slow and steady. Slow and steady will win this race.

Something as subtle as eliminating the three cans of V8 vegetable juice which have about 80 calories each which sound and are healthy (minus perhaps the sodium) are 240 calories a day which are more or less what I burn daily in my morning spin class.

Oh yes, incidentally, I joined Crunch gym https://www.crunch.com in New York City.

I do not serve to endorse nor advertise them. I simply liked that their fees were reasonable (for me) at $79 monthly, no annual commitment, cancel anytime. Their approach unlike other high end gyms like Equinox–where everyone seemed “too” good looking with 1% body fat, their skin tight “sports bras” matching their sneakers”–is “come as you are.” Or I might translate, ‘so you are a little chubby, that’s ok, maybe we can get you in better shape.’

They did pitch me hard on 20 personal training sessions which I sigedn up forbut I will credit Fitness Manager Tiran Winston for giving me special attention to diet and nutrition and positive encouragement.

Tiran told me not to weigh myself daily but weekly. I didn’t listen of course having just joined the gym 5 days ago but I have lost 4 pounds since so since joining.

Of additional note, I am doing the 30 Day One Gallon a Day Water Challenge.  More to follow on that…






A Weight Loss Doctor New Years Resolution to Lose Weight P.2

January 15th, 2017

by Natan Schleider, M.D.

So as a 41 year old male standing 5 feet 9 inches and weighing 220 pounds (I weighed about 180 in college, always been fairly stocky genetically but even I am not immune to desiring all the Hollywood actors incredible physiques my age or older), I calculated my BMR or Basal Metabolic Rate on line.

The BMR formula also called the Harris Benedict Equation can be calculated at these websites and tells you roughly how many calories you burn each day based on height, weight, gender, lifestyle, and age:



Once you know this, you can calculate how much of a calorie deficit you need to lose weight daily. For example, my BMR is guesstimates that if I lie in bed all day and do nothing, I burn 2441 calories to maintain my weight. Frankly that sounds high because I have been eating rather healthy (no sweets, pizza, french fries, etc) but have lost no weight in months (since I started paying attention at age 40).

Knowing that one pound of fat is 3500 calories, if I cut my calorie intake by 500 calories daily (or burn 500 more calories daily exercising), I should lose one pound a week if my diet remains unchanged. Alternatively, I reduce my calorie intake by 500 calories daily and should get the same result.

Note that after age 30, our metabolic rate slows by about 5-10 percent per decade (it feels like a lot slower personally so I’m with you if you are middle age and been eating and exercising on some level and not losing weight as you did in your 20s or 30s).

I plan on going to the gym for mostly weight lifting which I enjoy at least 15 minutes daily, cutting my daily calories by 500, and am currently trialing two medicines with data showing they promote weight loss, bupropion/naltrexone (Belviq) and will soon be adding on toprimate (Topamax).

I wish I could have the weight off in a few weeks but that is not realistic and “good things come to those who weight [pun intended].”

If anybody is reading this and wants to know how I am doing–or has any advice–I am all ears.

If I write a part 3 to this segment of my blog, I will research anti-aging medicine supplements to promote muscle mass and fat loss.


A Weight Loss Doctor’s New Years Resolution to Lose Weight

A Weight Loss Doctor’s New Years Resolution to Lose Weight

by Natan Schleider, M.D.

January 12th, 2017

Before starting New York House Call Physicians, I had a few temporary part time doctor jobs that honestly tough me a lot. I worked in a small emergency room. I worked for an urgenct care center chain. And I worked for a diet doctor practice.

While working as a “diet doctor,” I was 29, ran 6-10 miles every morning like a machine, and really watched my diet, namely caloric intake. If you want to lose weight simply put, put if fewer calories than you burn. As a chubby 8 year old, my grandfather whom I miss dearly–an attorney who hated his job weeding out the “fakers” who claimed disability at the insurance company he worked for, was an avid handball player in Brooklyn, NY and regular at the YMCA and bowling lanes.

Visiting him and my grandmother in Florida in their Jewish retirement community, Century Village, he pinched my love handles firmly and simply said: “What is this?”

Minutes later, he was showing me how to do leg raises and said I was to do 200 a day.

Not the first to “tease” me on my weight, by age 15 I had given up high school baseball for the gym and 10 years later, was an avid runner and “gym rat”, an athletic 175  pounds standing 5 feet 10 inches. I counted every calorie. Cocktails were always mixed with a diet beverage or club soda. No carbs were eaten after 2 pm. I took a rest day maybe once every 2 to 3 weeks. If my weight peaked 180 pounds, I would starve myself the next day. So it weant for years.

Now that I am 41, having spent my 30s building a medical practice and raising a daughter, I am 5’9″ and 220 pounds. I am obese based on my Body Mass Index. Me, obese, a former diet doctor! What happened?

Clearly my metabolism has slowed although comprehensive lab tests I collected on myself show I am in the normal range.

In recent weeks and months I have dropped my calorie intake to 1500 calories daily without weight loss. I have not had a cookie, a sweet, or ice cream in months. I have been in the gym 3-5 days weekly for at least 20-30 minutes breaking a sweat–not the ironman of workouts but something is better than nothing.

I consulted a bariatric surgeon, was signed up to have a $16,000 lap band put around my stomach. But after reviewing the data and speaking to half a dozen friends and patients who had the procedure, I cancelled the surgery. Most studies show patients regain their weight within a few years.

I have been on Belviq (bupropion plus naltrexone) which is a relatively new non-controlled non-stimulant weight loss drug for 6 weeks and my weight is unchanged.

Am I frustrated, yes! Have I given up my “skinny jeans” I wore 10 years ago, not yet.

Am I ready to starve myself for months to get back to 180 pounds? Not really.

Am I ready to dive back into the gym or start running again, given that it seems I would need to put in twice the time and energy to maintain my goal weight of 180 pounds, maybe.

I see these hollywood stars my age with terrific physiques and know if they can do it, so can I.

My current plan: drop my calorie intake to 800 to 1200 calories daily, double my time in the gym, speak to my doctor about Topamax which is a non-controlled medicine which also shows efficacy for weight loss. I will not take the stimulant weight loss medicines like phentermine or Vyvanse, they work but are habit forming and tolerance can easily occur within weeks to months if used daily.

My scale and I will keep you posted.

Alcohol Abuse, Love, and Frostbite

With the New Year ushering in, many of us will usher out for “celebration.” I won’t be one of them as most recent new years, being on call, I’ve managed cases of acute alcohol abuse, frostbite, and love.

Cliche dictates we brave the cold for a magical New Year’s kiss, for love essentially.

We brave the New York City street and Time Square, generally under-dressed: who wants to pay the extra money for the coat check, mess up their hair with a hat, sport boots in cocktail dresses? I don’t.

The US National Library of Medicine specifies alcohol as an independent risk factor for frostbite, here is the link if you don’t believe me: https://medlineplus.gov/ency/article/000057.htm.

Should love be added to the list of risk factors, displaying all of the aberrant behaviors of disease, the sleepless nights, the obsessions and compulsions of checking our Tinder and Facebook accounts, the mood fluctuations from elation to depression, I could go on.

I write as a physician wishing you a happy and healthy holiday. And as I query a recent question posed to me: Are you a “hopeless romantic?” I would answer “If it meant me risking frost bite for “true love” I suppose I am.

An aspirin a day keeps the heart attack (and colon cancer) away.

Aspirin, also known as acetylsalicylic acid (ASA), is a medication used to treat pain, fever, and inflammation and is an NSAID (Non-Steroidal Anti-Inflammatory Drug). It is often not grouped with other NSAIDs because of it’s blood thinning effect by binding platelets.

It went into mas production in 1899, sold by Bayer, and was a blockbuster, the Viagra of its day (and that’s an understatement).

Unlike it’s more commonly used competitors in the NSAID family like ibuprofen (Advil) or naproxen (Allve), aspirin 81 mg daily REDUCES THE RISK OF HEART ATTACK AND STROKE AND COLON CANCER in patients that have ANY risk factors for these conditions like high blood pressure, diabetes, obesity, male gender, the list goes on. [We can talk about the less discussed fact that most other NSAIDs like Advil and Alleve increase the risk of heart attack and stroke later, seems like some pharmaceutical companies don’t want this advertised, remember Bextra and Vioxx, I do].

Based on the United States Preventive Task Force a baby aspirin daily which is 81 mg is recommended ” for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.” [https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer].

I turned 41 this past November and I take a baby aspirin daily. It is dirt cheap. Does not bother my stomach. And, depending on the study, can reduce risk of a heart attack or stroke or colon cancer (and possibly breast cancer, endometrial cancer, and prostate cancer) by up to 10%, maybe more, maybe less, it is all about how much risk you have for developing those diseases.

There is a lot of data coming out about the benefits and risks of aspirin despite the fact that it was around two centuries ago–you’d think they would have come up with something conclusive by now, right?

Anywho, if I’m your doctor or you want to play doctor as many patients do by educating themselves on the internet, tell me your thoughts.

How to verify a patient’s insurance information is accurate, especially on Christmas Day?

5:30 am in a dark New York City, four days after the winter solstice, I guess Santa is making his final rounds for all the good children but what about all the good doctors?

Would it not be nice if, because it’s Christmas, if the Health Insurance Fairy left a health insurance company’s fee schedule under my pilliow?

Being an out-of-network physician–meaning I have no contractual relationship with any third party insurance companies including Medicaid and Medicare–I am constantly forced to guesstimate what I will be paid for my medical procedures and time.

To make matters worse–as medical schools do not offer any significant classes in medical billing–I am self-taught, having learned the mumbo jumbo language of CPT codes, ICD-10 coes. modifier codes, all sorts of weird numbers and letter that change often that I put on a “1500 claim form” and send in to my patient’s insurance company. (If you don’t know what any of this stuff is and your a doctor considering private practice, start studying my friend or contact me with questions, as if there is anyone reading this?).

Dropping that form in the mail is like a Hail Mary in football, except I will not find out the compensation (if any) for the doctor services provided.

I get back what is called an explanation of benefits (commonly called an EOB) from SOME insurance companies, not all. That is, in the last year, a few insurance companies like BCBS only send paperwork to the patient, not the doctor, so you have no idea if and when you’ve been paid unless you bug the patient to have them check their male and send you the EOB.

A few health insurance companies have even requested a HIPPA medical release for my office to determine claims and eligibility of a patient’s insurance plaa which is obviously ludicrous since the patient is not yet an established patient.

I can rant and rave for a while but this Christmas, my wish, some transparency from the insurance company “Matrix” unless there is a Neo out there?

So how to verify a patient’s insurance information is accurate, especially on Christmas Day? Would anyone reading this care to offer advice (and I know there are some automated systems that provide claims and eligibility but at least 50 percent of the time, in my experience, I need to speak to a human to get answers, yes, a human).

What do you call a house call doctor’s practice when the office is closed for vacation?

Question: What do you call a doctor’s practice when the office is closed for vacation?

Answer: Dead. Prognosis grave. Death imminent. Call the coroner.

My running joke since starting New York House Call Physicians: Your Doctor in the Family in 2005 is that I ask my patients to get sick only Monday-Friday 9am-5pm but they never listen.

Patients have the audacity to get sick on weekends and even on the holidays. The nerve. Can’t they respect a doctor’s time with their friends, family, religious and social obligations, etc?

These are all obviously rhetorical questions.

My patients want direct access to me when they are sick, period. Whether in rural Maine now where I am on my first “vacation” in a year or Christmas Day, my email and smart phone are alive and well with patients calling, labs coming in, prior authorizations that need me to sign off on, the normal rumblings of a medical practice/small business go on 24/7/365.

My office doesn’t close for vacation. i don’t close for vacation. Illness doesn’t close for vacation.

Bottom line: If you want to keep your practice alive and thriving, always pick-up the phone, a few minutes spent while on vacation will save hours of work when you get back.

Secrets of a House Call Doctor Part II

Secrets of a House Call Doctor Part II

A good house call doctor is only as good as the equipment carried with them including medications.

Let’s face it, as 21st century physicians, we can do little without our gear.

Not to be forgotten are the house call doctors that preceded us–which essentially means medical practice since Hippocrates as doctors performed house calls regularly historically.
Terms like “Urgent Care Facility” or “Tertiary Care Hospital” would not have been translatable easily to Galen or Liston.

One of my first house calls was for a sore throat, that was what the caller said anyway. Upon arrival, in addition to the sore throat, they mentioned they had “twisted their ankle” and could I “take a quick look at it and wrap it.” I’m thinking: “Why would I bring ace wraps for a sore throat, why didn’t you mention this when you called, I have plenty at the office.”

The ankle appeared mildly sprained. I hustled down to the nearest pharmacy, bought an ankle wrap for 10 dollars (they cost 1 dollar if that wholesale), and wrapped the ankle.

When I do home visits now, I have so much gear it actually scares most patients, seriously. Imagine calling for a headache and a doctor walking in, cargo patents bulging with equipment, rolling with more gear than two strapping paramedics might carry. That’s me. Better to have it and not need it than vice versa.