Concierge Medicine

Todd: It's a type of medicine and a preventative strategy that doesn't fit into traditional medical care. Right now, what the traditional system is missing is a strategy to maintain health span, to keep people healthy and active and functioning the way that they want to function.

Brent: Welcome to Death Clock. I am your host, Brent Franson. Today we speak with Doctor Todd Dorfman. Doctor Dorfman is a private doc here in Boulder, where I live most of the time, and I was consulting with him on something for myself and asked him to come on the show. We really wanted to dive deep on the practice of concierge health and what private docs recommend, as you'll hear, what you're getting from a private doc and a concierge.

Brent: Medicine practice is very different than the traditional primary care physician that contracts with your insurance. These private docs are typically cash pay. This model allows them to really practice medicine the way that it should be. Practice in the spirit of preventative health versus reactive health. So it's a really good conversation. We'll probably have him on again because there was a whole bunch of things we didn't get to touch.

Brent: Hope you enjoy.

Brent: Doctor Todd Dorfman, welcome to the show.

Todd: Well, thanks for having me. My pleasure.

Brent: We met. We're both here in Boulder. And this. I think this is a first for me in terms of all of our guests. We had met just personally. I've been. I've been. Well, I do some experimenting for my job as well, but I had been trying to track down a CT scan, which I think, you know, we'll end up talking about what that is.

Brent: But you're the doc I found. You know, the private doc I found here in Boulder. And so in our initial conversation, I was like, I want to ask him a lot of questions, so we should record it and share it with everybody else. So thanks for playing both. Both roles.

Todd: Yeah. Happy. Happy to help you personally and happy to help your, audience and answer a bunch of questions. Absolutely.

Brent: So you are a concierge doc here, and so can you just quickly give us your background, just your potted bio, and then your sentence or two on what concierge medicine is? And you know what that what means for you and your practice.

Todd: Yeah, absolutely. So I'm sort of a, traditionally trained, if you will, emergency physician. I came to, Boulder in 1999. I was one of the associate trauma directors of the Boulder Community Health, and I was in the E.R. for 20 some years. And I also ran all the emergency medical services, police, fire and ambulance locally.

Todd: I've had this practice since 2002, and it sort of started the concierge piece sort of started as almost a consulting practice for people with difficult medical problems. So, if a patient would have seen a few different doctors and, you know, sort of the traditional medical system, 15, 20 minutes at a time and they can't quite figure out the problem.

Todd: Patients started coming to me and I would have time to spend to talk to experts around the country, do medical, you know, literature research and sort of come up with a game plan. So that's how it all started. And then about five years ago or so, I focused. I left, the hospital system and focusing 100% on the concierge kind of, practice.

Todd: What it really means to me is my it really is my ability to practice medicine in this day and age on an individualized or customized basis. I mean, that's really what this is about, because I can spend as much time as I need with each patient. And obviously, you know, someone who's in their 80s with a bunch of medical problems takes a different amount of time and a different skill sets, so to speak, than, you know, someone like you who is healthy, you know, younger guys.

Todd: So it allows me to really customize and individualize things and not sort of do a one size fits all practice. It allows people to access me frequently. That's the other big sort of piece with concierge medicine. My patients have my cell phone number. They can get in touch with me 24 over seven. I keep the practice small and they talk to me directly.

Todd: There's not a bunch of interface with, you know, a phone tree before the message gets to the doctor and then the message isn't the right message and they get back to you. So what it really does, overwhelmingly, is allow me to practice medicine in a way that I think medicine should be practice, because there's so much information these days.

Todd: I mean, we our information doubles in about 18 months time, and you really have to have time to research that information and apply it appropriately to the patient. So that's really what concierge medicine is.

Brent: And why is that so hard in the context of a traditional practice. Because, you know, so concierge medicine is cash pay. It's hyper personalized. It's more focus on customization and prevention. But a lot of what you described, I hear myself thinking, well, shouldn't my primary care doc my my kind of quote unquote normal doc that I that is paid for through insurance, shouldn't they be doing all of that?

Brent: And the reality is that they aren't. But why? What is it structurally about that traditional format that doesn't allow for this?

Todd: Yeah, I think it's a really good question. So I think, you know, the first thing I would say is that the docs who are practicing in the traditional system, I know many, many of them, over the years, probably hundreds, right. And they're really good people and smart people, and they're really doing their best to practice. But the system itself has sort of handcuffed them where, you know, in order to generate a certain amount of revenue because of insurance billing, you know, comes down to money, quite frankly, in certain respects.

Todd: And they have to see a patient every 15 or 20 minutes. They have to do a certain amount of paperwork, which asks a number of questions that don't pertain to the visit, but they have to fill it out anyway. For example, when I first was an emergency doctor, if you came in with a sprained ankle, I'd write a little note about this big your ankle sprain.

Todd: It's not broken. I did an X-ray. Here's what you do. Have a nice day. Now it's like I'm writing a journal about your health as opposed to just focusing on that problem. And that's what it's become. So I think there's a huge paperwork burden. I also think that secondarily, it's kind of this monetary piece, right, in the insurance based system.

Todd: Like you were just talking at the opening of the show about a ccta, which is a CT coronary angiography. We use that test plus an AI platform to analyze your coronary arteries and get great information, just like you went to the Hardcastle lab. Well, there's no way Surance will pay for that at this point without a good reason, right?

Todd: You're having crushing chest pain. You're short of breath. They have to have a clinical reason. For me, my reason is that most of the people in the world die of cardiovascular disease. And I should be looking for it early in order to mitigate their risk moving forward. So I think that's why it's not really applicable. Plus, just to go over one of these tests like us, the Ccta you mentioned again, I spent about an hour with the patient just going over that test and coming up with a mitigation strategy around their lipid levels, their family history and all the other things.

Todd: So from my standpoint, it's a type of medicine and a preventative strategy that doesn't fit into traditional medical care right now.

Brent: But just to summarize, it's basically the economic model. So if I am a traditional all family doc or primary care doc, I have to maintain some threshold in terms of the volume of patients. And so I've got to see a patient every 15 minutes not, you know, the average I think doctor visit is like 15.8 minutes or something.

Brent: In order to cover the overhead for the office and the staff and the paperwork and all of the billing, etc. like, I have to pump that volume through my practice, which means that that volume, I am just only able to spend so much time with each patient. And so I have to focus on the reactive care, the urgent issues, as opposed to really sitting down and saying, hey, creating a roadmap for preventative health.

Todd: Yeah, I think that's that's totally accurate. I think it comes down to I kind of call it putting out fires right in 15 minutes. You can, you know, if you have high blood pressure, you get automatic. If you have a sore knee, if you examine the knee and figure it out. But all of those things are kind of putting out fires.

Todd: What, what the traditional system is missing is a strategy to maintain healthspan, to keep people healthy and active and, you know, functioning the way that they want to function.

Brent: So there's there's the one piece which is just like the economics of covering the overhead and paying myself. That doesn't leave much time for each individual patient. Need a certain number of patients okay. Kind of point one and now point two is the insurance piece. So if we take the example of the CT scan. So I'm 43 years old.

Brent: But I don't you know, my biomarkers for cardiovascular health are not that great. I my my cholesterol is high. My APB is high. Like I've got some things to work on in terms of my cardiovascular health. You would assume that it's in the long term economic interests of the insurance company for me to get the CT scan. I think the all in cost is call like a couple grand or $2,500.

Brent: With this, I think why is that not in the interests of the insurance company? Like why do you view that differently than they do?

Todd: It's a view of prevention versus again, you know, dealing with an immediate medical, problem. I don't know, I'm making an assumption, but if you look like an actuary data. Right. He look like it. Sure. Insurance companies, those things, it most likely it costs them less money to treat you if you get a heart attack as opposed to stop everyone you know, do CTAs on everyone and prevents everyone from getting a heart attack.

Todd: My guess is there's a monetary piece there. I don't know that for sure, but I got a pretty good sense. The suspicion there is. The other thing is, I will mention on the side of the insurance companies, there are a few, like Medicare, for example, is kind of turning the corner and they are actually starting to approve. Now some of these I plaque analyzes and things.

Todd: Now you have to have a certain set of symptoms. Right. Like you got to you know, you have to have whatever. Again chest pain shortness of breath. You have to have a reason to get that in order for it to be approved. It can't just be, hey, I'm 43 years old and my lipids are high and I have a bad family history.

Todd: That's why I do the test, right? Because I want to see what's going on in your coronaries to get it paid by the insurance companies, you have to have some other reasons, but the honest answer is they're starting to kind of turn the corner, particularly on the card. This this particular cardiovascular test we're talking about.

Brent: Back to the first piece, the economics of the practice. You just don't have much time in the traditional setting. And then the second piece is the insurance companies, they're doing this complicated math around, okay, what is the cost of prevention across everybody versus the cost of reactive care for some subset. And they're determining that math is, you know, like let's you know, to focus on the reactive care is probably less expensive and better for their bottom line.

Brent: But we will give them a little bit of credit and like, hey, they are starting to get it's the beginning of getting a little bit smarter.

Todd: Yeah, I think they are quite up quite honestly. You know, because for example, you know, going to the heart cath lab, which, which is the gold standard of looking at your coronary arteries, the tests that you're about to engage in is compared to that gold standard, and it has a really high status accuracy compared to that gold standard.

Todd: So in a noninvasive way, right. No real risk to you besides a CT scan, you know, some radiation, some contrast, but you're not risking, you know, a big, surgical injury or something in the, in the cath lab. The cath lab. My gosh, it probably costs 10 or 20 K minimum to, you know, just walk through the door before they do something.

Todd: So for a couple grand, we have the same information literally to help us plan your life moving forward. And then we can repeat a very repeatable kind of strategy to right, I can't send you the cath lab over two years, but in you we can see what your corners look like. I can analyze your lipids. I can come up with a mitigation strategy.

Todd: We can repeat the test and whatever a year, two years, three years, whatever it takes, and see how we're doing, because it really comes down to how your coronaries look, not how your lipids look. And on paper this does that kind of make sense? So I'm able to really use it as a reproducible, easily trackable test.

Brent: Yeah okay. And then it makes sense. I mean just maybe to put it put a pin in the car concierge versus traditional in any case okay. They're getting better. But all docs get into the work because they want to help people. But to really practice medicine the way that you feel it ought to be practiced based on your expertise is very hard to do in the traditional setting.

Todd: Absolutely. I think a great analogy is in the, you know, me being an ER doc, right? I mean, I might juggle ten, 20, 30 patients at once. It was very algorithmic. If this, do this, if this, do this, and we're just, you know, literally running around putting out fires, right? So I guess I can go that fast if I want to.

Todd: Right. But ultimately, that's not how medicine can be. Practice. If you're really focusing on prevention, like there are a lot of times I'll say to the patient, you know, you have this problem, this problem, I need to do some research. I need to take a few minutes. I need to talk to some experts. I need to look at the medical literature before I can give you an answer, because the amount of information available is just almost overwhelming.

Todd: And there's no other way to keep up with that. So a lot of what I do is it actually even with the patients, but it's behind the scenes on behalf of the patients. And the traditional docs don't have that kind of time.

Brent: Yeah. It's so interesting. It reminds me I'd forgotten about this. We were at the emergency room, actually, at Boulder Community with our my, my daughter's eight now, but maybe she was 6 or 7. She had this really nagging stomach ache that wouldn't go away. And so we're in the emergency room and they can't figure out what it is.

Brent: And the emergency room Doc's like, well, we can do this like pretty invasive procedure to like basically get more information. But there was this undertone of like, don't do it. Basically, he's got to throw up his hands and say, I only have so many tools at my disposal in this setting, and it's not the ideal set of tools.

Brent: So I'm now reaching for a tool. Maybe it finds the answer, but it might be an unnecessary treatment that's pretty invasive. We ultimately decided not to do it and the stomach ache went away. But it was why case? So I could tell the doc was just operating with one hand behind his back. He just only had so much at his disposal, and there was some very traumatic thing that had happened while we were there.

Brent: You know, the ambulances had showed up. And so his attention was he was distracted. And so there's a spectrum. The emergency room would be on one end of the spectrum. The concierge doc is at the other end, and then the traditional doc is somewhere in the middle.

Todd: Yeah, I think that's a good I think it's a good way, a good way to look at it. And, you know, and part of why I got into this was, you know, quite honestly, way back when it was like, gosh, you know, I see these people in the emergency department and I could fix this stuff. Like, I could have helped you before you got to the emergency department.

Todd: I mean, you have to engage in my help, you know, you can lead a horse to water and all that, but I still could have given a strategy to prevent you from coming in with whatever your stroke, your heart attack, potentially. I could never say 100%. I would, I could avoid it, but I certainly could help you try and avoid it.

Brent: Let's stay on the cardiovascular health quickly. And just how how you think about this as a private doc. So the CT scan is looking at the soft plaque buildup at the heart. And it's giving us a big picture of the heart. I mean, what exactly is it? Is it doing. Yeah, I.

Todd: Think the Ccta, which stands for CT coronary angiography. So you're using a CT scanner to look at the coronary arteries. And I think what people don't understand is a lot of people saying, well the the heart is filled with blood. So it just gets its blood from the heart, from the, blood supply, from what it pumps. But the heart is a muscle, just like a quadriceps or a bicep.

Todd: It requires blood and oxygen. And if your heart is my fist and you have three major vessels that sit on the surface of the heart, and those are actually the blood supply of the heart, and those are called the coronary arteries. And if you have obstruction of those, you get things like chest pain, shortness of breath, etc. if a plaque ruptures, you get, a heart attack.

Todd: So our goal in doing the ccta is to look at not necessarily just the soft plaque that you mentioned, but it looks at the soft plaque and the hard plaque. So a can SEOM score is calcified or hard plaque. It only gives you information on the calcified or hard plaque. It's a non contrast CT scan. When you use contrast and look at the coronary arteries, you're actually analyzing all different types of soft plaque.

Todd: Hard plaque. It also tells you the geography of, you know, where is the plaque. Is it in a place that if something happens, it's really bad or is it in a different place? And it also gives you information about the structure of the heart, right. The valves, how powerful the heart pumps and other kind of features that are important.

Todd: We use then that study to, upload to an artificial intelligence platform, which gives us this sort of pictorial, which allows me to look at the arteries in 360 degrees, you know, spin them all around, look at all these different factors and sizes. So it's really like going to the cath lab at that point. And that's when we can see everything about your coronary arteries and make decisions.

Todd: So it's like the calcium score on steroids. So to speak. It's just like calcium score is part of that. But it's much better and much more information.

Brent: Who would you recommend a CC to to this, assuming they can afford it or not. You know, who would you recommend it to? Like? What are you looking for in the health profile?

Todd: Well, you know, quite honestly, you could make an argument that you know, anyone in their 30s or 40s could have an initial ccta to establish whether or not they have disease. And the reason a reason I say that, Brent, is, you know, we use the term surrogate markers, right? So when I'm looking at your lipids or I talk about your, you know, on paper, what's your LDL, what's your apob, what's your lipo little way.

Todd: Right. And then I look at that and then I talk about your family history and you know, and do you smoke three packs of Lucky's a day or not? Do you have diabetes or not? Do you have high blood pressure or not? Those are all, quote, surrogate markers. And we can make an educated guesses based on that information.

Todd: But the real what we call phenotype of the disease, really looking at what all those surrogate markers do in you is really looking at your coronary arteries. So another way to say that is that about 20% of people with horrible looking lipids on paper don't have much cardiovascular disease, and about 20% of people with the most beautiful looking lipids on paper can have terrible disease.

Todd: And there's even a Dutch study that looked at people with zero calcium scores, and they took those people. And about a quarter of those people had pretty significant soft plaque, because, again, calcium only looks at hard plaque. And soft plaque is actually more dangerous than heart plaque in terms of the propensity for it to rupture and cause a heart attack.

Todd: So if you ask me, and if everyone had the money or the test was offered for free, I would literally do it. You know, most people in their 30s or for is to see if they're starting to develop heart disease and then mitigate their risk moving forward over the next, you know, 50 years.

Brent: Okay. Yeah. This was actually the reason it had come to my attention, was I was talking to somebody who all of their markers were healthy, but they just felt a little bit off and they went and got a CTA and they were I'm gonna get the terminology wrong here. But they were like mostly blocked. The doc basically said, oh, you would have had a heart attack in the next six week, six weeks had you not had we not dealt with this now and I got a stent and nothing ever.

Brent: There was a calcium score of zero. And, you know, the lipids were relatively healthy.

Todd: You are preaching to the choir. I will tell you this, the number one, the first sign of heart disease globally is a heart attack. That's not good. We need to reverse that. The first sign of heart disease is someone like me looking at your heart and deciding if, you know, we need to do something. I had a similar, patient, she's actually a nurse from the ER who came to me about a year ago.

Todd: She lives up a 10,000. She walks her dogs all the time. All this kind of stuff. I do this scan on her. She really doesn't have bad lipids and doesn't have any history, doesn't smoke. And she's very healthy, generally speaking. And she has a 98% blockage of one of her main arteries. She goes to the Cass lab and gets a stent.

Todd: She had zero symptoms. I mean, that morning she was walking around at 10,000ft for several miles. But she was a walking, you know, risk of heart attack. So again, you can't tell by symptoms and you can't tell by lipids on a piece of paper. Because again, this is the number one killer globally, right? It's cardiovascular disease. We should be looking pretty hard to find cardiovascular disease that that's one of the ways like as a concierge doc, I can help people get that figured out.

Brent: The CT scan. You need to find a doc who will refer you. It tends to be call it 2020 $500 with this eye piece that that companies call Cleary. Right? Or clearly,

Todd: Clearly health and they're one of the there's a there are some several companies I think they're sort of at the forefront. And that's the one that I tend to use. Yes. Okay.

Brent: So that's about $2,500 out of pocket. Now, the CT scan that just looks at the calcium score is less expensive, less invasive. We talk about that quickly, but it also tends to be cash pay.

Todd: I think it does generally tend to be cash pay. It's much less expensive. It can be it can be obtained for a few hundred bucks. It really is only though, telling you, as I was saying about the calcium. So it's telling you about one type of plaque, calcified plaque. It's not giving you any information about soft plaque. It's not giving you any information about the amount of blockage that that plaque is causing.

Todd: Right. So you're really looking at two big picture things. You're looking at the amount of plaque or the plaque burden that you have in your corner areas. And you're also looking at what is that plaque doing right. If you have all your plaque in one place and it's causing a huge blockage versus you have the same amount of plaque, but it's spread out a little smidge everywhere.

Todd: Those are two different scenarios. So the calcium score really just tells us about calcium. It does have excellent. One of the prime examiners, and investigators for calcium scores is a guy that Matthew boot off. He's from UCLA and preventative, cardiovascular health. He's very intelligent guy. And he has shown that if you have a zero calcium score, your risk of having a heart attack in the next, you know, several years, you can say five years, ten years.

Todd: And the stuff in statistics is very low. Okay. But to me it's more than, are you having a heart attack in the next ten years? To me, it's how can I prevent you from accumulating plaque the rest of your life, right? How can I protect you? So, I think the calcium score is important. And I think the calcium score is a good sort of second choice, but it's not nearly as robust.

Todd: Information set a data set as I would get from the SEC to in that in that clearly AI platform.

Brent: So the way I might summarize it is the calcium score. Few hundred dollars I went in, it was easy. It was like 15 minutes. The worst part about it was I have some chest hair. They shaved it, some chest hair. I think for the electron, whatever they were putting on their EKG. For the EKG, I had a calcium score of zero.

Brent: Okay, that's better than nothing. If you haven't done that and your middle age or above, do it now if you can afford the ccta, the ccta includes the calcium score. Like you don't need to do both.

Todd: You do not need to do both. Yeah. The calcium, the CT CTAs, just a more comprehensive type of test includes the calcium score. Yes.

Brent: And then how do you think about over screening? I think what's been interesting for me, as I've, as I've gone really deep on longevity generally is more screening not always better. Right. So there are, you know, there are cases, you know, we put the recommendations for colon screening or lung screening, whatever you want to call there at a particular age and risk profile for pretty good reasons that aren't just purely economic, because there are, you know, there are side effects of the biopsies that you might need to do or side effects of treatment.

Brent: You know, prostate cancer, there's some overtreatment that happens in, in prostate cancer. But it seems like with the CTA and the calcium score that the risks of over screening are pretty low.

Todd: Yes. Now there's always a chance, just like any. So you're talking about the statistical concept of false positives, right? You come up with, you find something incidentally, maybe and you got to figure out what that something is. So there's always a chance if you do a CT, you know, they might find a lung nodule, right. Because they have to, you know, and you need to be like, okay, well, we put it, we categorize it, then it's not necessarily a bad thing when they find a one nodule, because we can repeat it, you know, scan in six months and look at it.

Todd: Or, you know, if you're a smoker, maybe we do something more. But the long and short of it is, yeah, you can find some stuff with even a calcium score or CT. You're right. You're sort of distinguishing it from something like, okay, you have a, a mass on your adrenal gland, and we have to do a surgery to figure out what it is.

Todd: There's not nothing's going to happen like that. And there's a very low risk of false positives. There's a very low risk that you're going to, you know, end up in the cath lab because of a test like this. If it's not real, you know. So, yeah, I think it's a really nice statistical bang for the buck also.

Todd: Right. Because false positives are a big deal like some of these cancer tests that people are promoting. I mean, there's a lot of false positives. So the other way to look at as is sort of the negative predictive value, in other words, if you have totally clean coronary arteries at age 43, no matter what your lipids look like on paper, no matter what your family history is, that's awesome.

Todd: We'll look again in five years or more because you didn't build up any plaque in 43 years, you're not going to build it up in, you know, the next 20 years most likely. So that's that's also really good information. Okay.

Brent: So basically the unintended consequences of the screening related to the ccta and the and the screening for the calcium score. It's not that they're they're non-existent. They're pretty low and pretty good bang for the buck as you say.

Todd: Yeah I think cost benefit analysis is the benefit far outweighs the risk of those. Thanks.

Brent: Yeah okay. Now let's let's transition to the full body scan. So the pre Nuvo would be the scan. This also 20 $503,000. It's a full body MRI. That's basically just look you know you're not going in with some intention of oh I got a pain here. Let's just do a scan of my entire body and let's let's see what we find.

Brent: How often are you recommending that? How do you think about the cost benefit analysis of something like that.

Todd: Yeah, that so that's a really good question because more and more of these tests are coming up. Right. There's a blood test, called you know, gallery that's used for, you know, screening for cancers is the pre nouveau, which is the MRI scan. So this is a very kind of tricky topic, but let me do my best to kind of boil it down for everyone.

Todd: What people have to recognize is this concept of false positives. And false negatives okay. So false positives. That means I do a total body MRI on you and I see something, but I don't really know what it is, but it's not supposed to be there. Again, I'll use the example of a mass on your adrenal gland which is attached to your kidney.

Todd: It's really difficult at that point to start figuring out what that mass might be. I mean, maybe there's more testing you need to be exposed to. Maybe there's more, even something invasive, like a biopsy or a surgical procedure. A lap or scope or something to figure out what's going on. Now. It also causes a lot of health anxiety.

Todd: Right? If I told you. Oh, yeah. Hey, Brent, this study looks fabulous. Except you got this thing on your drain. Well, I don't know what the heck it is. Could be cancer. Could be nothing. Who knows what. So the question is usually people are like, well, go find out what that is, because I don't want that level of health anxiety knowing that I have this mass and, you know, etc..

Todd: So we usually, leads to further testing and further money spread and the false positive rates of these tests, like the for Nova are significant. I mean, they could almost be up to 40, 50% in a lot of studies. Okay. Now the other side of the coin is true. If it finds a mass in your pancreas and it's really early, boy, it might have saved your life because pancreatic cancer is terrible and aggressive.

Todd: And there are those only people that do really well is when we find it early. Incidentally. And they have a surgical procedure. But the other side that people don't really think about with this test is the false negatives, the false sense of hope that you do not have a cancer, let's say. So if I'm screening a woman who is at risk for breast cancer because let's say family history, and we decide that we're going to do traditional mammography, which is, you know, x ray, but we're also going to do MRIs every six months that kind of alternate, because she sits such a high risk that I want to be sure that we are using two

Todd: modalities to, to, to make sure we don't miss cancer. Well, the way I would order that test is by a with and without contrast MRI. That is the gold standard to look at a woman's breast or a male breast who is at risk for breast cancer and say you do not have breast cancer. This is the gold standard.

Todd: Well, the pre neuro test doesn't use any contrast. So when they come at the end of the test and they say oh you don't have any breast cancer, it's not really true because it's not the gold standard way to look for breast cancer. So that's a false negative. That's not necessarily a false negative. But it could be a false sense of hope.

Todd: Right. You may have a breast cancer that it doesn't see. You may not. But the test is saying don't worry about it. You don't have it. So I don't think those types of tests are ready for prime time. If you really look at the literature, they don't do that great job of determining, cancers in stage one or stage two that are really early.

Todd: There's also no proof that, if they find a cancer, it saves lives. For example, the gallery test is now being tested in that, national health system in England. And, you know, they're applying it to, you know, hundreds of thousands of people or something. And they're trying to say, does the test really save lives? Does it really work, you know, to find cancer?

Todd: So we don't have that data. And I think it's not quite prime time. And to answer your first question, I don't recommend it in my patients very often. You mentioned another thing that's really important, which is you're just screening people who don't have any problem. So this is another statistical concept that's a little tricky, but it's called pretest probability.

Todd: If you have a family history of prostate cancer, every male in your family had prostate cancer. You know, and you're 43. I would do an MRI of your prostate with and without contrast to look at it, look for prostate cancer, potentially as a screening modality. Now, if I did that same test on everybody that walked down the street who was 43 years old without a family history, then I'm just kind of going fishing and murky water and, you know, throwing some bait in and hoping something bites my hook.

Todd: What we're trying to do is be a little more sniper, like, if you will, and choose people who are at higher risk for the tests because that actually makes the test statistically better. In other words, if I do a head CT scan looking for bleeding on everyone who's walking down the street, it's not as good a test as if I only looked at people who fell off their bike without a helmet and hit their head.

Todd: I have a much higher chance of seeing the actual bleeding, so that's also important. And when they looked at some of these tests, they actually looked at groups of people who had a higher risk of cancer, for example, and used them in these studies and tests still aren't really great. So not there's not really any ecology, societies that are recommending, specific oncologists who I've talked to, who I consider to be really intelligent, are not recommending, it causes a lot of chaos right now, but I think they're going to get better and better.

Brent: Yeah. I think when I had originally started thinking about this question, I had thought I was going to get some broken health care system response like, well, not everybody can afford, and it'll overload the health care system. And so we don't recommend them. And my reaction to that would be, well, I don't care about me as an individual if it would be helpful for me as an individual and I can afford it, I want to do it.

Brent: But the way I've come to understand it, I really think about it in these three buckets because for me at least, the term false positive is a little bit misleading. False positive, I would say you tell me I have cancer, but I actually don't have cancer. The rate of that is pretty low with these tests. But there's the second piece, which is ambiguous results.

Brent: We've identified something and we don't know what it is. And you've just referred to that as false positive. But to me it's something slightly different, at least in my mind, which is no, it's something has been identified. There's not a claim as to what it is, but what you know is that you don't know what it is. There is something there, and you don't know what it is going in and figuring out what it is that can carry its own set of consequences.

Brent: Okay, if you have to cut me open and you've got a you've got to, you know, biopsy, you got to take a piece of tissue out of the adrenal gland, okay. That is not without its trauma to my body. Things can go wrong in those kind of procedures. And so there's risks there. And that's not to mention the psychological pain that I incur, you know, thinking that maybe I do have cancer.

Brent: And then there's the third piece, which is the false negatives, which is I actually do have cancer, but the screening is saying that I don't, which in this case you're saying is not really a false negative. It's a false sense of security, because none of these tests say you don't have cancer. They say nothing detected. It's a false sense of security.

Brent: And then maybe I should be doing a more proper screening for the breast cancer. But I feel like I spent $2,500 on this fancy scan. And so I don't need to. And I've got this. I've got this false sense of security. But what would what would your reaction be to somebody saying, like, I want to know as much as possible, and I'm going to be really smart about the way that I weigh the risks, because even though I don't have a family history of prostate cancer, if I'm the one person who's walking down the street and happens to get scanned, and you happen to find something that you wouldn't have found otherwise, well, great.

Brent: That makes all of the difference in the world to me. What would your response be to somebody saying, I'm going to think about it intelligently. I'm aware of all this stuff and like, I just want to.

Todd: Know, honestly, I have patients exactly like that. So it's not that I don't do the test or this test, but we just asked. We just have to have a realistic discussion like the one you and I are having and I have. Patients are like, you know, if we find something that we don't know what it is or whatever, then that's fine.

Todd: But I want to as much data about my body as I can get, and I want you as my doctor to help me analyze it and figure it out. And I'm not the type of person that's going to freak out. I realize these things can happen. They can find, you know, these unidentified objects, if you will, and we might have to deal with it.

Todd: So I definitely have a few pit, patients who have done both to produce a test and the gallery blood test, for, for cancer screenings. Unfortunately, quite honestly, they've come out, you know, negative. And so, you know, the negative predictive value is good. It makes those patients more comfortable. I think it's important for me to also realize as a, you know, as a physician, to not change their normal screening schedule.

Todd: Right? I'm not going to not do their colonoscopy or tell them, don't go to the dermatologist or tell, you know, if they have a negative pre nova test, for example. So it's some some added data, but I still maintain the same cancer screenings that I would normally do.

Brent: Okay. And then so on that topic let's let's switch to colon screening. So the current and we actually had this doctor Otis Brawley on the podcast, who is part of the team that had changed the recommendation on colon screenings from 50 to 45. But we continue to hear these really scary stories. I've got a friend of a friend at 38 having some GI distress, and then goes in and has advanced colon cancer and and dies a few weeks later, has a, you know, young child.

Brent: When do you recommend we're getting colon screens? It feels like for many people, doing it younger, even without a family history, might be better. But we've got concerns around perforation of the colon during those screenings and everything we just talked about. So how do you think about colon screening in particular?

Todd: I mean, it's a really good question. Obviously, colon cancer is one of the leading causes of cancer in the in the US, certainly and globally. And you're absolutely right. I'm not sure we know the exact reason, but the age of people being diagnosed with colon cancer sort of moving down into younger age groups. So we moved, as you alluded to, we moved the screening from starting at age 50 to age 45, recent, you know, over the last few years.

Todd: But this kind of ties back to our first question, which has to do is kind of, monetary stuff and insurance stuff. So no matter, it would take, you know, a tremendous amount of, I guess, momentum and effort to get you a colonoscopy at age 40, for example. So I had a guy who was, going to spend a year in Switzerland.

Todd: This is a patient of mine who's 44, and he's like, hey, I'm about to turn 45. I'm going to have a colon. I just want to do it a few months early. And if you think about that, right, it's not going to change how many times the insurance company pays for it or whatever. They absolutely 100% refuse. So he ended up having it closer to 46 because that's when he got back from Switzerland.

Todd: Right? So, so even a few months early, there was no buy in. Now, if he would have had a history of, you know, different things that can lead to colon cancer, we could have got that applied. But I think there's kind of a hedge test. And what I do in my practice is I utilize some of these other biomarker tests looking for, you know, DNA pieces of cancer and, one of the tests I think is really good is called the Cologuard plus test.

Todd: I guess I'm allowed to mention brand names. I don't, I don't have an association with Cologuard or clearly or anything else, but Cologuard plus is actually it looks at five different biomarkers and is sort of the DNA methylation and markers, that it looks for colon cancer. And it's about 95% sensitive for colorectal cancer. And it has a really good specificity.

Todd: So in other words, the false positives rate isn't that bad. It's about 90% specific. So and in this case it doesn't really matter about specificity. And let me tell you why. As opposed to if it comes up and says you have colon cancer, you have a positive cologuard test. The follow up test is a colon ask which now insurance will pay for.

Todd: The follow up test isn't like cutting your belly open and looking at your adrenal glands and taking out some nodules or something, right? So the follow up test for this really makes sense. So if people with any family history and anyone who hits about age 35, I actually have them just pay out of pocket for a cologuard test, it's a few hundred bucks.

Todd: A lot of times insurance will actually pay for that test. And it's a good in-between to the to the colonoscopy, quite frankly.

Brent: Why not cash pay for the colonoscopy this way? How much are they? You know, because it seems like in this case makes no sense. This guy should have gotten one. It's a big deal. So what? What does it cost to get a colonoscopy? You just cash paid it, you know.

Todd: I have no idea, but it's it. But, you know, you go in and you're in a there's an anesthesiologist there, you're taking a suite up in a, you know, basically an operating suite up at the GI center in the hospital. It's expensive. It's got to be. Yeah, it's in the tens of thousands, I would say, I don't know, or maybe I'm a little off, but the long and short of it is, it's not a few hundred bucks.

Todd: So if you have that kind of money. Yeah, you can schedule a cash pay colonoscopy, no question. But, I've never had anyone do that.

Brent: But basically what you're saying is like, look, maybe it should be a little earlier than 45, but like, this is one where the system is getting in the way and the circumvention of the system in the context of, you know, not being a billionaire and just cash paying for everything is a guard. It's a few hundred bucks. It tends to be pretty good.

Brent: But how does that you know, I feel like with colon cancer. So much of it is is finding precancerous polyps. And I would assume that cologuard does not do that.

Todd: It actually detects, so the Cologuard plus, according to the new studies, is supposed to detect the, it's a pretty high precancerous polyp precision rate. If those precancerous lesions are sort of high, what we call high grade dysplasia. So if they're about to be sort of cancerous and they're kind of really pre just pre-cancerous, it will pick those up if they're like, you know, going to be cancer in ten years.

Todd: It's probably not going to pick those up. So you're right. The gold standard the best test is a traditional colonoscopy. They remove polyps of the 100% of polyps that they remove every polyp they see. They remove about 20% of those has are destined to potentially be cancerous. So 80% of the polyps they remove, they could have left a man and nothing would have happened.

Todd: But it's just like going to the dermatologists and, you know, burning some barnacles, you know, off your skin so that they don't turn into cancer. So you're right, it's a much better test. But the hedges is how do you get how do I get my patients to do early screening for a disease that kills lots of people? The Cologuard is a home test.

Todd: You know, your wife's some poop on a on a saying and email it back in and they give you an analysis and it's pretty darn good. And if that analysis comes back positive, now I have grounds to go to the insurance company and say they need a traditional colonoscopy. So and I even use it in between sometimes. Right.

Todd: Because again, insurance companies pick intervals. So if you have, a bunch of polyps there, say maybe depending on different things, come back in five years for a colonoscopy. Well, I'm like, boy, maybe in two years we should do a cologuard two and a half year. Like in between. Maybe we should do a cologuard. You know, just because insurance has to come back in five years, it doesn't really fit you as an individual.

Todd: You have a really high risk of colon cancer, you know, that kind of thing. So I use it as an in-between interval test, and I use it as an early test, because that's the only way I can get this sort of screening done at this point.

Brent: Okay. So we've touched on, cardiovascular disease. You touched a little bit on a little bit on cancer. So let's just hit, diabetes and some of the more progressive, you know, treatments here that are also just used for longevity generally. So how do you think about metformin GLP ones in the context of like non-diabetic applications? I just want to be healthier and I want to live longer.

Brent: And these seem they seem to be good for cardiovascular health and reduction of risk of diabetes. There seems to be some neuro neurodegenerative risk reduction. So how in your practice are you thinking about things like metformin and I don't know, low dosing GLP ones.

Todd: Well I think quite I think quite a bit about it. I mean, at first I think the background here is that if someone is at risk for cardiovascular disease, which as we stated, is the number one killer globally of people and they have diabetes, that's like a synergistic disaster. Basically it makes the cardiovascular risk worse. The diabetes keeps getting worse.

Todd: And you know, and you're talking about it traditionally and you're talking about someone who's my age, who is overweight, who has a crappy diet, who doesn't exercise, who has a lot of as good as a, you know, those kinds of things. Okay. So that's the kind of patient we're talking about in, in a sort of a traditional setting.

Todd: I move it up again, sort of like I do a lot of things and I do some very specific screening for prediabetes and diabetes. So I look at the fasting blood sugar level, which is a common thing to look for in the labs. And then I look also at the insulin level, which is not a common thing to look for because generally speaking, your insulin levels start to shoot up before, you really turn into like a pre diabetic or diabetic.

Todd: So it's kind of an early warning sign. And then I look at the hemoglobin A1, see which is a three month average of blood sugar. And that's kind of our traditional marker of prediabetes and diabetes. And I'm a big fan of treating prediabetes really aggressively. So I do use metformin. And metformin has a few benefits right. There are some studies that show it might be a component in longevity studies, although that may be slightly disproven recently.

Todd: It's unclear. But metformin basically helps you control blood sugars, helps you be more sensitive to the insulin you do secrete. Basically, insulin comes from the pancreas and insulin controls blood sugar. And the analogy I give people, if you're cranking out insulin, it's like driving your car in first gear on the freeway. That engine's just going to explode, right?

Todd: You have to be able to demand less insulin out of it. You don't have any more gears. You just can't keep producing that amount of insulin. So what we do is we make the insulin. You do produce more sensitive and metformin does that. The GLP one agonists and the Alt two inhibitors are sort of the next classes as drugs.

Todd: And if anyone has any additional percent body fat of of significance, you know, but even like ten, 15 pounds. And if people have pre-diabetes and it's all those, those GLP one agonist are also approved for cardiovascular protection in diabetics that are produced for they're approved for cardiovascular protection. If you've had a heart attack or stroke or even for, approved for sleep apnea and obese people, that, of course, are approved for obesity.

Todd: So they do a lot of good things and they have kidney protection. They protect your kidneys because a lot of times these people who don't don't have kidney function. Okay. So the answer is I'm very aggressive with them. So what I'll do is I'll start people on an escalating dose of a GLP one inhibitor. I'll get them down to what we call their goal or their fighting weight, while at the same time, controlling their blood sugar.

Todd: And of course it helps, right? If you lose weight without doing anything else, your diabetes risk goes down. So we're kind of attacking it from a number of angles. And then I do use, I try and taper them back down. And if it's a point where they start gaining weight, then I kind of keep them at their maintenance dose, and that might be dosing it every other week instead of every week, or just keeping them on a low sort of maintenance dose.

Todd: I think there's plenty of literature that shows those drugs protect people from diabetes, cardiovascular disease, and putting on a bunch of weight, which, you know, again, if I put those three things together, your risk explodes to have a heart attack or stroke. So I'm very aggressive with those medicines, and I'm a big believer in using those medicines to control people's risk factors.

Brent: And what are the side effects?

Todd: The main side effects are gastrointestinal. You know, it was metformin. It's, a gastro. And to me, I think of metformin as kind of a first line sort of treatment. I may start that if there's not a lot of weight to lose and, you know, you're a little pre-diabetic, but if you really have a lot of weight to, you know, I jump to the bigger guns.

Todd: Mr.. The GLP one agonists. So it's really gastrointestinal again with those. And they can actually even slow your God. People can get nausea, people can get constipation. Others. Thanks. The product from Lilly actually has less side effect profile. So I've had much better luck in the literature bears that out. And in addition, it, causes more weight loss.

Todd: So I'm particularly really using the manure Zepp found, which is the term appetite is the chemical name that seems to have a better side effect profile. And the way I mitigate side effects is by really slowly stepping people up. So I started a really low dose once a week for a month, a little bit higher dose once a week for a month, a little bit higher dose until we get them to a weight loss plateau.

Todd: Then they start losing weight and then I back it down. If you start at a high dose out of the blocks, lots of people are going to have side effects. So I've had great loss doing it that way.

Brent: Do you think there's benefit to these outside of the context of risk factors? I mean, so if somebody comes in and they're, you know, let's just say they're A1, see, is on the higher end of normal. They're not overweight, but they just want to be as healthy as possible. Are you considering a metformin or a GLP one and or a low dose GOP one in cases like that?

Todd: Yeah, there's people that asked me about it and I definitely would consider, consider metformin. I do have people on it, you know, for for that purpose just to keep them, healthier. In terms of helping to control their sugars a little bit, they're kind of borderline. Maybe they don't need to lose a lot of weight. Absolutely.

Todd: The GLP ones. I mean, I think the issue with that is, again, it's sort of cost. They're not cheap if you're paying cash. So I try and, you know, just have a discussion with my patient. Like you said I have some patients don't care what they spend. They want the best thing that I can give them or advise them to take.

Todd: And that would be a GLP one agonist in this particular situation. I mean, there's no question if you look at studies on population based studies on healthspan and lifespan and everything else, if you're not fat moving through life, you've already way ahead of the game. Quite honestly, a lot of it's that simple, but it's hard for people to do so.

Todd: I help them do that.

Brent: I just have a general skepticism of, you know, I was somebody who got put on a bunch of meds for bipolar when I was young, and I was just a wild teenager. I don't, you know, there's nothing wrong with bipolar, but I'm not bipolar. And one of them was this antipsychotic called Seroquel that it, like, just took forever to learn how to sleep normally because I was reliant on Seroquel.

Brent: And so I have this disdain for like just kind of throw pills at the saying, and they're somewhere in the back of my mind, I'm like, are we going to run into this same thing with, you know, the Ozempic and the GLP one? We're down the road. We're like, we were a little bit too loose with those, but it sounds like you don't feel that way.

Brent: Like, like, how do you think about, you know, what if over the long term, we, we feel like, maybe we were we were doing too much of it.

Todd: If you're trying to get a six back and you to lose 5 pounds, there's nothing else going on. That is not who I offer that medicine to, right? I offer that medicine to people who could benefit from losing weight, improving their sugars. So then I feel like that the benefit, the long term benefit of keeping sugars under control or keeping weight under control far outweighs the risk, because we've had people on these type of droughts for years and years and years and years, and it basically just shows that it decreases the risk of cardiovascular disease and diabetes.

Todd: So I think that's a pretty good thing to do. But again, yeah, you got to pick your you got to pick the right patient. Like I said, you know. So like someone when people come to me I do a lot of hormone management. You know people come to me and they have normal hormones and they're like, I want to turn into, you know, whatever, Arnold Schwarzenegger tomorrow, you know, like, I don't take normal and make it super normal.

Todd: I take subnormal and make it normal, you know? So I think people need to understand that it's up to the doctor to, to be, kind of a good steward of the medicines and use them when the benefit outweighs the risk.

Brent: Great. And then where can we find you? If people want to know more about your practice or you. Where do we find you?

Todd: Yeah. So I'm here. I'm here in Boulder. And I, have a bunch of patients, actually, all over the country. I consult on people all over the country. And you can just go to, Dorfman, md.com, and that's my website. And, you can call the office. The numbers are on there. And, I'm happy to talk to you and see if it's a good fit.

Todd: If you're interested in talking to me, there's no obligation or anything I can help you figure out if we should work together or not.

Brent: Doctor Todd Dorfman, thank you so much for joining.

Todd: Thanks for having me. I really enjoyed it.

Brent: Death clock is recorded in Boulder, Colorado, sometime, San Francisco, California, produced by Patrick Gudino, music by Patrick Lee, and hosted by Yours truly. Brent Franson, founder and CEO of Clark.