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The Next Generation Physical Exam

Doctors who work outside the insurance reimbursement system – concierge docs or age management/functional medicine docs -- can afford the luxury of spending enough time with their patients to build rapport and trust. But when it comes to everyday health, what is the quality of the diagnostic information they provide?

All too often, frankly, it’s the same battery of diagnostic tests that the hurried and harassed conventional primary doc has to offer during an annual physical, that same annual physical that in study after study has shown to confer no health advantage on the conscientious patient as compared to patients who check in with their doctors at irregular intervals or only when they’re sick.

How can this be so?

Even doctors who want to practice something better than “conventional” medicine are mostly locked in a binary way of thinking: healthy/sick, normal risk/high risk. If a patient’s lipids or blood pressure or glucose isn’t outside the lab reference range, he or she gets the equivalent of a lollypop, the “keep up the good work” pat on the head. If one or more tests fall outside the range, then and only then does the doctor go to work – usually generic admonishments to eat and exercise better and maybe the prescription pad comes out.

So, the “healthy” patients get nothing, they might as well have skipped the visit, and the less fortunate patients get a wake-up call, but it comes late in the game after a disease process may have had a chance to sink in its teeth.

What the conventional system lacks is an evidence-based approach to provide a good early warning system, to get a sense of when and at what rate a “healthy” patient is headed toward “high-risk” or “sick” status. It knows the outcome – after age 40 , the majority of people in the developed world are on at least one medication for a chronic condition like atherosclerosis or hypertension or type 2 diabetes. But evidently not much about how to prevent it at an early enough stage that it can be reversed without significant consequences.

Conventional medicine also lacks diagnostic data that’s tailored to the individual patient. We might tell a patient they’re at 15 % higher risk of heart attack because they have an LDL of 166. Well, maybe. But that’s average risk that researchers derive from pooling the results from life histories of thousands or even hundreds of thousands of people in population studies. What does it mean for your patient? A good physician depends on his clinical judgment to appreciate that the number means one thing for a patient who’s 50 lbs. overweight and whose father died at 50 from a heart attack. And something else again for the patient with reassuring family history and a healthy lifestyle. But how to quantify that? How to weight all the patient’s risk factors and decide which problems require a more aggressive lifestyle intervention and possibly a pharmaceutical prescription and which don’t?

PhysioAge was developed by Dr. Joseph Raffaele, Cornell-trained internist turned Manhattan age-management specialist working with a Stanford University biostatistician, who decided things needed to be done differently. The PhysioAge program makes use of an innovative web-based application that allows the doctor to collate all the patients diagnostic info, the conventional ones as well as PhysioAge-specific, into one easy-to-follow report that the patient has ready access to on-line, at his or her own proprietary account, or for that matter, projected on the doctor’s office wall during patient consults, a kind of PowerPoint for an audience of one. But as compelling as this technology is (and it is very compelling, patients get grades instead of just indecipherable lab values), PhysioAge’s diagnostic tests themselves represent an even more profound paradigm shift.

PhysioAge looks at sickness and health through the prism of aging. Every doctor understands that illness – that is, the most common illnesses that cripple or kill most of us in the developed world, from heart disease to Alzheimer’s – is intimately bound up with aging. The term we often use, “diseases of aging,” says as much. But whereas conventional medicine waits for disease symptoms or risk factors to manifest with age – as they almost surely will – PhysioAge has assembled the diagnostic tools to measure the aging process in our key physiological systems and to track it over time. In effect, it has replaced the “risk factor” approach with “biomarkers of aging” approach. These biomarkers are measurable aspects of our physiology which, according to a huge literature of academic research, strongly correlate with longevity much more powerfully than the grab bag of diagnostic tests on offer at a typical physical which, whatever their individual merit, don't give a coherent picture of how the patient is really doing. PhysioAge has assembled a basket of six such biomarkers, using diagnostic technology that has been validated in academic studies but that you won't find in your internist's office, to provide a deeper dive into the cardiovascular, pulmonary, neurological, dermatologic, as well as immune system and telomere length. While a conventional “risk factor” like high LDL is factored into the diagnostic “big picture,” it pales in importance to the data generated by the PhysioAge-specific test for cardiovascular function, measured on the FDA-approved SphygmoCor device, which generates data on arterial stiffness – how smoothly the cardiovascular system is actually pumping blood throughout the body.

Generally speaking, we know that from about age 30 on, most systems in the body age at roughly the same rate, losing about 1-2 % of functional capacity every year. PhysioAge gives you a far more precise read-out for each individual patient, and a road map for how and when and where to intervene, with a targeted plan that may include diet and exercise guidance, supplements, stress reduction, hormonal therapies, pharmaceutical drugs. Call it the “next-generation physical.”

Taken together, CardioAge, PulmoAge, NeuroAge, CutoAge, ImmunoAge, and TelomerAge give the clinician the ability to “look under the hood.” You’re able to assess how slowly or quickly your patient is losing function in each system, tracking that precisely over time, and comparing those numbers to a national and growing global data base of a same-age cohort. The faster any one system is losing ground, the faster your patient is headed for disease and the sooner you and he need to intervene.

So yes, aging is an inevitable fact of biological life. But bad aging isn’t. Some of us are genetically gifted and make the right lifestyle choices without being prompted. For everyone else, the less lucky majority, the PhysioAge approach offers the best and most scientifically-grounded approach to maximizing “healthspan.” We now have the ability to identify and shore up the weak links in a patient’s physiological functioning before they break down and usher in chronic disease, as well, the ability to measure the effectiveness of lifestyle changes and medical interventions according to how they affect the biomarkers, a whole-body barometer if you will.

As Dr. Raffaele says, “if you understand how you’re aging, you can slow it down.”

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