David Borenstein, M.D. is an integrative physician in private practice in New York City. He specializes in rehabilitative medicine, thyroid, adrenal and reproductive hormone balance. This is one in a series of interviews with practitioners who treat thyroid disease from varying perspectives and approaches.
Mary: Can you share a bit about your educational background?
David: I attended medical school in Israel, at the Technion Faculty of Medicine in Haifa. I returned to the U.S. to do my internship at Staten Island University Hospital and my residency at Stony Brook University Hospital in New York. I've done additional training in radiation oncology and acupuncture, and am certified with both the American Academy of Anti-Aging Medicine and the American Academy of Environmental Medicine. I've been in practice for more than a decade and now have a private practice in holistic, integrative and rehabilitative medicine in Manhattan.
Mary:When did you decide to become a physician?
David: Honestly, I never knew a time when I didn't want to be physician. From when I was a little child, I always knew in my heart that being a doctor was my goal. I couldn't see myself doing anything else.
Mary: Your training was in conventional medicine. How did you end up becoming an "integrative" physician?
David: Like many physicians, I completed my medical education with a bias against integrative medicine. But fresh out of my residency, I needed to supplement my income while I was building up my practice. So I worked at an integrative medical center a few days a week. Slowly, I started to apply the things I was learning - and saw that integrative treatments were working. I was so impressed with how effective many of these treatments were that I eventually did additional training in integrative medicine and incorporated more integrative approaches into my overall philosophy.
Mary:What is your favorite part about being a doctor?
David: For me, the greatest feeling of accomplishment comes from helping make real changes in people's lives, especially after they've been through a difficult time. Many come to me after they've seen numerous practitioners and had little or no improvement - or they're even worse than when they started. We work together to help them get properly diagnosed and apply integrative treatments. They improve tremendously. Knowing that I've helped them is the greatest feeling in the world.
Mary: What is the most frustrating part of being a doctor for you?
David: It has to be dealing with the bureaucracy of medicine. Because I am one of the rare integrative physicians who take insurance, when I see a patient who is using insurance to pay, I am facing time limitations. Insurance doesn't allow me to spend as much time as I would like to with a patient. I would love to spend an hour with every patient, but insurance pays only for the first seven to eight minutes of a visit; after that, I'm working for free. That's frustrating.
Mary: What do you feel that a holistic or integrative doctor like yourself brings to thyroid care, in contrast to conventional practitioners?
David: As an integrative physician, I'm making a diagnosis, recommending treatment and monitoring results based not only on a few lab results, but also on a number of diagnostic criteria and tests, detailed medical history and symptoms. In addition, I am able and willing to consider a much wider variety of treatment options. With hypothyroidism, for example, the typical conventional doctor looks at the TSH test and prescribes levothyroxine. They do not go beyond this narrow approach.
I regularly evaluate not only the TSH test, but Free T3, Free T4 and Reverse T3 and antibodies. I also carefully look for other health issues - like adrenal dysfunction and gut disturbances - that are associated with, or may complicate, the thyroid situation.
Mary: What is your favorite kind of patient?
David: Some of my favorite patients come in very prepared and knowledgeable. They're concise, they explain their symptoms and history proactively. When I tell them I'm going to order this or that test, they know exactly what I'm talking about. They are informed, and that makes the appointment more productive because we have more time to explore and explain the treatments.
Mary: Do you have any tips to make a visit more productive for you and your patients?
David: I always encourage patients to bring a pen and pencil and take notes during an appointment. I've also found that it can be very helpful for patients to bring along someone they trust as an advocate. That person can help by asking questions that the patient might forget, and even take notes. I've even had an entire family sit in on an appointment.
Mary: Some physicians seem to resent patients who come to an appointment with all sorts of printed studies and articles. Some even refer to them derisively as "googlers" or "petits papiers" (little papers) patients. What are your thoughts about this?
David: I have no problem with patients who come in with stacks of articles and research, unless it's going to take too much time from their visit. The most important part of the visit is for me to get to know the patient, listen to them and understand their symptoms. So, if it's done judiciously, that's fine. A couple of pages are fine. But reams of paper will take away from the patient's time and doesn't serve either of us.
Mary: How do you feel about opinionated/empowered thyroid patients who come in with ideas about what they want, in terms of treatment?
David: My goal is to have a collaborative relationship with my patients. So while I appreciate patients who have preferences about what they want, our decisions have to make sense for them medically. For example, I've had many patients come in who feel strongly that they want natural desiccated thyroid for their hypothyroidism. And when I look at their test results, they have a high Free T4, a high Reverse T3 and a low Free T3. That's not the profile of a patient I typically want to put on Armour Thyroid. They require a tailored approach that may include a T3-only treatment or slow-release T3 and reduction in the T4.
Mary: When you see a woman who is suffering from fatigue, depression or mood changes, struggling to lose weight or other similar symptoms, besides blood tests, what process do you typically go through to get to a diagnosis?
David: For me, a thorough history and physical examination are crucial and will offer a great deal of information. I palpate the thyroid, feeling for enlargement and nodules. I check hair and eyebrows, looking for changes in texture and sparse or bare patches. I check the Achilles reflex, pulse and blood pressure. I want to hear about symptoms, look for signs of a low thyroid or other hormonal imbalances, and pay particular attention to such symptoms as fatigue, weight gain, brain fog, swelling, hair loss, brittle nails and constipation, among others.
I also ask patients about bloating, sugar cravings and sinus congestion - which are often seen in patients who have underlying yeast overgrowth. I ask about difficulty getting out of bed, higher energy at night, dark circles under the eyes, low blood pressure, exercise intolerance and salt cravings, which can be signs of an adrenal imbalance. I look for signs and symptoms of perimenopause and insulin resistance. And, of course, family history of thyroid and autoimmune disease in general. It’s no longer a surprise to me how many patients tell me that a mother or grandmother had some sort of thyroid disorder.
Mary: Do you think thyroid diagnosis and treatment have changed since you first went into practice. If so, how?
David: Among endocrinologists, I have seen little change in diagnosis and treatment. Like any field of medicine, it takes years before the findings and literature become applicable in clinical practice. There appears to be more openness among primary care and integrative physicians, however. Integrative doctors in particular seem to be more interested in, and open to, the latest thinking and findings.