Episode Transcript

Daniel Lobell: (00:00)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only, and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.

Daniel Lobell: (00:21)
Hello, and welcome once again to the Doctorpedia podcast. I’m your host, Daniel Lobell, and I’m very honored today to be on the line with Dr. Paul Scheinberg. How are you, Dr. Scheinberg?

Dr. Paul Scheinberg: (00:32)
Great Daniel, great to be at your place.

Daniel Lobell: (00:36)
Great to have you here. And I was thrilled to find out that you’re a listener of the podcast, before we started recording. And thank you for tuning in, it means a lot.

Dr. Paul Scheinberg: (00:46)
It’s been quite an eye-opener to, first of all, learn about the podcast all along. It’s my cure for insomnia sometimes at night, but it’s fascinating. It’s endless. Endless information.

Daniel Lobell: (00:59)
Yeah. Yeah. That’s something that I know that we’ll get into is that you are on a quest for information these days. So I’m glad that…

Dr. Paul Scheinberg: (01:09)
I am. It’s a lifelong journey.

Daniel Lobell: (01:10)
Your story is interesting. I got some background from you and you wrote that you wanted to be a doctor from the age of five years old. Before that, you had another ambition from age four to five, but that was the only other time you wanted to be something other than a doctor. What was that?

Dr. Paul Scheinberg: (01:29)
Oh yeah, when I was four, I wanted to be a fireman, but actually that was very transient because I knew I was going to be a doctor since I was a zygote, as you may recall, from basic biology. That’s the fertilized ovum. I really don’t think there was ever an alternative in my life. I knew always, and even at the age of three, before I was going to be a fireman, I was going to be a doctor. I think that the fireman thing probably came with part of being potty trained.

Daniel Lobell: (01:55)
Or maybe it’s just that you like putting out fires, which you wound up doing medically anyway.

Dr. Paul Scheinberg: (01:59)
In fact that’s what basically we all do, when we problem-solve, correct.

Daniel Lobell: (02:05)
So, your father is, or was, a doctor. What type of doctor?

Dr. Paul Scheinberg: (02:12)
So my dad was an internist in Brooklyn, where I was born. And ever since I was a little kid, I would see my father back in the old days when doctors made house calls and followed urgencies all the time. I would be awakened when the phone would ring in the middle of the night and he would throw his clothes on over his pajamas and run out the door. And I thought that was so neat. That was so cool to be called in the middle of the night to go out and see somebody’s emergency. My older brother, a year and a half senior to me, was a little smarter than I. He said ,”That really sucks. I’m never going to want to do that.” So it wasn’t that I was influenced by my parents, it was simply, I was turned on by that insanity. And my brother was not. And it pursued, because it continued. Even at the age of five and six, I was accompanying my dad on hospital rounds.

Daniel Lobell: (03:06)
Wow. Your dad was basically Batman to you as a kid. The signal went up.

Dr. Paul Scheinberg: (03:10)
He was Batman, yes. And I was Robin. And of course I got a lot of attention from the nurses. I realize actually my father got a lot of attention from the nurses too. And that may have had an influence on me being a doctor as well.

Daniel Lobell: (03:21)
What did your brother end up going into?

Dr. Paul Scheinberg: (03:23)
My brother’s an engineer. He became an electrical engineer and had a very steady career with developing computer programs for missile guidance systems and things that I never understood. I never understood anything he did.

Daniel Lobell: (03:37)
Okay. Well, he probably doesn’t understand what you do either, right?

Dr. Paul Scheinberg: (03:39)
Yeah, that’s correct. I have two sisters and they both married dermatologists. The joke that my dad gave, and this is no disrespect to dermatologists who I think do great work, but because my father felt that the intern is for the real thinking doctors, he would say that the girls married dermatologists instead of marrying real doctors. [Daniel chuckles] That’s just a little family joke.

Daniel Lobell: (04:04)
Well, you know, I had a dermatologist growing up and the joke we had with him was that you go into his office, before you could even tell him anything, he shot you with cortisone. So [Daniel chuckles] before you could even get the word “hello” out.

Dr. Paul Scheinberg: (04:19)
Absolutely. The old one in simplified dermatology was, “If it’s wet, you dry it. If it’s dry, you wet it. And if you don’t know, you use steroids.” [Daniel chuckles] It’s a little disrespectful to doctors who do dermatology. And I don’t want anybody listening in dermatology to be offended by that. But there is some humor. There was more humor about surgeons, too. My father being an internist always felt that he was a thinking doctor and the surgeons were the cutting doctor. And if you’re on an elevator and the doors are closing, the internist would of course take his hand out to block the door from closing. The surgeon could put his head in the door because he would want to protect his head. He would need his head. [Daniel laughs] Also very much in humor, and I hope nobody gets offended because we know that surgeons in fact always have to make decisions on their feet all the time.

Daniel Lobell: (05:04)
Right. I thought the joke was going to be, the surgeon will cut the hand out of the elevator doors or something. [Both chuckle] I have a lot of respect for dermatologists, especially because I have eczema that I’ve suffered with for a long time. And I find them very helpful.

Dr. Paul Scheinberg: (05:22)
Absolutely. They are.

Daniel Lobell: (05:25)
I want to talk to you a little bit about your military service. When did that start and how did that come about?

Dr. Paul Scheinberg: (05:33)
Well, I’m a product of the Vietnam era. I was in college when Vietnam was really cranking up, as the leading edge of the baby boomers. And so we all had to register at the age of 18 for the draft. And typically if you didn’t go to college, you got classified as draftable as soon as you finished high school. You would defer to four years of college, as long as you were a student in good standing, as a student deferment. And then if you went to medical school, you still got student deferment. But of course the selective service agency that was responsible for drafting people knew when you were in medical school and they would give you eight years of deferment and as soon as you get out of medical school, they gave you one year of internship.

Dr. Paul Scheinberg: (06:20)
And then you got a notice that said, you’re now draftable. “You don’t really want to come in as a drafted private, do you, doctor? We’d like you to sign up and be a commissioned officer.” So of course that offer came to me and I was offered another year of internal medicine residency before I had to go in. At that point, I hadn’t completed my medicine training. And I was told by those returning from the military doctors that I don’t want to be a general medical officer, they give you the worst jobs doing physical exams on recruits. And so I elected to apply for the flight surgeon program. So aviation medicine is a big deal in the Navy. They have a six month program. You go to Pensacola and study at the Naval Aerospace Medical Institute, NAMI, in Pensacola. And it’s a very extensive program, including six weeks of learning to fly an airplane.

Daniel Lobell: (07:13)
So you can fly an airplane?

Dr. Paul Scheinberg: (07:15)
Well, I wouldn’t say that I can fly an airplane, but I did have basic, I would say —

Daniel Lobell: (07:23)
Can you crash an airplane? [Daniel laughs]

Dr. Paul Scheinberg: (07:24)
Vicariously. I did fly, but I had some vision problems that disqualified me from soloing. And actually there’s a story here. I had some congenital oculomotor problems. That is, my eyes didn’t always converge. So depth perception was an issue. It made it challenging for me to play ball. But, my parents were a little reluctant to let surgeons operate on my eyes, because those surgeries are relatively new. So when I found out that I was not qualified to solo, I called my mother from Pensacola and I said, “Mom, you and Dad really screwed me up. You didn’t fix my eyes when I was an infant. And now I can’t solo.” And my mother’s response: “Thank God.” [Daniel chuckles].

Dr. Paul Scheinberg: (08:08)
I didn’t solo, so I did learn to fly, but I would say I learned more about aviation… For an aviator, they would consider my aviation experience to be pre-kindergarten. I wouldn’t consider myself an aviator, but I was assigned to aviation units and I worked as a doctor for aviation units. So we had to do deployments. I went over to the Middle East, we did helicopter minesweeping in the Suez canal after the Yom Kippur war, it was a very fascinating experience.

Daniel Lobell: (08:33)
Wow. Can you talk a little bit more about it?

Dr. Paul Scheinberg: (08:37)
Oh yeah. It was a very dramatic thing. I was in Pensacola when the war broke out in Israel and I felt that I really wanted to go because I’d been there in 1967, right next to the Six Day war. But of course I was now in the military and sure enough, I get assigned to this helicopter mine sweeping unit, six months later, they told us we were going to sweep the mines in the Suez canal.

Dr. Paul Scheinberg: (09:01)
And it was helicopter base. And at the end of the mission, which took us about four or five months, this is a little part of reopening the Suez canal, which had been closed since 1967, I then managed to get a helicopter flight into Israel, which was an unusual way to get to Israel. But the aviation experience though influenced me greatly because I was always fascinated by pulmonary physiology, respiratory physiology and how it relates to the basic gas laws that you learn in high school, chemistry and physics. And as a result, when I went back to do more training after the Navy, I chose pulmonology because it was an extension of the study of pulmonary physiology.

Daniel Lobell: (09:53)
So how does it relate to the gas that you learned about?

Dr. Paul Scheinberg: (09:56)
So it’s interesting thing that in most of the pulmonary diseases we see, whether it’s COPD, chronic lung disease, chronic bronchitis, emphysema… The laws of physics are the laws of physics and patients have difficulty, patients who have lung pathology, having trouble moving air in and out. Of course, in aviation medicine, it was quite the contrary. We were dealing with a very, very healthy population in the abnormal environment. So if you take a person and put them in a cockpit that is flying at 50,000 feet in a high performance jet aircraft, if the canopy of the cockpit is penetrated, suddenly the cabin pressure that had been at about 18,000 feet suddenly becomes 50,000 feet, which is not survivable. And so aviators have to wear supplemental oxygen under pressure from takeoff to landing in a high-performance aircraft. That’s just one example of the impact.

Daniel Lobell: (11:05)
Very interesting.

Dr. Paul Scheinberg: (11:05)
And in fact today, I don’t know if you’ve heard this, today there was a recall by Boeing of all 737s, not a recall, but a check on a switch in the cockpit that monitors cabin pressure. Apparently some of those switches have been found to be faulty because if cabin pressure isn’t properly maintained in a commercial aircraft, which by the way, is pressurized to an altitude of about 6,000 feet. When you’re flying at 35, 37,000 feet, you will become oxygen deprived, which wouldn’t be good for anybody and certainly not for the pilots. So that’s in the news today.

Daniel Lobell: (11:42)
That’s a pretty big recall. I saw a recall yesterday because they sent it to me. I have sleep apnea and I sleep with a C-PAP and Phillips is being recalled. Did you see that?

Dr. Paul Scheinberg: (11:58)
Yes, yes. I have the same unit. Yes. It’s so remote and unlikely, but there’s apparently some minuscule risk of some component degenerating that might have some carcinogenicity associated with it. So I don’t think you need to not use your unit, but it’s okay to take advantage of the recall and get some fixed up equipment. Yes. I got the same information. It’s interesting.

Daniel Lobell: (12:34)
So that’s basically right up your alley, I suppose, because…

Dr. Paul Scheinberg: (12:38)
It is. Yeah. Sleep apnea, in fact, has been really pushed by the pulmonologists. Sleep disorders in general, which you would think would be under the expertise of a neurologist, really have been pushed by the pulmonologists. And in my practice, we had eight doctors in my practice, each of us had, in addition to general pulmonary medicine, each of us had subspecialty interests. And two of my partners were board certified in sleep medicine. And that’s primarily what they did was, diagnosing people with sleep disorders and those who had respiratory associated problems, sleep apnea, and other sorts of disorders were managed by them.

Daniel Lobell: (13:22)
I wonder how much crossover there is when we’re talking about things that have to do with the GI tract with the lungs, because, for instance, the esophagus plays a pretty big role in lung health, doesn’t it?

Dr. Paul Scheinberg: (13:42)
It does.

Daniel Lobell: (13:42)
And it’s also pretty much under the jurisdiction of the GI with regards to reflux and such.

Dr. Paul Scheinberg: (13:52)
Correct.

Daniel Lobell: (13:52)
Where do you see crossover there?

Dr. Paul Scheinberg: (13:55)
Well, the crossover is really at the epiglottis. So the epiglottis is a little flapper valve that really is the switching mechanism between passage from the oral pharynx, basically the back of the throat, to decide whether something goes down the airway, which should be only air, and anything that you swallow, which should go down the esophagus. So in the normal swallow mechanism, it’s a very intricate sequence of muscle contractions, including the closure of the epiglottis to protect the airway. Often with age and with certain conditions like Parkinson’s disease and other kinds of paralytic conditions, the epiglottis loses its functionality and the patient is more likely to aspirate or have liquid go down the wrong pipe, is the phrase often used. The liquid that should go the esophagus gets past the Sentinel guardian there, the epiglottitis. And it goes into the airway.

Dr. Paul Scheinberg: (14:58)
If it’s a small amount of water, probably nothing happened. You usually cough a little bit, but if it’s a vomitus, that is, acidic juices from the stomach, that reflux that has come the wrong way up the esophagus, that can be very toxic to the lung because it’s acid and it can do damage to the lung and often be responsible for developing aspiration pneumonia. And it’s one of the big risks associated with anesthesia because when you’re anesthetized, all of that reflexive protections are basically bypassed by the anesthetic. And this is why anesthesiologists are very concerned about people having a full stomach before putting you to sleep because the likelihood of reflux is increased and the likelihood of not protecting your own airway by an impacted epiglottitis is also increased and that can lead to aspiration pneumonia.

Daniel Lobell: (15:55)
So in an event where acid does go into the lungs, I assume that’s what we’re talking about.

Dr. Paul Scheinberg: (16:02)
Yes.

Daniel Lobell: (16:02)
What are the things people can do?

Dr. Paul Scheinberg: (16:04)
So if an aspiration event is suspected, aside from minimizing it, so if you’re, for example, under anesthesia or in a procedure, the doctor will want to aspirate out as much of the stuff that went down there as possible. For example, with a bronchoscope, something that I did as a pulmonologist, we would flush out the lungs. If there would be an aspiration event, for example, during a bronchoscopy, but sometimes you could observe it, then you quickly want to flush it out with saline to minimize the damage. And once you clear it out, there’s also the possibility of using systemic steroids to minimize the inflammatory response to the injury, because it’s often the inflammatory response to the injury. When I say injury, I’m talking about like a chemical burn, when acid goes down there. So steroids and antibiotics together often can at least modulate or temper the consequence of an aspiration event, maybe avoid it altogether. Not every aspiration leads to pneumonia, but that’s often a quick response to a suspected aspiration event.

Daniel Lobell: (17:16)
How would somebody at home know if they have this problem already?

Dr. Paul Scheinberg: (17:20)
People who have reflux will know when they’re aspirating because they choke and their throat burns. It’s usually a small volume. So it’s not like you’re drowning in a large volume of [?]. You get a burn in your airway and you start coughing, but sometimes it’s silent. People have silent aspiration at night when they’re sleeping if they have a hiatal hernia, which is a looseness of the sphincter or the valve at the stomach at the lower end of the esophagus, at the gastroesophageal junction. If that becomes weakened or loose, which often happens in older people and obese people, they may have silent aspiration and not know about it. And they may just end up with a chronic lung problem. So that’s one of the things that you can… It’s a lot more challenging to diagnose chronic silent aspiration than an acute aspiration event, because it can creep up on you and occur over a long period of time.

Daniel Lobell: (18:21)
What should elderly or obese people do if they suspect that this is happening to them?

Dr. Paul Scheinberg: (18:27)
I think on a routine exam, when you’re seeing your doctor, you should mention that you suspect you might be aspirating because they look for things. So sometimes a chest x-ray or even getting a CT scan of the chest will reveal some of the subtle chronic changes that can occur in the lung as a result of chronic aspiration. An acute event would be noted, because that would be a major issue if you have an acute aspiration event, but it’s the chronic aspiration events that occur with people who are constantly choking and coughing when they eat. They would tell that to the doctor and the doctor may want to look for the chronic sequelae or the consequence of that kind of damage. And one of the consequences is developing bronchiectasis, which is usually localized in the right lower lobe.

Daniel Lobell: (19:23)
And how is that treated?

Dr. Paul Scheinberg: (19:26)
Well, the biggest thing is to prevent the recurring injury. There are some people that have such severe impairment of the swallow mechanism that they really can’t eat anymore. I mean, when it becomes so impaired, and we’re talk now about total paralysis of the pharynx, where they can’t coordinate a swallow and direct food substances directly into the esophagus, instead it goes into the larynx. And some of those people really can’t eat, they have to be fed by tube.

Daniel Lobell: (20:00)
Wow.

Dr. Paul Scheinberg: (20:02)
And those are extreme. Those are rare and extreme cases.

Daniel Lobell: (20:06)
Yeah. I would think so, but still scary nonetheless.

Dr. Paul Scheinberg: (20:10)
It’s scary. I mean, that’s correct. There’s no end to what you can discuss in this arena because that’s only one little tiny piece of pulmonary medicine. The bulk of it is, these days, smoking related diseases. Chronic COPD, which comprises — COPD stands for chronic obstructive pulmonary disease, chronic by virtue of the fact that it doesn’t just happen. It’s sort of a long term issue, obstructive meaning the manifestation is an obstruction to the normal flow of air in and predominantly out of the lung. So chronic obstructive pulmonary disease, and they basically have, they can be classified into two main groups: chronic bronchitis group in which there’s chronic inflammation of the airways, the large airways that the trachea and the main bronchi, the main airways that bring the air to the lung, and emphysema, which is really damage in the business end of the lung. The part where the alveoli are, the air sacs where gas exchange takes place. That’s where oxygen goes into the blood and carbon dioxide actually comes out of the blood into the air so we can exhale it. So those are two different pathologic processes, both of which are associated with cigarette smoking.

Daniel Lobell: (21:33)
For folks who don’t smoke to begin with, what general advice do you give people for healthy lung care?

Dr. Paul Scheinberg: (21:41)
Well, you know, one good thing is that the body is pretty much on autopilot. When we don’t damage things, most things do well. There’s not much you need to do. Other than live a healthy lifestyle. But the things that affect lungs negatively, not just cigarette smoke, but any noxious material, other than air, that you inhale can cause lung damage. So in some cases, there are occupational risks. And those people who work in occupations where there’s a risk usually know it because…

Daniel Lobell: (22:18)
Like firefighters, I would imagine, who breathe in a lot of smoke.

Dr. Paul Scheinberg: (22:21)
Firefighters are one. Firefighters have, they can have very acute toxic exposures intermittently. It’s not like every day, but if they have to go into a fire, so what they do is they wear protective equipment. And you’ll notice, anytime a firefighter is going to go into a burning building, they’re wearing respiratory equipment. What is that equipment? It’s not oxygen, it’s air. It’s simply air that’s isolated from the outside air. So they’re wearing a full face mask that covers the nose and mouth and the compressed air, which is in the tank on their back, goes through a regulator to lower the pressure from the high pressure of a compressed tank to regular pressure for the air around you and they’re basically inhaling air that comes out of the tank and then exhaling it into the room. They’re just not inhaling the smoke. So that’s the biggest protection they can do.

Dr. Paul Scheinberg: (23:12)
And there are a lot of other industries that require it. For example, if you are exposed to certain chemicals, if you spray paint cars, for example, which uses polyurethane paint and the polyurethane paint requires a hardener agent called methyl isocyanate, which is very toxic to the lungs. So people who work in that environment have to wear respirators all the time. Again, it’s not oxygen, it’s air, but air that comes from an external source so that the toxic environment around them doesn’t ever get into their lungs. The biggest cause of COPD, by the way, around the world, is not cigarette smoking. It’s in countries that are still using primitive ways of cooking, where they cook indoors with burning wood or burning coal. They have a lot of carbonaceous material, smoke, that’s in their world all the time. Even if they never saw a cigarette, they get COPD in the same way.

Daniel Lobell: (24:10)
I wouldn’t have guessed that, but that makes sense.

Dr. Paul Scheinberg: (24:14)
Yeah. It’s interesting.

Daniel Lobell: (24:16)
Very interesting.

Daniel Lobell: (24:17)
I want to go back a little bit. We were talking about your time sweeping mines, or, as we call it, minesweeper.

Dr. Paul Scheinberg: (24:27)
Yes. Yes.

Daniel Lobell: (24:27)
I think it’s probably a little different than the game, right? What does it actually look like?

Dr. Paul Scheinberg: (24:34)
Oh, this is very interesting. We typically, those of us of a certain age will think about World War II movies, where you see a big spiked ball, and waiting for a ship to hit it. So the World War II mines were basically dropped from ships or from planes. Basically it’s a bomb with triggers around it, and an anchor. And by the way, mines are always in shallow water. There’s no point in mining deep water. They’re usually at entrances to harbors. So they usually have an anchor that goes to the bottom and that tether between the anchor and the floating bomb. And so it floats at a level that should be hit by a ship. But that’s no longer what mines are these days. Mine warfare has become very sophisticated. These are bombs which have triggering devices, which can detect a particular kind of ship, either by its magnetic signature, by its sonic signature or sound waves, or by pressure transduction.

Dr. Paul Scheinberg: (25:36)
That is the displacement. And a ship doesn’t have to hit it anymore. So as mines became more sophisticated, then the military had to develop ways of doing counter measures to your mine, because even in the Vietnam War, you may remember, we bombed Haiphong Harbor and mined it to keep the Chinese from delivering all kinds of weapons to the north Vietnamese. And they came through Haiphong Harbor near Hanoi. When the Paris Peace Accords were signed in the war, one of the deals was to go in there and get rid of the mines because otherwise you can’t leave the mines in the water. So my unit actually had done that right before I joined them and they were going after the war. And they basically, it’s a helicopter that drags a very sophisticated minesweeping sled through the water. That sled has a jet engine on it, which generates electrical current. It has an anode and cathode trailing behind it, and it can generate a magnetic signature in the water. Also, it can generate sound signatures and pressure signatures basically to mimic a ship. And these sleds would float on pontoons, but when they would pick up speed, they would lower hydrofoils from the pontoon so they could be dragged through the water by the helicopter. The helicopter’s flying at about 50 feet off the water. And they would hope to find any mines and trigger them until they would blow up, but they wouldn’t be blowing up any ships.

Daniel Lobell: (27:14)
That’s pretty intense stuff. And that is that one of the helicopters that flew you into Israel, was one of those pulling a sled?

Dr. Paul Scheinberg: (27:21)
Yes. In fact, yes, it was — interesting story. During the minesweeping aberration, President Nixon had come to visit Egypt, to convince Egypt to come under the American sphere of influence. Up to that point, the Egyptians had been under the Soviet sphere and this was very much a mission aimed at ending the — well, it was a Cold War issue. And so when Nixon was visiting, our ship was his medical facility in case anything were to happen, which of course nothing happened, but they sent them additional medical support team from the naval hospital. And their instructions were that as soon as the Air Force One took off from wherever it took off from, they would be going to a commercial airport. And so the commercial airport that was nearest was in Tel Aviv, the last site for the president’s visit was in Amman, Jordan.

Dr. Paul Scheinberg: (28:19)
So we were like 20 miles off the coast of Israel. And I hitched a ride along on the helicopter. It was being flown by my roommate at the time. And there was a Marine colonel who didn’t like the idea that I was getting on this helicopter. He tried to stop me. Of course, he outranked me. I was just a doctor, a lieutenant, and he was a colonel in the Marines. And he said, “You can’t go.” I said, “You can’t stop me.” He was a little bit procured by my insolence. But I said, “I didn’t have to be the flight surgeon for this squadron, and the commander of this aircraft is that guy up there, the pilot, is my roommate. And he decides who gets on his aircraft, not you.” Well, he was really getting a little irritated. He said, “Well, you can get on, but you won’t be able to get off at the other end.” I said, “That’s not your problem either.” He said, “Well, we’ll see.” They know that I’ve been working on this for days. They know that six people are getting off and only six because nothing can change. These people are in a state of war. Well, I get off the other end. There was a little guy, Yossi, drives up with a bus and he says, “I thought there was six.” And he said to him in Hebrew, “I’m the seventh. I came to visit my relatives.” He says “No problem, I got a seventh car, come.”

Daniel Lobell: (29:36)
[Daniel chuckles] Good to know a little Hebrew. So Israel plays a pretty big part in your story again years later when you’re on a flight there and you experienced some heart problems, can you talk a little bit about that?

Dr. Paul Scheinberg: (29:52)
Yeah, it’s a great story. I was pretty good health, and I just retired, I was taking my second trip in two months to Israel, I was on a non-stop from JFK to Tel Aviv. It was an 11 hour flight. And about five hours into the flight after stuffing my face to get my money’s worth out of the dinner and eating more than I needed to, I started having a little epigastric distress, you know, stomach pain, heartburn. I never get heartburn, but it persisted, persisted, persisted. And I began to get a little concerned and it turns out that I was having a heart attack, but I didn’t want to divert because I felt more comfortable getting all the way to Israel. And I was just lucky, maybe luckier than smart, by not opting for a diversion, which would be an appropriate thing to do. In case of a heart attack, there were a lot of places we could have landed. And when I got to Tel Aviv, they had an ambulance meet me and took me right to a Tel HaShomer hospital where I ended up getting two stents and excellent care. It was quite an experience.

Daniel Lobell: (30:58)
I wonder if most people would have recognized that they were having a heart attack in that situation, or if they would have written it off as heartburn.

Dr. Paul Scheinberg: (31:04)
You know, that’s an interesting thing. It’s a real problem because on the aircraft, while they have emergency equipment to deal with a cardiac arrest, they really don’t have diagnostic equipment. And while we think about a heart attack being so obvious with crushing chest pain, I wasn’t having typical chest pain. I wasn’t having the typical symptoms. So even I, a pretty experienced physician, my denial, I think I’m a better doctor than I am a patient. So I was playing patient and staying in denial. And also I wasn’t sure about the medical care that I might get along the way. So I opted to tough it out. And I would say I was very lucky. It was quite an experience.

Daniel Lobell: (31:54)
Your heart really was in Israel.

Dr. Paul Scheinberg: (31:56)
My heart was in Israel. Actually, there was an interesting story. The reason I was going on that trip was to support an organization in Israel called Ichud Hatzalah, which is a United…. You may have heard of it. Hatzalah means rescue in Hebrew. And it’s an organization that has 7,000 volunteers throughout Israel that have a special communications device, and they can be sent anywhere. They ride what they call ambucycles, motorcycles equipped with emergency equipment. They don’t transport patients, but they can get to a patient or a victim of an illness or an injury much more quickly than an ambulance can. So these volunteers get there fast and they work in concert with the official ambulance service of the country. They save lots of lives simply by getting there very quickly. Well, when the flight attendant finally, despite my denials told me that I didn’t look good, and she was going to call for medical help, the guy who came to help me was a EMT from United Hatzalah. And so it was very impressive. They love to say they can get to anybody in Israel within 90 seconds, they said, but at 35,000 feet, they can get you within 30 seconds.

Daniel Lobell: (33:10)
[Daniel chuckles].

Dr. Paul Scheinberg: (33:10)
It was very impressive.

Daniel Lobell: (33:11)
It justified the trip, maybe they put something into your food just to…. [Both chuckle]

Dr. Paul Scheinberg: (33:17)
Yeah, that’d be good marketing. And I do support that organization because I owe them a lot, they were very good and anybody should help support them. They do good work.

Daniel Lobell: (33:27)
So, you touched on this a little bit, but some of the things you focus your attention on now in retirement are bronchitis and bronchi — and tell me if I’m saying it right.

Dr. Paul Scheinberg: (33:38)
Bronchiectasis. Yeah, so I can explain the difference. And it’s often misunderstood by lots of folks. Bronchitis, which is very common, is simply inflammation, “-itis” implies it’s inflammation, of the bronchial tubes. And as you may remember from basic high school biology, the trachea, the windpipe that goes from right below the larynx, the voice box, down into the mid chest where it divides into right and left lungs. So that’s the trachea and the right and left main stem bronchi. Now these are tubes that are supported and maintain open by cartilaginous rings. Just like a vacuum cleaner tube has rings in it, because the pressure inside the tube is less than the pressure outside the tube and if it didn’t have those supporting rings, if the pressure outside of a tube is greater than the pressure inside, would cause the tube to collapse.

Dr. Paul Scheinberg: (34:39)
So we wouldn’t be able to inhale at all. We inhale by lowering the pressure inside the airway. Okay, so the bronchi are the large airways supported by cartilaginous rings and that align with mucus membrane, whose job it is to secrete mucus and sweep the garbage we inhale that isn’t intended to go down deep in the lung and sweep that stuff up. So inflammation of the bronchi is bronchitis. In a very distal, small peripheral airways, as we approach the air sacs, the alveoli, the airway no longer has those cartilaginous supporting rings. And those airways are very, very tiny. If they become inflamed or the wall becomes thickened, it also leads to obstruction of airflow. Airflow can’t go in that big, and it can’t go through narrow airways as efficiently. Those are bronchioles and when the bronchioles become dilated and stiff and full of mucus, and the mucus stays, doesn’t move because it gets gummed up in there. That’s bronchiectasis.

Daniel Lobell: (35:57)
Bronchioles sounds like a baseball team.

Dr. Paul Scheinberg: (36:00)
Yeah, they could make a good team, the Bronchioles.

Daniel Lobell: (36:04)
Yeah, the Brooklyn Bronchioles.

Dr. Paul Scheinberg: (36:09)
The Brooklyn Bronchioles. That’s correct. And so bronchiectasis can be caused by lots of different things, but it’s a chronic lung disease. These people are coughing all the time. Some people have bronchiectasis as a result, for example, of cystic fibrosis, which you know, is a genetic disorder where they can’t sweep the mucus. But it can also be a result of chronic aspiration, which we talked about before. If somebody has recurring aspiration when they’re upright, they’re more likely to have that goop slip down to the right lower lobe. And so they will have a localized bronchiectasis in the right lower lobe. And there are many other causes, which is probably beyond worthy of discussing in this platform. It’s prevalent condition, but not usually life threatening except in very severe circumstances.

Dr. Paul Scheinberg: (37:02)
And it really leads to chronic infections and chronic difficulty mobilizing secretions. We often have to treat those patients with antibiotics recurrently, and mechanical measures to help them clear secretions.

Daniel Lobell: (37:17)
What are the mechanical measures?

Dr. Paul Scheinberg: (37:20)
There’s actually a device now called the vest, which vibrates the chest. So imagine jello, thickened jello, lining the airways and plugging up some of those airways. So using a vibrator on those airways would jiggle it. And if you use that in combination with postural grading, meaning leaning over from the, say a bed over some pillows and on an incline with your head down using gravity to your advantage while vibrating your chest, you can move that mucus and clear those airways. You can also inhale certain substances that irritate or that liquefy that mucus. And actually I did a good bit of research early on in inhaling antibiotics, which is now a conventional standard of therapy, which wasn’t at the time that we were doing the research years ago. Sort of to help minimize the infection because the mucus, it puddles there. It’s a great culture medium. And so the infection leads to more damage and then more damage leads to more infection and it’s a vicious cycle. So it’s important that patients with bronchiectasis institute some process of what we call pulmonary toilet, basically cleaning the airways.

Daniel Lobell: (38:38)
Well the problem with the antibiotics is that it kills off all the good gut flora, and then you can get inflammation in the intestines and in the stomach. And that puts pressure on the lungs all over again.

Dr. Paul Scheinberg: (38:51)
Correct. Which is why we started focusing on research applying the antibiotic directly into the airway. Rather than giving the antibiotics systemically, which could also go to the gut, give it by inhalation. So we’ve found that certain antibiotics can be put in a solution and nebulized in a mist and inhaled. And that gets down to the deep airway and inhibits the growth of bacteria only in the airway without having the systemic effects that you just addressed.

Daniel Lobell: (39:24)
Interesting. Why aren’t all antibiotics administered that way then?

Dr. Paul Scheinberg: (39:32)
Well that’s a good question. And the answer is that the reason for administering antibiotics into the lung would be lung infection. The most common kind of lung infection is really pneumonia. But pneumonia, you won’t get enough antibiotic into the tissue of the lung by inhalation. It’s much better to deliver it to the bloodstream. So for severe pneumonia, you’re going to go with a systemic antibiotic. The only time you really — a systemic antibiotic either delivered intravenously or orally. And the blood flow to the lung will deliver the antibiotic properly to the tissue of the lung. We’ve talked so far about the airways, but between the airways is the substance of the lung, which is made up of spongy material, lots of blood vessels and air sacs, and they have a very rich blood supply. So the blood is a better way to get to the parenchyma of the lung tissue. The inhaled antibiotics is a good way to deliver antibiotic. The inhaled pathway is a good way to deliver antibiotic to the peripheral airways.

Daniel Lobell: (40:45)
I see. Okay. Okay. That makes sense. You also deal a lot with lung cancer, correct?

Dr. Paul Scheinberg: (40:54)
Yes. I would say the last 15 to 20 years of my practice was focused on early detection of lung cancer. And I would like to say a couple of words about this. Lung cancer has got a reputation of being pretty much lethal. And people think that if you get a diagnosis of lung cancer, you’re dead. The reason for that is that most lung cancer is diagnosed very late in its course. And the reason it’s diagnosed late in its course is that early lung cancers don’t produce any symptoms. So people don’t know they have it until the tumor is late. Most of the time you go when you’re coughing up blood, or you’ve lost a lot of weight, or you’ve been coughing for a year and then take an x-ray and see a large mass. Well, all the cancers when they’re already in stage four or metastatic have a worse prognosis.

Dr. Paul Scheinberg: (41:39)
So the trick in all cancers is to find them early. Well, nobody argues with having colonoscopy to find a little polyp that may be colon cancer. And nobody’s arguing against doing mammograms to find tiny little nodules in the breast that might be a problem. We do that, but for lung cancer, tiny little pulmonary nodules hadn’t been on the radar for assessment. And so I was involved in a very large international study. If any of your listeners want to learn more about it, they can go to a website called ELCAP, E L C A P, and actually it became international so they put an I in front of it. I E L C A P, which is an International Early Lung Cancer Action Plan. The idea is, can we, by routine CT scans of the chest, which can identify small nodules, find lung cancers before they become problematic and take them out when it’s easy to take them out.

Daniel Lobell: (42:41)
What’s the answer?

Dr. Paul Scheinberg: (42:41)
So, well, it is, but the trouble is, now who do you screen? Do you screen everybody? Right now the current recommendations of our federal government, the United States, Preventative Medicine Task Force has recommended only screening people who are defined as “high risk.” And who do they define as high risk? Patients who have greater than 30 pack years of smoking — a pack a day for 30 years or two packs a day for 15 years — who have quit less than 15 years ago, and who are over the age of 15 and under the age of 80. And those specific criteria are defined only because the study that they base it on, which is the lung — it’s a lung cancer study that was published in 2010. It was 10 years, 11 years ago. Those are the criteria for inclusion in the study.

Dr. Paul Scheinberg: (43:41)
That doesn’t mean that people outside of that cohort don’t need the same kind of screening, but they weigh it against the cost of screening a large population with CT scans. And some people are worried about the radiation associated with large population screening.

Daniel Lobell: (44:00)
Is that a legitimate risk?

Dr. Paul Scheinberg: (44:00)
I don’t think so. No, I don’t think so. Because the computerization of CT scans now can calculate, at the time of the scan based on the thickness of your body, the lowest dose of radiation that you need to get a tolerable image. Just as your iPhone can take a good image in darkness, because the sensors are so much more sensitive to minimal light, the CT scan, scan receptors, are so much more receptive to low dose radiation. So early CT scanners emit quite a bit of radiation, a lot more than a chest x-ray. But right now, the dose of radiation emitted during a screening CT scan of the lung is quite low. It’s not zero, but nobody’s suggesting that you do it every day. You do it once, maybe once every five years, it’s minimal and not significant. So I favor broader screening than the current guidelines recommend.

Daniel Lobell: (45:05)
Well, it sounds to me like a perfectly reasonable recommendation. I hope that…

Dr. Paul Scheinberg: (45:12)
It is. But there’s something that has to go along with it. And that is, what do you do if you find a nodule? And the problem is that not every doctor knows what to do with a nodule because most of the nodules are benign. So if you find a nodule, it doesn’t mean it’s cancer. A nodule is simply a density. An x-ray reads it as simply an area that is more dense than the surrounding lung issue. And because lung tissue is very spongy and has a lot of air in it, in relation to the blood vessels, it’s very loosened to an x-ray. That is, it’s not opaque. It’s loosened. Bone is opaque to an x-ray. Air is very loosened to an x-ray. Therefore, on an x-ray, it looks black. Okay? And a nodule may look a little white. Most of the nodules that you come across accidentally are benign.

Dr. Paul Scheinberg: (45:53)
The only way you’d know is by following it over time. So I feel very strongly that along the recommendation for screening, the screening has to be done in a multidisciplinary way with a team of people that knows exactly how to follow it. That is, you look at another one in one year, two years. Do you look at it in three months or six months? It depends on the size and the characteristics of the nodule to see whether… And was there a prior x-ray, so you find the nodule and somebody incidentally had an x-ray, had a CT five years earlier, and you see it the same if you look in the back of the old scan and it was unchanged, then forget it. It’s not changed in five years, it’s not a cancer. Don’t even look at it again. So it really has to be done wisely and smartly with a multidisciplinary team.

Dr. Paul Scheinberg: (46:42)
And once you decide that it needs further investigation, that doesn’t mean it’s cancer either, okay? There are other studies that can be done, all with minimal invasion of the body, to learn more about it before you ever touch anything with a biopsy or poking. Like PET scans. PET scans, I don’t know if you’ve talked about that in any of your studies, but a PET scan is more of a functional scan, whereas the CT looks at the anatomy. How dense is the body to the penetration of an x-ray. A PET scan looks at its metabolic activity, okay? When somebody says a PET is positive, it means, positron emission tomography means that the area of concern basically was waving to the Geiger counter. It’s looking at radioactivity after being given a dose of radioactive glucose. And all cells in the body are metabolizing glucose all the time. But if one area of the body is metabolizing much more avidly, it soaks up that marker of radioactive glucose, it’s got a radioactive fluoride attached to the glucose. So it basically waves the Geiger counter. And so there’s a lot of that concentrated in the areas that are metabolically active. Tumors tend to be more metabolically active than surrounding tissue. But just because it lights up doesn’t mean it’s cancer, because there are some benign issues that also light up. So as much as we want to simplify everything into a simple story, it ain’t simple, and that’s why you need to go to competent people. You need to go to the right doctor and you need to know the right doctor for the right thing. There are great doctors, but nobody is great at everything.

Daniel Lobell: (48:24)
How do you know who the great ones are? Because if you ask them, they usually all tell you they’re great.

Dr. Paul Scheinberg: (48:28)
Exactly. And that is a big challenge. That’s the problem that we have, that doctors come in all forms and shapes. I would say that almost all doctors want to do the right thing. And most doctors will steer you to the right person if they’re not the right person. But one of the challenges that we have is trying to define who’s great at what. And I think that’s one of the advantages of the Doctorpedia platform, is to have doctors be peer reviewers of each other. To just go somebody spends a lot of money on marketing, but none of the other doctors agree with him doesn’t mean he’s actually as great as he thinks he is.

Daniel Lobell: (49:14)
Well, that’s a good point that we’ve never really talked about about Doctorpedia, that it has that great potential for it that you could find out from — yeah.

Dr. Paul Scheinberg: (49:25)
I think that’s one of the strengths of this platform, exactly, to — there are people who market themselves as being the best at everything, right? But who decides if you’re great? Well, your patients do, but your colleagues do. Your peers do. And I think we need to see more peer input in evaluating the claims made by professionals. Not only in medicine, but in everything.

Daniel Lobell: (49:58)
What role are you playing in Doctorpedia and how can the listeners find it?

Dr. Paul Scheinberg: (50:04)
Yeah, well the Doctorpedia website, Doctorpedia.com, is starting up as a platform for physicians to provide information to patients, this stuff like we’re talking about right now. If you have a specific question or a specific targeted interest, there’s likely a doctor, who’s already a participant in Doctorpedia who will give videos and tell short vignettes, one or two minutes worth. Not lectures, not half hour boring things, but specifically targeted messages that a doctor wants to share with his patients all the time. But they often can’t because right now they don’t have the time. A doctor’s time has been truncated because they’re now working for companies that pressure them to do more with less. And the doctors want to share information with patients. So I was attracted to it. I’m a recently retired doctor, so I’m not looking to market myself in any way. I’m done.

Dr. Paul Scheinberg: (51:00)
I’m finished. I love sharing information. And I’m a resource in my own community. People call me all the time because I know everybody in my community and they tell me, who should I go to for this and who should I go to for that? And if I don’t know, I’ll find out and help them out.

Daniel Lobell: (51:14)
That’s great.

Dr. Paul Scheinberg: (51:14)
This is something that I can do because I have the contacts in my community and I’ve been in my community, in the medical community for 40 years. And I’ve been very visible here. I think with Doctorpedia, it’s gonna hopefully become the platform to allow anybody to get that access to that kind of information. And you see, you’ll hear doctors and hear them talk about what they do. You can listen to them. The other doctor tells him the same story. And also, if a doctor puts on a claim and the other doctors who listen to it are not that impressed, well, the Doctorpedia people will hear about it. So I think it’s an opportunity for peer review and I think doctors do it to maintain high quality among their peers.

Daniel Lobell: (52:05)
So are you going to be putting any videos or content out on Doctorpedia?

Dr. Paul Scheinberg: (52:08)
Well, I probably will. Probably some of the material that we’re talking about today is going to be ideas about things I might talk about with them. And again, I have no — for me, there’s no marketing objective at all. But I certainly have an incentive to educate patients which is what I’ve done for the 40 years of my career. And so I’m relatively new in the game, but I latched onto it because I was very impressed with the stated goals and objectives of Doctorpedia. And I hope they continue to grow and be successful in that arena.

Daniel Lobell: (52:48)
Please God they will. What was the name of the organization that you mentioned again?

Dr. Paul Scheinberg: (52:52)
I E L C A P. I guess it’s dot org. I think because it’s a nonprofit entity.

Daniel Lobell: (52:58)
So I for international and then ELCAP. I might add an I to the beginning of my name because I’ve been into enough —

Dr. Paul Scheinberg: (53:07)
Yeah, you’re right, absolutely.

Daniel Lobell: (53:07)
I’m IDaniel.

Dr. Paul Scheinberg: (53:09)
IDaniel, you can do that. [Daniel chuckles] I’m just checking right now to ensure that we got it. I’m pretty sure, but it’s a wealth of information. They’re a tremendous resource. IELCAP.org. It’s an initial early lung cancer action program. And it’s a nonprofit entity, it’s been going on for about 25 years, maybe more, maybe 30 years by now. I was one of the researchers involved, it involves many great institutions throughout the United States and other countries. Back before COVID, we were having meetings all over the place.

Daniel Lobell: (53:46)
Doctor, thank you so much for this time and for this great information, I’m going to ask you what I ask all the doctors to round these interviews off, which is, what do you personally do to stay healthy?

Dr. Paul Scheinberg: (53:58)
I’m only now figuring it out because I really, during my years of practice, I really didn’t pay much attention to myself. So I found myself, I prefer, I don’t like to —

Daniel Lobell: (54:05)
A bad patient. [Daniel chuckles]

Dr. Paul Scheinberg: (54:05)
Ah, yes. I’m under height for my weight, put it that way. Does that sound better? [Daniel chuckles] So I now, I walk every morning with a bunch of old guys and walk in the mall. So it’s independent of weather. And I do go to the gym and I exercise and I try to be more judicious in my diet, but I don’t think it’s extreme. I think the biggest message is balance. That’s the toughest thing. I don’t think I had balance during many of my years working in medicine because basically, medicine will consume your whole life if you let it. And I think I did let it. But I’m also taking up one hobby that I enjoyed in high school, wood turning. Basically turning wood on a lathe to make round things.

Dr. Paul Scheinberg: (54:53)
And if it doesn’t come out the way you wanted it, you just have an opportunity to call it a redesign rather than furniture building, where things have to fit together.

Daniel Lobell: (55:01)
That sounds interesting.

Dr. Paul Scheinberg: (55:02)
And I’m also spending the rest of my time learning. I mean, there’s so much information available everywhere. And I don’t think even when my day is not so scheduled, like it used to be, there’s so much opportunity to learn from everything. And in fact, one of the things that I enjoyed in my years of practice, every time I saw a new patient and I would ask him what he did for a living and they always had something to tell me about something that I knew nothing about.

Daniel Lobell: (55:32)
Wow, well, I hope you’ll —

Dr. Paul Scheinberg: (55:33)
There’s an old adage in the Pirkei Avot that says, “who is the wise man, is the man who learns from every man.”

Daniel Lobell: (55:41)
I think it also says in the Pirkei Avot, who is the wise man, someone who keeps listening to the Doctorpedia podcast.

Dr. Paul Scheinberg: (55:47)
Oh, maybe that’s it too. [Both laugh]

Daniel Lobell: (55:47)
So I hope you’ll continue to tune in and I’m honored to have you as a listener. And thank you so much for your time.

Dr. Paul Scheinberg: (55:55)
I appreciate it. It’s been a lot of fun. Thank you again.

Daniel Lobell: (55:58)
Thank you.

Daniel Lobell: (56:04)
This podcast or any written material derived from its transcripts represents the opinions of the medical professional being interviewed. The content here is for informational purposes only and should not be taken as medical advice since every person is unique. Please consult your healthcare professional for any personal or specific needs.

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