Best Practices: Gotham Medical Group
Dr. Bungay and Dr. Linetskaya on the changing landscape of LGBTQ health.
Gotham Medical operates as a loose group of some of the city’s most talented physicians, many of whom happen to have extensive experience in the realm of LGBTQ health, including HIV. They’re also adored by their patients simply for their superlative service for all things primary care. Here, Dr. Krisczar Bungay, one of the practice’s principals, and integrative specialist and primary care provider Dr. Irina Linetskaya, discuss their individual approaches and show how this internal medicine practice covers all the bases any New Yorker could want.
Dr. Bungay, can you introduce us to Gotham Medical and what types of patients you see?
When I started as chief resident at St. Vincent’s in 2013, I met a lot of doctors, since the position includes a significant amount of administrative work. Among those physicians were Bill Shay, Steve Dillon and Robert Cohen, all of whom worked at Gotham Medical and were all great people and doing good HIV work. By that time, I knew I wanted to work in this field of primary care. I didn’t want to rely on a company to be employed, so private practice was appealing to me. There was an extra room in the office at Gotham Medical — and to me, this was far preferable to hanging my own shingle — so I started part-time, and supplemented with reviewing medical claims for insurance companies.
Dr. Shay moved out-of-state, and Dr. Dillon and I decided to split the work of running the practice in 2009. We’re really a loose group of partners and physician’s assistants who refer patients to each other. Our business has grown by word-of-mouth. We don’t advertise as an LGBTQ office, we just happen to be very comfortable with that rubric of the patient population. The Chelsea location helps, too!
Your office is one of the largest distributors of PrEP in the state. Can you explain what that is, and how has that medication has changed the field of HIV?
PrEP, which stands for Pre-exposure prophylaxis, began as an experiment based on PEP, or post-exposure prophylaxis, which was medication given to hospital workers after they experienced a needle stick. PrEP is now a preventive measure taken on a daily basis by anyone considered to be at risk for HIV. To prove that someone is eligible, a physician has to submit to insurance that a patient is HIV negative, shows normal kidney function, and is at risk for HIV. And PrEP has definitely changed the landscape, at least in the downtown Manhattan area.
About 10 years ago, we used to diagnose HIV about once a month. The last few years, that number has come down to about once a year. Those figures might be different up in the Bronx, where PrEP use is significantly less for a variety of reasons — be that because there isn’t as much awareness of it, access to an office that distributes it might be rarer, or there isn’t the necessary staff at clinics to do the work for prior authorization.
It is now very rewarding to treat someone with HIV; we have so many medications available, I’ve actually lost track of how many are on the market (we regularly prescribe a small handful of those that we consider to be the best in terms of minimal side effects). In the early days, many doctors in HIV medicine would burn out. It’s the opposite now, because you know your patients will do well, it’s just a matter of finding the perfect drug, and making sure they take it regularly. So it really becomes about the relationship we develop with the patient.
Interestingly, many patients actually experience an improvement in their general health after their diagnosis because they are coming in more frequently and getting more in tune and involved with their bodies and overall needs!
Dr. Linetskaya, can you describe your path in medicine for me? You have trained in multiple modalities and bring so much experience to the table.
I grew up in the Soviet Union around tremendous illness and loss. My parents passed away when I was a child, and my grandfather died of untreated gastric cancer shortly after our arrival to the US. The Soviet medical system was terrifying and antiquated, and you had to bribe doctors at every step for the poor care they offered. When I immigrated with my grandmother to San Francisco at age 12 , the first pediatrician I saw was a fun young woman with a short haircut wearing a short skirt. Although I didn’t understand a word she was saying, I loved her and declared that I too would become a doctor. I never changed my mind.
As an undergrad at Stanford in the late 1990s, I gravitated toward serving people in my community, and in San Francisco, HIV/AIDS was part of that health landscape. Fast forward to Harvard Medical School where I got to take my passion for HIV work on the road with clinical internships in Senegal, Brazil, and Portugal. By the end of medical school, I spoke Spanish, French, Portuguese, and Russian and I felt sure that my future was in global HIV medicine.
But then something really interesting happened. I was considering taking an HIV treatment rollout job in Mozambique when I started seeing a psychotherapist to deal with some of my early life trauma and the way it was impacting my relationships. I recognized that the indefatigable speed of my life, the relentless internal pressure to be of maximal use, maximal service, maximal impact, was my mind’s way to stay one step ahead of the terror of dying young like my parents, or living an insignificant life. And in this state of “high purpose/high pressure living,” I didn’t know how to slow down, how to take good care of myself, how to breathe or take a nap.
A 10-day silent Vipassana meditation course in 2012 changed the course of my life. I had, to that point, lived a life of the mind. My body was my transportation accessory or, as it felt to me, the stick holding up the lollipop of my head. The Vipassana meditation technique taught me to experience my body, its complexities and processes, and showed me the inextricable connection between mind and body. This radically changed the way I approached not just my own life, but the lives of my patients as well as their treatment.
Your website describes something called contemplative medicine. Can you elaborate and how that is particularly well suited to helping HIV patients?
Contemplative Medicine is the phrase I came up with to describe my evolving understanding of health and healing — a patient-tailored combination of Western medicine, mindfulness, somatic therapy, nutrition, physical activity, and plain old common sense. The human nervous system is an exquisitely sensitive detection device, constantly interpreting information from our senses to detect threat, to brace for self-defense. In New York, for example, we tend to live frazzled, over-crowded lives of constant sensory overstimulation, and yet we somehow expect our bodies to be calm, collaborative, and relaxed.
With the exception of infectious illnesses or orthopedic injuries, I’ve found that most chronic illnesses are manifestations of perpetual imbalance in the body. In fact, if you follow most chronic illnesses back to the time they started (often as minor symptoms of this and that which escalate over time to become more and more severe and, eventually, entrenched in the body), you will find a person who had lost the balance of their life — be it diet, exercise pattern, relationships, finances, work-life balance, sense of purpose and value, and so on.
I teach people how to listen to their bodies, how to interpret their symptoms not as signs of disease, but as messages from their nervous systems in response to inappropriate circumstances of life. As such, it is my job (and my enormous privilege) to help people retrace their steps, to reconnect to their bodies, and to re-engage their support systems and their sense of purpose and belonging.
HIV patients in particular have been through trauma on many levels — their immune systems have undoubtedly survived a deadly threat. But so, often, have their minds, their sense of self, their sense of reality.
You’ve mentioned that you are integrating therapy into your practice. How are you doing that?
I just finished a four-year body-oriented psychotherapy training, which has given me tremendous added perspective into the interaction between the life of mind and the health of the body. I am now developing what I call Mind Body Skills Labs which are 90–120 minute participatory, interactive group workshops aimed at ushering patients into deeper relationship with their bodies, nervous systems, and lived experiences.
This is also an effort to create community and camaraderie among people who are often isolated and demoralized by chronic illness. Rather than grouping patients by specific symptom or diagnosis, I am inviting people to explore fundamental skills such as body awareness, self-regulation under duress, and creating and maintaining healthy boundaries. Patients have been very enthusiastic about this unique, embodied way to explore illness and interact with their physician and peers. I am excited to expand this branch of my practice in the coming months.
Vital Signs
How do you keep balanced with the demands of your practice?
Dr. Bungay: I go to the gym first thing in the morning, and if the weather is above 27 degrees, I bike to work — it’s faster than the subway! I also make sure I get 7 or 8 hours of sleep, and make sure I get away every two months or so. Patients appreciate that, and I have great staff members who cover for me while I’m away.
Dr. Linetskaya: I have come a very long way from ignoring my body altogether to taking better and better care of it. This involves very regular movement, a mostly home-cooked, plant-focused diet, investing time into relationships I hold dear, and work-life balance. I work part-time and spend my free time studying, delving ever deeper into understanding the mind-body continuum, swinging in a hammock in Prospect Park, or hiking upstate.
Best piece of advice you’ve received in your career:
Dr. Bungay: It was a long time ago as a student, when another practitioner told me that I should enjoy my way of life now, because this isn’t a dress rehearsal.
Dr. Linetskaya: The role models I admire most are people who have lived unusual, creative, and intrepid lives — people who regard life as an adventure, who are able to flow and adapt to opportunities and challenges alike, and who surrender to life rather than trying to wield or control it. I am steering my life to follow their course.
Piece of tech that makes your life easier?
Dr. Bungay: We offer people a variety of tools they can use to access us, because we have a wide range of patient ages and comfort levels with tech. We of course have a patient portal, which makes our life easier because everything is recorded through the interactions, but we also still have a traditional voicemail service where people leave messages. It’s a bit of a pain for us, but we respect people’s different communication needs!
Dr. Linetskaya: I am a hopeless Luddite in my personal life — my iPhone 6 is essentially all the tech I own. But I always strive to create a streamlined, easey communication experience for my patients!
Any favorite lunch spots near your office in Chelsea you’d recommend?
Dr. Bungay: Yes, Som Bo as well as Chelsea Market and Gansevoort Market!
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