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The private practice in Manhattan is expanding to include psychiatric house calls including care for Adolescents, Adults, Geriatrics, Family Therapy, and Psychopharmacology.

Tele-health options available for established patients.

Raymond Zakhari, NP is a board certified nurse practitioner in Family Practice and Family Psychiatr

The interface between medicine and psychiatry is the crack that many patients often fall through in terms of having their health care needs met. A small group of health care providers in the United States is uniquely qualified to care for patients with both mental health and primary care needs. This group of health care providers is double board certified in internal medicine/ family practice and psychiatry. That means they were equally trained in the traditional aspects of primary care as well as trained in the field of psychiatry. This health care provider can either be a physician or a nurse practitioner. If the provider is a physician they may be known as the Internist-Psychiatrist, and if the provider is a nurse practitioner they will be known as a Family Practitioner- and Family Psychiatric Mental Health Nurse Practitioner.

These two professions address the needs of people with mental health problems that impact a medical condition, as well as care for people with general medical concerns who develop a mental illness. They also have a great deal of experience in dealing with the adverse effects of psychotropic medications including diabetes, kidney trouble, and anemia. 

On average a patient with a serious mental illness such as bipolar disorder or schizophrenia can have a 10-20 year reduced life expectancy because of the barriers in accessing routine and preventative care, and the reduced adherence to treatment. People with mental illness can also suffer from the same conditions that affect the general population including heart disease, diabetes, and high blood pressure. Similarly it is not uncommon for a patient who has suffered a heart attack or stroke to become depressed or anxious to the degree that it impairs daily life functions. 

This holistic type of care which integrates primary care and mental health is an approach to care which seeks to optimize mental and physical well being with the added convenience of a one stop shop.  

What are your thoughts on getting your physical and mental health care from one clinician?

Most men hate going to the doctor. If you could design your ideal health encounter what would it include, and what would you like to see changed?  

Use the comments section to create your wish list. You may get what you are looking for.



Raymond Zakhari, NP  

How’s it hanging?   You may never be asked this question by your doctor, but I assure you it is one of the most important questions you should be asked at every visit.

Sexual dysfunction in men is often a barometer of overall health: problems with desire, arousal and climax can often indicate underlying heart disease, diabetes, obesity, thyroid conditions, depression, and anxiety, adverse effects of medication, substance abuse, nutritional deficiency, testosterone levels, circulation problems, and infections. So I will ask again: How’s it hanging? More importantly when was the last time you climaxed and are you satisfied with your level of desire, arousal and orgasm.

In an effort to treat you with dignity, modesty, privacy, and respect many doctors cut corners with a comprehensive physical exam, and ask leading questions with the hope that you will not report any problems so they can move on to the next person. In fact many physician groups are now reporting that an annual physical exam is worthless in terms of promoting health, and preventing death. They have even gone so far as to advise against you performing testicular self-exams, deemphasized prostate cancer screening all the while jumping on the bandwagon of low testosterone as the holy grail fountain of youth and virility.

Most men dread a visit to the doctor because it is often a cursory drive by physical that ends in a list of things they should not do. That, combined with the nearly universal all female ancillary staff, from the receptionist who insists we share the most intimate details of our lives as a prerequisite for an appointment, to the tech, seldom medical assistant, who records those same details in our records, all prior to even seeing the doctor for 10 minutes. Given the extremely personal nature of men’s health care and the potential for embarrassment, why is privacy and dignity so callously disregarded on a routine basis for male patients? How would female patients feel if their OB/GYN was accompanied by a male assistant or chaperon barely out of high school. This double standard needs to change for men to feel comfortable in seeking health-care. I’m convinced a significant percentage avoid needed medical care for this exact issue. These are difficult issues to admit even to yourself, more so with your wife, and then we’re expected to share the most intimate details of our lives with multiple female strangers.

Another reason men avoid formal health care is they don’t trust the doctor. They feel that in their compromised state of undress they will be sold a bill of goods.  The main reason for this is that many doctors do not have the time to explain the game plan and explore alternatives. The patient is left feeling bullied into a decision they may not have been prepared to make. Therein lays the rub. Unfortunately, we all reach that moment in life when have to face our fears. For that reason it is important to find a primary care provider you can trust so that you retain control over your health care rather than settling for the doc of the day when you are truly in need.

  • You wouldn’t drive your car for 100,000 miles without an oil change and a tune-up, and expect it to be fine, would you?
  • Erectile dysfunction may be an early marker of cardiovascular disease

Fortunately, there is an alternative. Metro Medical Direct offers personalized men’s health care in the comfort of your domain (home, office, or hotel). This practice was founded in 2009 to take the hassles out of going to the doctor. Imagine no ancillary staff, no paper gown, no endless unproductive waiting, and no condescending tongue thrashing of what you are doing wrong. Imagine a partner in care who acts as your coach. A mutually beneficial and therapeutic partner with whom you can speak freely and ask any question that comes to mind. Medical house calls and a virtual one stop shop in which you can text or video chat for those times when you do not actually need to be examined.

The Men’s Health service offers specialized primary and psychiatric care to optimize your overall health.

If you would like improved:

  • Sexual health, libido, stamina, erectile function , urinary stream
  • Cardiovascular health
  • Evaluation and management of testosterone deficiency
  • Psychological treatment and support
  • Couples therapy when sexual issues are paramount
  • Manual therapy for pelvic pain and prostatitis
  • Evaluation and management of bone health
  • General and mental health

Services are confidential, no third party insurance accepted,

appointments are evenings and weekends.

Request an appointment online call or text 917-484-2709


By Raymond Zakhari, NP

Many patients do not exactly know what the difference is between these various mental health care providers and hopefully this article will clarify the difference.  A psychotherapist is a term used to describe any mental health professional regardless of their training level. It refers to the talk therapy that occurs within the session. Simply stated a psychotherapist is anyone who practices psychotherapy.

So what is psychotherapy you may wonder?

Psychotherapy is a structured conversation with the intent of supporting a patient or client in making changes in the way they think or act in order to be congruent with their personal values system. The goal is to restore balance to the environment in which they live. The person who has this conversation with you is a psychotherapist. The title psychotherapist is not protected because it can be used by many different disciplines. So the titles of the disciplines that use the tool of psychotherapy are protected and subject to licensure and state laws.

So who can do psychotherapy?

 Usually people that claim to do psychotherapy are licensed professionals and they can be physicians, nurses, social workers, clergy, psychologists, and mental health counselors.

  • A psychiatrist is a physician either an MD or a DO. They have completed a residency in psychiatry after medical school for at least 3-4 years. They can order and interpret tests, prescribe medications, provide psychotherapy, and order a commitment to an institution.
  • A psychiatric nurse practitioner is a registered nurse who has completed either a masters or doctorate degree with a specialization in psychiatry. A psychiatric nurse practitioner is licensed to order and interpret tests, prescribe medication, and provide psychotherapy.  State laws vary regarding their ability to order a commitment to an institution, and the types of medications that can be prescribed.
  • A psychologist is a doctoral educated person who has either a PhD or a Psy.D. This person is usually an expert in diagnostic testing, in the field of mental health they are primarily the ones that adminsiter Neuro Psychological Tests and interpret them. In some states psychologists can prescribe medication. Most states do not allow psychologists to order physiological tests or imaging studies. Psychologists can provide psychotherapy.
  • Social Workers, Mental Health Counselors, Marriage and Family Therapists, and Clergy: all of these professionals can provide psychotherapy. These mental health professionals cannot order and interpret physiological tests, or prescribe medication. These professionals cannot order a commitment to an institution. These are the most abundant and most common providers of psychotherapy. They are sometimes referred to as simply therapists.

How do I combine both my family practice training and family psychiatry training in a medical house calls practice?

As a nurse practitioner, I am able to diagnose medical illnesses some of which may present as mental health problems.  I pay particular attention to the medical impact of psychological problems and the psychological impact of acute and chronic medical problems. I can also prescribe medications and order and interpret diagnostic tests.

I had a patient with difficulty breathing, who happens to be at home on a CPAP machine, she was frequently getting admitted to the hospital for difficulty breathing. After I evaluated the patient I was able to identify the underlying cause as panic attacks. This same patient subsequently became depressed because of her ailing health, and stopped eating. This led to problems with her blood pressure. Once I was able to diagnose the three problems that were affecting and perpetuating each other I was able to effectively treat the panic attacks, depression, and low blood pressure. This patient whom I had treated complained that these symptoms had progressed over the last 2 years and had not gotten better despite 5 hospitalizations and ICU admissions.  

The patient had been seeing a psychiatrist, pulmonologist, and neurologist. Because I was able to see the patient in her home I was able to physically assess her during the panic attack I was able to distinguish her feeling of respiratory distress from actual respiratory distress.  Also, because of my psychotherapy training I was able to help the family around her cope with the psychological impact of chronic illness, issues of their own mortality, the patients sense of powerlessness, and to explore the likelihood of the patient’s death. I instructed the caregivers and family members how to assess for true respiratory distress, and how to respond to a panic attack. The patient was never readmitted to the hospital again, and eventually died peacefully at home surrounded by family.  Afterwards I was able to provide grief counseling to the family members.

I hope this posting clarifies the differences between all the various mental health professionals that can provide psychotherapy. I also hope it assists you in choosing they type of psychotherapist to best meet your needs.  The most important indicator and predictor of a successful therapeutic outcome is not the type of professional you choose or even they type of talk therapy they provide. It is if you like them and feel they understand you. Mental health professionals call this the therapeutic alliance. More on this later—

Headaches can vary from mild to severe. The pain can feel sharp, dull, throbbing, or aching. The type, severity, and location of the pain depend on the cause of the headache.

Most headaches do not have a serious cause, and most be treated at home.
Here is some care advice that should help. (This is intended for general information, and is not intended to be specific to your situation. You should seek personal care from your primary care provider)

Types of Headaches:

Migraine Headache:
This type of headache is called a vascular headache. It can be mildly to severely painful. People who get migraines often describe them as throbbing or pulsing. A migraine headache is often felt on just one side of the head.
You may also vomit or have an upset stomach. Some people will have visual warning signs before they get migraines.

Muscle Tension Headache:
Most headaches are caused by muscle tension.
People say the headache feels like a tight band around their head. You may feel tension down into your neck and shoulders. These headaches can be made worse by emotional stress.
These headaches are painful. There are pain medications you can take to help the pain.

Pain Medicines:

Acetaminophen (Tylenol):
Regular Strength Tylenol: Take 2 pills (650 mg) every 4-6 hours. Each pill has 325 mg of acetaminophen.
Extra Strength Tylenol: Take 2 pills (1,000 mg) every 8 hours. Each pill has 500 mg of acetaminophen.
Do not take more than (3,000 mg) of this drug per 24 hour period

Ibuprofen (Motrin, Advil):
Motrin and Advil: Take 2 pills (400 mg) every 6 hours. Each pill has 200 mg of ibuprofen
A second choice is to take 3 pills (600 mg) every 8 hours. DO not take MORE than 1800mg in 24 hours.

Naproxen (Aleve):
Aleve: Take 1 pill (220 mg) every 8 hours. Each pill has 220 mg of naproxen.
A second choice is to take 2 pills (440 mg) every 12 hours. DO not. TAKE more than 880mg in 24 hours

Extra Notes:
Use the lowest amount of a drug that makes your pain feel better.
Your healthcare provider might tell you to take more than what is shown above. That is because your doctor knows you and your health problems.

Acetaminophen is safer than ibuprofen or naproxen in people over 65 years old. Acetaminophen is in many OTC and prescription drugs. It might be in more than one drug you are taking. Be careful how much you take. Too much of this drug can hurt the liver.
Caution- Acetaminophen: Do not take it if you have liver disease.
Caution- Ibuprofen and Naproxen:
Do not take ibuprofen or naproxen if you are pregnant.
Do not take these drugs if you have stomach problems or kidney disease.
Do not take these drugs for more than 7 days without checking with your health care provider.
Read and follow all package instructions.

Migraine Medication: Take your prescription migraine medicine as soon as it starts.
Rest: Lie down in a dark, quiet place and try to relax. Close your eyes and try to relax your whole body.
Cold Pack: For pain, put a cold pack or cold wet washcloth on your forehead for 20 minutes.
Stretching: Stretch and massage any tight neck muscles.

Call Your Primary care provider If:
Headache lasts more than 24 hours or your symptoms worsen

Call 911 if you are falling asleep, feeling confused, having any weakness or numbness, or having slurred speech, this is the worst headache of your life, have a fever > 100.5 or believe you are having a life threatening emergency.

Raymond Zakhari, NP
Medical House Calls in New York City

You should establish a relationship with a primary care provider who is able to learn about your normal state of health and customize your care when you are ill.

It is estimated that one fourth to one third of patients transitioning in care will be re-hospitalized within 30 days due to preventable complications. The following risk factors have been identified as increasing the risk of hospital readmission within the first 30 days. The more risk factors the greater the likelihood the patient would benefit from a formal a transitional care plan and intensive primary care.

  • Age 80 or older
  • Moderate to severe functional deficits
  • An active behavioral and/or psychiatric health issue (diagnosed or not : most patients have not had a psychiatric evaluation)
  • Four or more active co-existing health conditions
  • Six or more prescribed medications (includes vitamins, supplements, and occasional pain medications)
  • Two or more hospitalizations within the past 6 months
  • A hospitalization within the past 30 days
  • Inadequate support system
  • Low health literacy
  • Documented history of non-adherence to the therapeutic regimen

Older adults are often hospitalized for a newly diagnosed condition or an exacerbation of a chronic condition. They are at an increased risk of re-hospitalization due to poorly managed transitions from home to hospital, and from hospital to home or other care settings.  Further complicating this situation is the condition of delirium which can be caused by a change in environment. Delirium can take several weeks to clear up particularly in an elderly patient with many medical problems. For older patients with multiple chronic conditions this “transition in care” is a point of great vulnerability along the continuum of care where many errors of omission and commission can occur.

The intensive primary care model is a patient-centered; nurse practitioner led interdisciplinary process that begins with an initial assessment of the patient’s potential needs prior to discharge. The primary aim is to help keep the patient at home safely. Patients are seen consistently and preventive to help detect subtle changes in condition that could result in a hospital admission. The nurse practitioner will attempt to streamline the medications that may be causing adverse effects leading to a decline in function. Intensive primary care is best suited for patients with multiple medical problems and or psychiatric co-morbidities that maybe increasing the risk of emergency room utilization. Emergency room utilization increases the risk of hospital admission in elderly people.

When a patient requires a transition of care from the hospital to home ongoing communication with the patient’s hospital care team and prospective care coordinator (loved one or professional care manager) help ensure a successful care transition while reducing the risk of readmission.

What should you expect from an intensive primary care evaluation?

In planning for a transition in care the patient’s medical record is reviewed and an assessment of the medical condition, and functional, social, cognitive capabilities is conducted to help assures that the comprehensive needs of the patient can be addressed. The patients, family member (professional care manager) are included in the process to help everyone understand and feel comfortable with the intended plan of care.  The process concludes with the coordination and implementation of services and transition to the patient’s home.

Intensive primary care does not require the patient be admitted to a hospital. Patients, family members, care managers can request the evaluation if they feel the medical condition is becoming increasingly complex. A good indicator that the condition is becoming increasingly complex:

  • Being prescribed increased amounts of medications
  • Being referred to numerous specialists
  • Being advised to have many diagnostic tests
  • You have had to utilize the emergency room more frequently
  •  You have been readmitted to the hospital more than once in the last 6 months.

If have a family member or are the care manager for a patient who has had to transition in care what lessons have you learned, and what advice would you pass on? Please share your comments so that together we can help each other.