Friday, December 5, 2014

The Main Factor Leading to Weight Loss Success!

In previous blogposts, we have underlined how being overweight can hinder a patient’s recovery and that weight loss is an integral part to their treatment plan.   Whenever discussing weight loss, two things often come to mind: nutrition and exercise. 

Now ask yourself this: which factor (exercise or nutrition) is the main determinant for weight loss success?  For those of you who guessed nutrition, you’re right!  Our society puts a huge focus on exercise as a tool for weight loss, and while exercise is essential to overall health, diet is the overwhelming key to weight loss.  Getting one’s nutrition on track (by using or utilizing a top-notch nutritionist/dietician) is, hands down, the most critical component in order to achieve your weight loss goals.  

Here at Lake Washington Sports & Spine, we are huge advocates of exercise, consistently championing its overall health benefits.  However, if your specific goal is weight loss, we find that patients often prioritize exercise over diet, which is a mistake. We understand this.  Frankly, exercise is more fun than dieting.  Studies have shown that diet is 10-20 times more important for weight loss success than exercise. Many patients will counter with “I always was able to maintain my weight with exercise in college”.

For people under 25 years old, exercise is often the “go to” in order to lose weight, which allows for sloppy eating to continue.  However, after 25, this method is no longer sustainable and easily leads to weight GAIN.  This is because, as a person ages, the amount of exercise required in order to lose weight (without changing their diet) is unrealistic. In order to lose weight via exercise, a person has to do as much as 90 minutes of intense cardio per day (yes, that means seven days a week)!  For most people, this is clearly unsustainable, for a couple reasons: either a person does not have an extra hour and a half per day to devote to intense exercise or their bodies break down and physically cannot handle the demands of such a workout regimen. The only realistic way to achieve one’s weight loss goals is to concentrate on one’s diet and make sure they are eating clean. 

Now, before you go off and think that losing weight requires becoming a gluten-free, lactose-free, vegetarian, it doesn’t need to be quite so drastic (unless you have specific medical requirements, of course). There are even relatively small changes to one’s diet that can make a monumental difference and lead to weight loss success. 

One pound is equivalent to approximately 3500 calories.  That means that if a person removes 500 calories from their diet per day, every day, they’ll be down one pound after a week! Now that’s some serious progress made! 

What this comes down to is TRACKING.  Every morsel that goes into your mouth needs to be documented, for instance in an app such as  Just keeping this information in your brain is not enough.  First of all, humans forget things.  It happens.  Without proper documentation, a person will forget that tablespoon of peanut butter they ate or the several handfuls of trail mix that was scarfed down during their break. 

Second, people have a tendency to drastically underestimate how many calories are in different types of food.  That tiny cake pop from Starbucks? That can’t be more than 50 calories.  Wrong! Those will put you back about 170 calories.  Myfitnesspal is the diet buddy that keeps people honest about their diet choices and can make the difference between weight loss success and failure.

Here at Lake Washington Sports & Spine, our goal is to help our patients stay active and become the best possible versions of themselves.  If weight loss is part of a patient’s journey to staying fit and healthy, we want to make sure they are given the best tools and recommendations for success.  For those wanting to lose some pounds, diet changes are essential in order to attain that goal and, as always, our team is here to offer advice and encouragement on your path to weight loss success!

Wednesday, December 3, 2014

What to expect during your visit at Lake Washington Sports and Spine

What to expect at your visit at Lake Washington Sports and Spine

We have all made a new appointment with a doctor’s office. After making that appointment do you ever find yourself setting expectations or having a vision of how the office looks, how the staff and physicians will act or how the examinations goes? I know I have! Hopefully this article will give you a better understanding of what to expect when being seen at Lake Washington Sports and Spine.
Here at LWSS our goal is to KEEP PEOPLE ACTIVE “KPA” and provide the best possible care for our patients. From the moment you walk in the door, to the minute you leave we want you to have a warm, positive experience, leaving you wanting to come back (until you’re better, of course!)
When you walk in, you will be greeted by our friendly front office staff and they will guide you through the check-in process. Per our office policy, if you are a new patient they will expect you to have all your new patient paperwork completed and to arrive at your check-in time.  If you are here for a follow up appointment, they will help you check in and will have you fill out a follow up form. These need to be completed prior to being seen by the physicians.  Arriving 15 minutes early to all appointments is important. If you are a new patient with NO paperwork filled out PRIOR to the normal 15 minute check in time you are required to come in 30 minutes prior to your appointment time.  Besides simply filling out paperwork arriving early helps patients get themselves into the right state of mind for the visit. Just as you wouldn’t want to show up at a soccer game five minutes into the start of the game and immediately start running full speed, similarly arriving early allows time to stop thinking about traffic and work and mentally prepare for the visit. This really does make a huge difference. 
While filling out your updated information and forms you can take a seat and relax in the waiting room. You may be greeted by Nala, Dr. Hyman’s twelve year old Cockapoo who joins us in the office a couple of times a week, or hear a friendly bark from Wynnie.   You will have approximately fifteen minutes prior to being called back by the medical assistants to enjoy the positive atmosphere, upbeat music, and also have a moment to help yourself to some coffee or tea. By the time the medical assistants call you back, our hope is that you had a chance to relax, center yourself  and prepare your thoughts for your appointment.  This time is helpful to reflect on your chief complaint, your goal for the visit and/or how you’ve improved thus far.
The medical assistant will call you back at your scheduled appointment time. They will introduce themselves and lead you to the patient room. Their main goal is to determine what your chief complaint is for this visit and what your specific goals are. They will also advise you that the physician will focus on your main complaint. This is due to a couple of reasons. 1) We want to provide the best possible care and be thorough during exams to rule out any possibilities that could be causing the issue. 2)Appointment times for new patients are  45 minutes long and follow up appointments are 15 minutes. This is why it is important to be on time for your check-in time, stay focused and resolve the, most important issue. If more time is needed to address other concerns we will ask you to make a follow up appointment so the physician can have a thorough appointment for that particular concern.
After speaking with the medical assistant and vitals are obtained you will be advised that the physician will be in to see you (usually within a few minutes.)

By the time the physician comes in the room he will have a better understanding of your chief complaint and goals to focus on. This will allow more time for a thorough exam and explanation for what the plan of care should be. To get the most out of your visit it is important to allow your physician to use their tools in a way or order that works best for them. They have a certain technique and questions they need answered in order to make a clear diagnosis. At the end of your visit they will take the time to listen to your feedback, concerns and ask if there is any additional information that may be pertinent to your symptoms that was not previously asked or heard.
For example: Say you were on a flight to New York, you would not benefit from trying to give a pilot directions on how to fly a plane since you are not the one with the training, likewise, if you knew what your diagnosis was you would not need to come and be seen by a physician and you would be able to diagnosis yourself. So relax and trust that our physicians are guiding the conversation to obtain the most important information that will be needed to get you back to your normal function.
At the end of the appointment the physicians, medical assistants and front office staff will be sure you have all documents needed for your plan of care (Referrals, chart notes, procedure documentation, imaging reports…etc) and will schedule any further appointments needed. If you are graduating at the end of your appointment we will have a graduation ceremony for you and a surprise bag to celebrate your fitness success and all the hard work you have put in to reach your goal.
We look forward to assisting you in your journey to maintain a healthy and active lifestyle!

Tuesday, December 2, 2014

Getting Your Test Results In Office

If you’ve ever been to a doctor’s office, chances are you’ve probably had medical tests, labs and/or imaging done to rule out or confirm different diagnoses.  At LWSS, a follow-up with the ordering physician is required to receive your medical test results.  Some patients wonder why their physician requires them to return to the office to get their test results.  It can be easy to let impatience and worries take over regarding a result follow-up appointment; What if something bad is found?  Why should I have to come all the way to the clinic for a quick answer over the phone?  Why is my physician charging my insurance and me for a result on a test they ordered?

LWSS physicians and staff are dedicated to providing the best care possible to our patients and a follow-up appointment to review test results is needed for several reasons:

·     To provide details- While reports are generated for any test performed, often times they are confusing and hard to read for the patient.  Test results associated with imaging especially are important to be given in the office since the physician will go over the actual images with the patient.  The images provide a “visual medium” which the physician can use to help explain what the results mean.  This cannot be done over the phone since the physician will have the images pulled up on the computer for both of him and the patient to view during the follow-up appointment.

·     To provide context- The physicians at LWSS are specialized at interpreting test results to determine some “false positives” and “false negatives” that could appear.  A false positive is a result with an abnormal finding but the patient is not affected; a false negative is a result with a normal finding but the patient is affected.  By coming in for a follow-up appointment, the physician can contextualize the findings for the patient.  For example: You’re buying a new home and have a home inspection to check on the condition of the house.  Within the home inspection report, there are a lot of incidental findings but you as the home buyer need to know which findings need to be acted on before you purchase the house.

·     To provide security- The physician recognizes the importance of disclosing test results to patients in a warm, safe environment.  Certain test results may include difficult diagnoses that can prompt many questions from the patient.  The physician wants you in office so they can answer any questions you may have, in person.  They will provide explanations of your treatment options, creating a referral and/or appointment for your treatment choice and more.  Also, it protects the patient’s confidentiality; while it sometimes is more convenient to receive a test result via phone or email there is no 100% way to confirm the patient’s identity unless they’re in the office.

·      To provide your physician fair compensation- When any test results are received, the physician takes dedicated time to review the results and determine the next steps involved in the patient’s care.  When the physician has invested his time and efforts into your care, it's only fair that he be paid.  A medical claim can only be sent to health insurance when a patient is seen for an office appointment; by disclosing test results to you over the phone the physician is unable to bill the insurance for the services they’ve just provided to you.

It is important to come in for your results follow-up appointment.  As a patient, you need to understand what these results mean and discuss the next best steps with your physician.  I hope this provides a better understanding of the importance of attending your results follow-up appointment and as always our team is here to support you on your path to staying active!

Wednesday, November 5, 2014

Knowing Your Benefits: In-Office Procedures

The great thing about coming to Lake Washington Sports and Spine is that for many patients we are a “one stop shop”.  A consultation at LWSS includes a guided interview with a physician, followed by a physical examination, to help diagnose a chief complaint and determine the next best step.  Our physicians not only provide a consultation but also have the capacity to perform in-office (or outpatient) procedures saving the patient an extra trip to a different location for another visit.  Some health insurance policies require a co-pay up front, which can cover the consultation portion of a visit...but what if you have an in-office procedure in addition to the consultation?

Some of the procedures that may be performed during an office visit are:

·         Diagnostic testing -including ultrasound and electrodiagnostic testing 
·         Ultrasound-guided injections -including but not limited to  joint, tendon, and bursa injections, viscosupplement, prolotherapy and platelet-rich plasma

Most procedures done in-office are going to be subject to your insurance policy deductible and co-insurance.  Prolotherapy and platelet-rich plasma injections are non-covered under any health insurance policy, these are self-pay procedures.
What is a deductible and what is co-insurance?

·         Deductible -a set amount that you must pay each year before your plan pays for certain services such as outpatient procedures, hospitalizations, and radiology. You meet this deductible once each calendar year.
·         Co-insurance -your share of the fee for a service in the form of a percentage.  If your plan’s coinsurance share is 20%, you pay 20% of the allowable charge and your health plan pays the remaining 80% of the allowable charge.

For example:
New patient Wynnie Smith gets referred for a consultation and ultrasound for shoulder pain, and she has Regence Bluecross Blueshield insurance.  The physician takes her through a consultation of the shoulder pain, and additionally performs a diagnostic ultrasound procedure to check the muscles, ligaments and tendons surrounding the shoulder.  After discussing various treatment options, the physician advises an injection of corticosteroid (Triamcinolone) in the subacromial bursa to ease some discomfort.  As there is time left in the appointment to perform this procedure, Wynnie elects to have the injection.

For example (What we would bill to Regence Bluecross Blueshield):

CPT Code 99204 (New patient consultation) subject to co-pay OR deductible (based on individual policy)
CPT Code 76881 (Diagnostic Ultrasound) subject to deductible and co-insurance
CPT Code 76942 (Ultrasound guidance for the injection) subject to deductible and co-insurance
CPT Code 20610 (Arthrocentesis, aspiration and/or injection, the actual “injection” code) subject to deductible and co-insurance
CPT Code J3301 (corticosteroid-Triamcinolone, medication injected) subject to deductible and co-insurance

While your first reaction may be “Whoa! That’s a lot of charges!”, consider this:  When visiting LWSS, you really are getting the benefit of an all-inclusive experience.  A patient can receive not only a top-notch consultation by a specialist but also a diagnostic procedure and injection all within the same appointment.  By having the capacity to perform these in-office procedures all at one location, you’ve just saved yourself 3 separate visits. 

It’s important as a patient that you take ownership of what your benefits are ahead of time, so if and when you have an in-office procedure you know what your deductible amount is and what your co-insurance responsibility will be after the deductible has been met.  I encourage you to contact your health insurance provider for that information and as always I wish you well on your path to staying active!  

Friday, October 24, 2014

Knowing Your Benefits: Outpatient Injections

Understanding your health insurance benefits can feel like navigating your way through stormy seas without a compass.  It is important to find out your benefits ahead of time so there are no surprises when you receive an Explanation Of Benefits (or EOB) from your insurance or a billing statement from your health provider.  Here are some tips below to help the process go more smoothly!

To determine your insurance benefits prior to coming in for a procedure at the surgery center, you may contact your insurance provider directly and follow the steps below:

·         Call the Member Services number located on your insurance card; if needed our Tax ID is 45-4054764.
·       Ask the representative what the benefits are for the CPT Codes associated with your procedure (please see list below):

99144- Conscious Sedation
64483- Transforaminal Epidural/Nerve Block (Lumbar/Sacral) (1st level)
64484- Transforaminal Epidural/Nerve Block (Lumbar/Sacral) (2nd level)
64490- Paravertebral Facet (Cervical/Thoracic) (1st level)
64491- Paravertebral Facet (Cervical/Thoracic) (2nd level)
64492- Paravertebral Facet (Cervical/Thoracic) (3rd level)
64493- Facet or Medial Branch Block (Lumbar/Sacral) (1st level)
64494- Facet or Medial Branch Block (Lumbar/Sacral) (2nd level)
64495- Facet or Medial Branch Block (Lumbar/Sacral) (3rd level)
62310- Interlaminar Epidural (Cervical/Thoracic)
62311- Interlaminar Epidural (Lumbar/Sacral/Caudal)

Remember, there are going to be 2 separate sets of charges associated with your procedure; one set for the physician (Dr. Hyman or Dr. Chimes) and one set for the Ambulatory Surgery Center (Overlake or Evergreen).  To determine what the charges are for the surgery center, please contact them directly at the phone number provided on your injection forms.  I hope this information can assist you in obtaining your insurance benefits and continuing on the path to staying active!

Wednesday, October 22, 2014

Cervicogenic Headache

The following excellent article is from my friends and former colleagues Eric Helm and Robert Donlan on the topic of cervicogenic headache

Cervicogenic headache means "Headaches caused by the neck."  I think Drs Helm and Donlan outline a good overview of how diagnosis and management

Helping physicians be better listeners- through patient responsibility

One piece of feedback that patients give all clinicians is that they want to "feel really listened to."  They don't want clinicians to spend time questioning whether they are being honest or mis-representing themselves.

Imagine yourself in the scary situation of a new onset of pain in your neck, and beyond just the horrible pain, you are worried that the pain is just the tip of the iceberg and may indicate evidence of a more serious condition.  Because of your concern, you go to the Emergency Room.  Tell me which of these situations you'd prefer:

Situation A: You are immediately evaluated by Clinician A, who assumes that everything you are saying is true, and assumes your only motivations are to be assessed by a skilled clinician and get steered efficiently toward an appropriate treatment

Situation B: Clinician B, who has the same basic skill set, but before they can speak to you, they saw 2 patients with similar symptoms, but who had a long history of drug abuse, and have histories of using the ER to obtain opiates.  Clinician B needs to take seriously that these patients may actually have real pathology that needs to be treated, but is appropriately concerned that they are abusing the ER to obtain drugs.

I'd obviously be seen by Clinician A.

Thinking about this, what is the difference between the two clinicians?  There is nothing intrinsic to the physician that is different- the difference is all things outside of their control.

So, if you are are the patient, it would be ideal to create a social environment that allows people stuck in the situation of Situation B, and allow them to practice in an environment more similar to Situation A.  This would allow the clinician to be a better listener.

Unfortunately, that is NOT the current healthcare environment we have created.  The excellent blog had a wonderful post this week called The ER Demonstrates the Inverted Priorities of American Society.  In this blog post, Dr. Edwin Leap details how our current healthcare structure creates a Moral Hazard, where patients no longer have societal checks in place to prioritize their own health.

My experience with blog posts like these is that people react to this as follows:
- Clinicians- read it, and feel "At last!  Someone is getting the word out about what we have to deal with!"
- Some patients - read it, and feel "I get what they are talking about, but this doesn't explain ALL patients, and I'm a little bit uncomfortable with the 'blame the patient' mentality."
- Other patients- read it, and feel "This jerk hates patients!  Proof that doctors are evil!"

Clearly, there is a disconnect.  I think the main disconnect is related to how many unreasonable patients there are.  If the unreasonable patients described in Dr. Leap's post accounts for 1 in 5000 patients, then I'd agree that he may not be sufficiently prioritizing empathy.

But what if the % of unreasonable patients is much higher?  Speaking with colleagues who work in Emergency Room settings, the % of unreasonable patients can be very high, often over 50%.  I feel for the patients, but also feel for the physicians treating them.

Ideally, I like to work in one mode, which is "get patients better" mode.  I don't like having a second gear of "let me figure out if this patient is telling me the truth" mode

Therefore, creating systems where patients have some "skin in the game" is a necessary measure to make sure that patient's spend effort prioritizing their own health.

Tuesday, October 21, 2014

The Key to Age Defiance? Exercise!

Remember in your younger years when a cold might wipe you out for a few days, but then you were quickly back to running and jumping on the playground?  Well, as people age, their ability to bounce back from disease and injury takes longer and a bigger toll on the body.  These changes are MOST noticeable during the transition out of middle age and into the senior years, when even the flu can be detrimental to your health. In order to delay aging, there is in fact a “Fountain of Youth”:EXERCISE!

The American College of Sports Medicine (ACSM) has designed exercise guidelines both for adults under and over the age of 65.  The guidelines include a mixture of aerobic and strength training recommendations that, when combined, can help a person reach and maintain optimum fitness and delay aging.


The following exercise guidelines are recommended by the American College of Sports Medicine:

  •  Do moderately intense cardio 30 minutes a day, five days per week (intense enough that you cannot sing, but can hold a conversation)


  • Do vigorously intense cardio 20 minutes a day, 3 days per week (intense enough that you cannot sing)

  •  Do eight to 10 strength-training exercises, eight to 12 repetitions of each exercise twice a week.

Moderate-intensity physical activity means working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation. The 30-minute recommendation is for the average healthy adult to maintain health and reduce the risk for chronic disease.

 It should be noted that to lose weight or maintain weight loss, 60 to 90 minutes of daily physical activity may be necessary.  For most adults over 25, this is NOT a sustainable level of exercise, both because most professional adults frankly do not have that time of time available every day, and because most adults who exercise for that duration usually break down from injury.  This has several consequences:
      We emphasize the importance of FREQUENCY rather than DURATION.  Some people are inclined to circumvent the 30 minutes per day, 5 days per week by trying to catch up and do one super-long workout over the weekend.  That is NOT equivalent.  Just as it is important to divide your food intake into 3-4 meals per day rather than one big meal, it is important to divide exercise so that is a DAILY activity.

2       For overall health, exercise is the most important intervention.  However, for the specific goal of losing weight, diet matters significantly more than exercise.  We will discuss this more in a future blog post, but no one is capable of sustainably overcoming poor dietary habits with exercise.

**With busy work schedules, family obligations, and packed weekends, it can often be difficult to get the recommended amount of physical activity. Try these tips for incorporating exercise into your life:
- Do it in short bouts. Research shows that moderate-intensity physical activity can be accumulated throughout the day in 10-minute bouts, which can be just as effective as exercising for 30 minutes straight. This can be useful when trying to fit physical activity into a busy schedule.
- Mix it up. Combinations of moderate- and vigorous-intensity physical activity can be used to meet the guidelines. For example, you can walk briskly for 30 minutes twice per week and jog at a higher intensity on two other days.
- Set your schedule. Maybe it's easier for you to walk during your lunch hour, or perhaps hitting the pavement right after dinner is best for you. The key is to set aside specific days and times for exercise, making it just as much a regular part of your schedule as everything else.
- The gym isn't a necessity. It doesn't take an expensive gym membership to get the daily recommended amount of physical activity. A pair of athletic shoes and a little motivation are all you need to live a more active, healthier life.
- Make it a family affair. Take your spouse, your children, or a friend with you during exercise to add some fun to your routine. This is also a good way to encourage your kids to be physically active and get them committed early to a lifetime of health.


The following exercise guidelines are recommended by the American College of Sports Medicine:

  • Do moderately intense aerobic exercise 30 minutes a day, five days a week (intense enough that you cannot sing, but can hold a conversation)


  • Do vigorously intense aerobic exercise 20 minutes a day, 3 days a week (intense enough that you cannot hold a conversation)


  • Do eight to 10 strength-training exercises, 10-15 repetitions of each exercise twice to three times per week

·        ** If you are at risk of falling, perform balance exercises **

Both aerobic and muscle-strengthening activity is critical for healthy aging. Moderate-intensity aerobic exercise means working hard at about a level-six intensity on a scale of 10. You should still be able to carry on a conversation during exercise.

Older adults or adults with chronic conditions should develop an activity plan with a health professional to manage risks and take therapeutic needs into account. This will maximize the benefits of physical activity and ensure your safety.

Starting an exercise program can sound like a daunting task, but just remember that your main goal is to meet the basic physical activity recommendations: 30 minutes of moderate-intensity physical activity at least five days per week, or vigorous-intensity activity at least three days per week, and strength training two to three times per week.

Choose activities that appeal to you and will make exercise fun. Walking is a great, easy way to do moderate-intensity physical activity.


  • Start, and get help if you need it.  The general recommendation is that older adults should meet or exceed 30 minutes of moderate physical activity on most days of the week; however, it is also recognized that goals below this threshold may be necessary for older adults who have physical impairments or functional limitations.
  • Functional health is an important benefit of physical activity for older adults. Physical activity contributes to the ease of doing everyday activities, such as gardening, walking or cleaning the house.
  • Strength training is extremely important. Strength training is important for all adults, but especially so for older adults, as it prevents loss of muscle mass and bone, and is beneficial for functional health.
  • If you can exceed the minimum recommendations, do it! The minimum recommendations are just that: the minimum needed to maintain health and see fitness benefits. If you can exceed the minimum, you can improve your personal fitness, improve management of an existing disease or condition, and reduce your risk for health conditions and mortality.
  • Flexibility is also important. Each day you perform aerobic or strength-training activities, take an extra 10 minutes to stretch the major muscle and tendon groups, with 10-30 seconds for each stretch. Repeat each stretch three to four times. Flexibility training will promote the ease of performing everyday activities.