Jill

I had a delightful bike ride today along the Sammamish River Trail this afternoon.  One of my favorite things about cycling is getting lost in meditative thought, never knowing where your mind is going to take you .....

I started thinking about the dinner party game of asking people which of your bodily senses- vision, hearing, taste, etc- you would least like to lose.  Most people answer vision, sometimes people answer hearing.  To me, the answer is touch.

From a physician's standpoint, while losing vision would be challenging, I think it's even more dangerous to lose touch.  Touch is important for safety- avoiding hot or sharp objects, for example.  When diabetic patient's develop peripheral neuropathy, they often do severe damage to their feet, sometimes leading to amputation.  Loss of touch is one of the reasons old men tend to break their cars in a ratchety, choppy motion- they can't feel the gas pedal reliably, so they rely on visual stimuli to break, which isn't as sensitive.  Loss of touch leads to falls, which can be fatal.

But it's more than that- touch, to me, is the essence of what it means to be human.  The feeling of warmth of a mother's hug, cuddling a loved one, the feel of a dog's fur- so many of our most joyful experiences are touch.

I think touch is clearly the most important sense, but because it is so intimate to what means to be a person, it's hard to conceptualize not having it.  And for that reason, it often goes unappreciated.

..... so I continued cycling past the vineyards in Woodinville, and started thinking about another big picture question- who is the most influential person I've ever known.  Since I am not far removed working in academia, my first thoughts turned to my academic mentors.  Then I thought to my close friends, many of whom I've known and remained close to since grade school, and my parents, and my older brother Mike, who I grew up idolizing ....

and then it occurred to me that the obvious person was my twin sister Jill.  Jill is clearly the most important person in my life, the one person who has had more impact on making me the person I am than anyone else in the world.

For those who don't have a twin, we certainly don't have any superpowers or a hidden telepathic bond (as awesome as that would be).  There was a period from our early teens through our 20s when Jill and I weren't even particularly close.  One of the joys of middle age, however, is the perspective you gain from being able to look back on life decisions and realize how much someone has made an impact on your life even when you didn't realize it.

The greatest gift of having Jill as a twin as that I've always had a peer comparison for everything I've done.  I think, for me, having a twin sister was particularly valuable, and my entire life I have been fascinated with the variation between boys and girls.  One obvious example is my PhD work, looking at sex differences in overhand throwing performance, and another is my current clinical interest in the role of sex differences in musculoskeletal injuries, whether it be because of differences in biomechanics or hormones.

But it's more than that. I think that I've always positioned myself to have two pathways in life, whether it's being a double major in college (Math and Zoology), having two possible career pathways (MD/PhD, or Professional Wrestler), doing a dual degree MD/PhD ... I think I always craved the comfort of having two options available to me.

I've also always craved partnership.  Ever since Jill wasn't in my life on a daily basis, I've been on the look for surrogate twins.  One such person was Jim McLean, my best friend in both residency and fellowship.  We just passed the 6th anniversary of Jim passing away (http://jimmcleanmd.blogspot.com/), and perhaps my thoughts about Jill are part of my coping with how much I miss Jim.  I often struggle in wondering whether I am doing right by Jim's memory ....

.... and that brings my back to Jill.  I am fortunate not just in having a twin sister, but specifically in that my twin sister is Jill.  One of my great joys in life is introducing Jill to people close to me for the first time.  She's .... kind is probably the best word.  She's very sweet, both in how she treats me, but in how she treats everyone - her husband Steve, her children Kaine, Landon, and Kaylen.

That kindness is Jill's greatest gift to me.  There are lots of forms of love that exist in the world, but I don't think there is any as pure as that of a twin sister.  One of my favorite memories of Jill is finding a tape when we were teenagers, at an age when we were frequently bickering with one another.  It was a tape that we made when we were 5 years old, singing the soundtrack to "Grease".  It was pure, it was sweet, it was joyful and it was kind.  It was a wonderful reminder of how it's easy to take for granted having Jill in my life from the beginning, and not taking her for granted.

It's nice to have moments to reflect back on how much kindness matters.  It's nice to know you have someone who loves you unconditionally, who is rooting for you, takes joy in your successes, is a source of comfort for your struggles, and is such an intimate part of the fabric of who you are that to be without them would be like living in a world without touch.

So, thank you Jill, for your kindness, and reminding me what it means to be a good person.  I love you.

Differential Diagnosis- Understanding How a Doctor Thinks

One thing that I think will help patients get more out of their doctor's visit is understanding the concept of a "Differential Diagnosis" and how this affects how doctor's think.

A "Differential Diagnosis" is a list of all the possible explanations for what may be causing a patient's symptoms.  When a patient comes to see me, the first thing I want to know is what their main symptom is, what we sometimes refer to as a "Chief Complaint".  Since I am a Sports & Spine specialist, most commonly this may be an injured body part.

Once I know the area of concern, I can start formulating a list of the things that may affect the patient.  For example, let's say the patient's chief complaint is "pain near the shoulder blade" (.... doctor-speak, I would call that peri-scapular pain, but I actually prefer the lay term of pain near the shoulder blade).  Given that chief complaint, I would start formulating a list of things that cause cause the symptom (this list may be intimidating, so for those not familiar with the terminology, the point is that I am thinking of a big list):

Chief Complaint: Right shoulder blade pain

Differential Diagnosis:
- Middle Trapezius/ Rhomboid/ Levator Scapula/ Serratus muscle strain
- Right lower cervical facet arthropathy
- Notaliga paresthetica caused by lower cervical radiculopathy
- Cervical myelopathy
- Costo-transverse joint dysfunction
- Thoracic facet syndrome
- "T4" syndrome
- Insertional Enthesopathy from the common tendon insertion of the Rhomboids and Serratus Anterior
- Thoracic herniated disk
- Thoracic radiculopathy
- Referred pain from gall bladder
- Thoracic compression fracture
- Aortic aneurysm
- Postural fatigue from the thoracic paraspinals
- Somatic manifestation of anxiety
- Contusion from blunt trauma
- Metastatic lesion from cancer
- Primary pulmonary tumor
- Tuberculosis

This list could go on for a while.  Because of the nature of my practice, there are certain things that are more likely or less likely, depending on referral source, patient demographics, etc

At this point, I like to go through a structured interview to help ruling in and ruling out different causes.  Some of these causes are rare (e.g., tubercolosis), but because the consequence of missing this diagnosis is so high, I ask anyway.  For example, I may ask about tripping and falling, which may seem irrelevant to someone with pain in the shoulder blade.  However, if the person has a spinal cord compression (cervical myelopathy), often the first sign is a loss of balance.  This is why the patient is paying for my expertise and judgment- I've learned over time which details matter and which details don't.

The patients who allow me to work my way through the structured interview usually find the process rewarding and time efficient.  To me, the process is very similar to how I solicit expertise from my attorney or accountant.  Rather than asking my accountant questions about the tax code I read about on the internet, I let him guide me through those issues that I should be most concerned with, and at the end I'll let him know if there are things I still was wondering about.  There usually isn't - he knows what he is doing.

Usually, based just on chief complaint, age, and gender, the top 3 things on my list would account for over 80% of what is going on.  I still go through this process, though, because the 20% of the time that something else is involved is pretty high.

After performing my structured interview, I like to perform my physical examination.  This again helps me alter the probability for each of the items within my differential diagnosis.  Some examination maneuvers are, again, not obvious.  For example, for a patient like the one we are describing, I will usually perform a Babinski test, when I scrape the bottom of their bare feet.  Many patients wonder why I ask them to take off their shoes for shoulder pain, but for the less than 1% of patients who have positive Babinski test, it may be a critically important indication that they have a more serious neurologic condition.

Only after I have performed my structured interview and physical examination will I look at tests, like MRI imaging or electrodiagnostic studies.  Many patients will ask (.... or not really ask ... they state) "I don't understand why you are asking these questions- I already had an MRI."  The reason is that most tests have significant limitations.  For example, the false positive rate in spine MRIs can be EXTREMELY high- in some patient populations - well over 70%.

After this process, I then formulate what I think the most likely cause of the patient's symptoms are, formulate a treatment plan, and do my best to educate the patient on what I am thinking and why I think that way.   I like to think it works well.

Now, here is the key detail for patients- I've spent well over Malcolm Gladwell's recommended 10,000 hours refining the process, and I am very good at it.  When patients allow me to practice in the way that I've practiced, my success rates are high, and more importantly, the PATIENT's success rates are high.

Sometimes, however, the patient prefers that I modify the way I think about things to fit another approach.  While I am capable of doing this, it takes me out of my primary skill set.  Just like Michael Jordan is not as good a baseball player as he is a basketball player, I am better at being a physician than I am at anything else, and when I am asked to work in a way that is different than how I have practiced (.... and this is why we call it a "Physician Practice"), I am not as good.

This reminds me of a story Dr. Drew Pinsky told about his experiences with prostate cancer.  The main points that he learned from interacting with his own urologist, who saved him from prostate cancer:
1. Don't ask for special treatment.  Ask for treatment most consistent with the way the doctor normally does things
2. You are paying for the judgment of a highly educated and experienced professional.  Allow them to use their judgment

I would add a few suggestions as well:
1. Show up on time.  Nothing throws a physician off more than feeling time pressure. It's also a courtesy to every other patient seen that day
2. Make the doctor's job easier.  Filling out paperwork, bringing imaging and records, allows the doctor freedom to think, rather than looking stuff up
3. Have a clear chief complaint.  The differential thinking process starts with a chief complaint.
4. Don't worry about what factors led you to the doctor's office.  Many patients want to give a narrative story of what events led to them visiting the office.  It is much more important to have a chief complaint- that's when I can start problem solving.
5. If something seems irrelevant, go with it anyway.  The doctor is probably going through their differential thinking process, and trying to rule in and rule out different causes
6. If at the end, you are still confused, let the doctor know
7. Clearly state your goals for the visit

Hope this is helpful

Posture

A lot of discomfort can be attributed to maintaining poor posture (check out this previous blog post). One easy way to maintain good posture is by starting off the day with good postures. Here is a simple way to get your day started off on the right foot.

Good Mornings:

1. When you wake up in the morning, stretch your arms overhead like you are having a good yawn

2. Keep your arms overhead

3. Concentrate on reaching upward toward the sky

4. Look upward

5. Try to reach your arms back, so that you feel like you have a good stretch in your chest

6. With your arms overhead, but looking forward, walk for 1 minute.  Make sure you watch where you are walking, but keep your arms overhead

- Now that you have started your day with a good posture, try to remind yourself throughout the day to stand tall, proud, and energized

It is especially difficult to maintain good posture throughout the day because as you tire, your body will naturally try to assume the fetal position and hunch over. Here is a very easy technique that you can use to “reset” your posture, helping to properly load your spine.

-Stand up with your back against a wall

-With your buttock and shoulder blades touching the wall, lift both arms above your head

-With your arms above your head, turn your head to the right, then to the left

-Bring your arms down, and step away from the wall, you should notice that you are standing straighter

-Try to maintain this posture throughout the day, and repeat as necessary

What's right with you?

One of the things that I think is off about modern medicine is that we are constantly asking "What's wrong with you?"

Part of the reason with this is that the main governing body that dictates most healthcare policy, the Centers for Medicare and Medicaid Services (CMS), won't pay for a patient visit unless we have a chief complaint.

If you think about that, it's an absurd way to approach life.  Imagine this any other domain of life. Imagine you went to a restaurant, and they asked "What's wrong with you?  What's your problem?"

There is an alternative approach, which is asking about your goals, your aspirations, and what barriers prevent you from achieving these goals.  I find this a much more positive way to talk to patients, and leads to a happier end point.

Along those same lines, in the Impression/Plan section of our notes, we often include a list of all the things wrong with a patient, which again strikes me as an overly negative way to approach medicine, and to approach life.  One of the things I try to include in notes with patients are predictors for success.

For example, I just met a lovely 63-year young retired educator with multiple musculoskeletal conditions.  I made sure my note included:

Predictors of good outcome:
- kindness
- intelligence
- nice skin (a marker for overall connective tissue health)
- non-smoker
- married
- educator
- minimal focal weakness
- has not hired an attorney
- primary motivation is to exercise

One of the joys of working in a physician-owned practice with my partner Garrett Hyman is that Garrett and I have the latitude to focus on the positive aspects of patient care.  CMS may not think these things are important (.... and you can see where CMS's true value system is, because they don't pay you for talking about the positive, only the negative), Garrett and I think it's important.  And we think that a focus on the positive is the "secret sauce" that leads to better patient outcomes.

Biggest Loser Group

Like many people, I struggle with my body weight.  I obviously treat health and wellness for a living, and I know what I need to do, but I need a support structure to help keep me accountable.

One tool that has helped me immensely is MyFitnessPal (www.myfitnesspal.com), which I will discuss in another post.

The most helpful intervention I've ever had, though, is a Biggest Loser Group started by one of my high school friends, Dan Stewart.

Our group, Dan's Friends are Losers, is a Facebook group started by Dan, and has been incredibly successful in creating a positive atmosphere that has kept us accountable.

This is a picture of Dan and I from April.  It's a bit cloudy- we took it right after Dan and I did two hours of mixed martial arts training at his gym in New Jersey.  Dan was training for his first MMA competition (which he won!  I think by a 1st round Kimura), and I visited his gym on my cross-country drive moving to the Pacific Northwest.

Dan has many great attributes a coach and motivator, and these are things I try to bring into my medical practice when I coach and motivate patients, the most important being positive energy and focusing on what I can do to help patients get better.

One thing that I've learned is that people can be in one of two modes, and you can't be in both simultaneously:
Mode 1: "What can I do to improve and get better" mode
Mode 2: "How do I make excuses for why I can't get better" mode

Dan is great at making sure we stay in Mode 1, keep our eyes on the prize, and focus on continuously improving.  Dan asks no less from me, and I owe it to my patients to try and be a positive motivator like Dan.

This is Kate.  She was my "summer buddy" - I life guarded at the pool in her home town of Roosevelt, NJ back in 1989, and she taught me everything I know about 1970s rock music, and kept me in good spirits while I hung out at the pool.  Kate is one of those great friends you lose track with over time, and we've reconnected through our Loser's group.

Kate's lost an enormous amount of weight - I think it's well over 100 bs, and is again a source of positive inspiration.  Whenever I think of Kate, she reminds how important weight loss really needs to be through a lifestyle change, and not just a periodic deprivation.

Scott and I went to high school together, but did not know each other then.  Scott's a great example of how you can make friends through the support group.  He won one of the rounds, and has managed to keep losing weight even after he "won."

More importantly, through our Loser group, I've developed a friendship with Scott.  I find him a thoughtful, philosophical colleague who constantly broadens the way I think about things.

This is Mike and I.  Mike and I first met as 9 year olds playing soccer, and what I've realized from getting to know Mike again while we are middle-aged guys in our early 40s is that you don't really know people when you are 9 years old.  Before Mike and I became friends again as adults, the most I could tell you about Mike was that he had a great cross pass for a 9 year old.  It's been enjoyable getting to know Mike the adult.

Ok, enough reminiscing.  What are some of the best tactics for weight loss I've learned a Loser?

Some tactical tips:
1. Go to bed early.  Sleep is necessary for proper healing.  Also, it's really hard to eat when you are asleep
2. Don't eat after dinner.  Most of my weight gain happens from night eating
3. Keep yourself accountable
4. Buy cheap jeans at Costco.  One of my favorite tricks is to buy a pair of jeans one size too small from Costco, and wear those when walking the dog in the morning.  Powerful incentive to stay on task
5. Keep tempting foods out of your sight-line.  Whenever people bring in "gifts" of chocolate or pastry, I immediately give it to my medical assistant to hide from me.  Even if I don't eat it, I think about it all day and then make bad food decisions.
6. Create opportunities for incidental exercise.  I have a Jungle Gym XT and Pull up bar set up both at the office and at home, which allows me to bang out a few quick reps .... BAM!- just did 5 pull ups before writing point #7
7. Focus on the positive.  I constantly repeat the mantra of "I want to be the best possible version of myself everyday" to remind myself of my goals
8. Focus on being better, not perfect. Better is obtainable, perfect isn't
9. Focus on what I can do, not on what I can't do
10. Express gratitude to the people in my life who have helped me get where I am today.  That starts with my girlfriend and my dog, extends to my partner Garrett and the rest of my practice, and most definitely includes my patients and my Loser group who inspire me every day

As Dan would say, "I'm a Loser, and that makes me a Winner!"

Hip Flexor Stretch

Hip Flexor Stretch

Limited hip mobility is often a major contributing factor to lower limb and back injuries. Your hip flexors — which allow you to lift your knees and bend at the waist — are located on your upper thighs, just below your hipbones. In fact, research by Casey Kerrigan has shown this one stretch in particular, performed 30 seconds daily, can dramatically improve many conditions. It can make a huge impact for many of our patients: 
1. Patients with spinal stenosis
2. Young athletic patients with tight hip flexors
3. Patients with lumbar facet arthropathy

To stretch your hip flexors:

Kneel on your right knee, cushioning your kneecap with a folded towel.

Place your left foot in front of you, bending your knee and placing your left hand on your left leg for stability.

Place your right hand on your right hip to avoid bending at the waist. Keep your back straight and abdominal muscles tight.

Lean forward, shifting more body weight onto your front leg. You'll feel a stretch in your right thigh.

Hold for about 30 seconds.

Switch legs and repeat.

The USMST and Professional Gratification

WALKING THE TALK

Physicians have an interesting background when it comes to defending the public health and engaging in health promotion activities.  Take smoking cigarettes, for example.  While this week marked the 50th anniversary of the landmark Surgeon General's report on smoking and health (published 1964), some of us can remember magazine ads of that time-period showing the wise-old white-coated doctor lighting up in his leather-bound office chair, promoting the supposed health benefits of smoking Newport Lights!  Now after decades of exposure to fervent anti-smoking messages, the tobacco industry's 'next generation of smokers' is smaller than ever.  

Next think about the obesity epidemic.  Many of us think we should lose a few pounds.  More and more physicians are discussing body mass index (BMI) and recommending weight loss and describing the health benefits.  Yet many physicians are themselves overweight or obese.  The same can be said about getting the recommended weekly amount of exercise?  Quite a significant percentage of exercise-prescribing physicians do not get the recommended amount themselves.   

What does it mean to our patients when we, as physicians, do not embrace our own teachings?  I think it means a lot.  We know that a person is 8x more likely to try and quit smoking cigarettes when counseled to do so by their physician as compared to a family member.  That's powerful.  However, I imagine the smell of smoke on my breath or clothes would dilute that message.

I recently stayed at a hotel that also hosted a regional dance competition, and there were hundreds of very athletic young women participants.  I was impressed, however, that these slender and strong dancers invariably were accompanied by a set of portly and stout family parental figures.  And I thought to myself, "what message do we send to our youth, as parents or teachers or physicians, when we fail to practice what we preach?"  The clear message is, it's great to be active when you're young, but adults are too busy to exercise and eat right.  Someday, when I am given the choice to live as I want, without anyone pressuring me to live and behave a certain way, I can be fat too.

TAKING ACTION

As an established mid-career physician two-years into a new privately held business, I recognize that I am very fortunate to have the flexibility to refine my practice direction.  Together with my wonderful partner, Gary Chimes, we are dreaming big as to how we as sports and musculoskeletal specialists can best serve the health needs of our community.  We truly hope to elevate the standards of health and well-being of the greater Eastside community.  And we understand that part of doing so involves demonstrating our own personal commitment to health and fitness.

SOCCER FOR HEALTH

And this brings me to the highlight of this post.  I just finished a fabulous weekend in Los Angeles at a 'tryout' for the US Medical Soccer Team (USMST).  The US Medical what, you ask?  That's right, you read correctly, the US Medical Soccer Team.  This fabulous not-for-profit organization was created approximately 5 years ago by two soccer-devotee physician friends.  A German physician told them about the World Medical Football Championships, and how about 8 other countries had been gathering each July for a combined conference (The Global Conference on Health and Medicine in Sport) and mini-World Cup event where national teams of physician footballers compete for glory and bragging rights.  These two visionary American physicians recruited other physician footballers (FYI around the world, soccer is referred to as 'football') from around the nation, and have been competing at the World Medical Football Championships ever since.

The physicians of the USMST are a special group in that the mission of the organization includes health promotion.  The team presently convenes for training and community service events 3 times per year, and these events are held on both coasts and somewhere in the central US.  

I learned about the team while attending the American College of Sports Medicine (ACSM) conference in June 2013.  The ACSM solicited the USMST to partner and collaborate on spreading the message that "Exercise is Medicine."  They signed a formal memorandum -- I attended this ceremony.  I then joined the team for their practice at the Indiana University stadium field, and I was immediately hooked!  I kept in touch with the team leaders, and was invited to their tryout in LA this past weekend.

In addition to a weekend of intensive soccer training, this gathering involved a health promotion event at the Boys and Girls Club of Long Beach.  In collaboration with the LA Galaxy (MLS team), we put on a dynamic and interactive program for children ages 6-16.  There were stations teaching about healthy eating and nutrition, why exercise is good for you, and we taught kids how to exercise.  The event built on past USMST events, and by all accounts was a great success.

Our weekend of training was expertly guided by a professional coach.  With most of the team at or older than the age of 40, we perservered through approximately 9 cumulative hours of intensive training.  By hour 3 it wasn't pretty.  Our moans and groans began to overshadow the roars of the airplanes landing at nearby LAX.  Though through all of the muscle cramping and arthritic joint aching, it became clear that this is a group of physician players with great devotion and heart.  

This year the World Medical Football Championships will be in Brazil, concurrent with the actual FIFA World Cup.  For this reason, getting a spot on the USMST roster is competitive.  Should I be called upon, I would feel lucky to be included.

It bears mentioning that this is not only a group of doctors who play soccer, these are physician leaders.  The USMST wants to make a difference in the health and well-being of Americans.   And they are partnering with the ACSM, and other organizations, to do just that.  Presently the USMST is self-funded.

Please see the organization's website for additional information -- www.usmst.org

I am so excited to find another outlet to practice what I preach...and it doesn't hurt that I may earn the opportunity to represent my country playing soccer in so doing....