Simple, realistic ways to incorporate movement into your busy day

Sedentary is the problem, exercise is the solution!

There are lots of simple ways to incorporate exercise into your daily routine at home or work.  Anything you can do to increase your physical activity each day is a step in the right direction!   

Here are some simple ideas you can start immediately.  Bonus- they cost NOTHING at all.

1.       Always take the stairs

2.       Do 5-10 minutes of jumping jacks (A 150-pound woman can burn 90 calories in   one 10-minute session!)

3.       Use part or all of your lunch break to take a brisk walk

4.       Do leg exercises &  lifts with small weights while you watch TV

5.       Cooking dinner? Do standing push-ups while you wait for a pot to boil

6.       While watching your favorite TV show, jog in place during commercials

7.       Do 10 “Sun Salutations”

8.       Stand while talking on the phone.  While you’re at it, do some calf lifts

9.       Take your dog for a walk! 

10.   Have a dance party: put on your favorite music and DANCE!

KPA!

Our goal is to K.P.A: Keep People ACTIVE.  Our employees embody our mission!

Do you have a job that requires extended periods of sitting?   Build "activity breaks" into your schedule.  There are so many great exercises that only require one thing: your body weight!  Push-ups, sit-ups, downward facing dog, lunges, squats, wall sits.... Get up and get moving!

link from the Atlantic about Hospitals purchasing physician practices

This article in the Atlantic monthly discusses how hospitals are purchasing physician practices.

Speaking from my own personal experience as both an employed physician and an independent physician, I think that being an employed physician was worse, both for the patient and for the physician.

The Atlantic article hits on a key point- when you do not have control over your own environment, it hurts morale.  From a patient standpoint, you can tell when your physician has low morale, and it affects the quality of your care and the quality of your patient experience.

I'll give one seemingly small but crucial element where I love being an independent physician- calling to make an appointment.  One common trend amongst employed physicians is a "central call" system, where you call the hospital operator, and get stuck in a phone tree.  It's unpleasant and tedious, and even more importantly can lead to errors in being sent to the wrong clinic.

In our office, when you call, you reach a live person who is in the same office as Garrett and I.  If they have a question, they can walk 5 meters and ask us a question.  It makes life easier, more pleasant, and dramatically increases the likelihood that we are the appropriate clinic for the patient's needs.

What to expect from a diagnostic ultrasound and ultrasound guided procedure

For more detailed information on musculoskeletal ultrasound and its benefits please see this blog post.

Diagnostic ultrasound

When being examined, the doctor will be scanning the desired area by placing gel on the skin and applying the probe. The doctor will then proceed to look at the different structures in a systematic manner using established protocols. To make sure they don't miss important structures, they may not start with the area that bothers you first, but don't worry- they will indeed scan your most painful area.

When the physicians are scanning your body, they will often find structural changes to different body parts that are not painful, and may be incidental findings.  This would the equivalent to taking a high resolution photo of an older home- there may be many small signs of wear and tear that do not actually affect the function of the house.  This is especially true when scanning the body with ultrasound- since ultrasound is extremely high resolution (over three times higher than MRI), incidental structural changes are extremely common.

To help distinguish between incidental structural changes and those that are symptomatic, an important part of the examination is sonopalpation, which is applying pressure using the ultrasound probe.  This is one of the greatest strengths of diagnostic ultrasound- we can identify those structures that both have architectural changes and are also painful.  We refer to this as concordantly painful.  Throughout the exam the doctor will often ask if you are experiencing any pain. While the positioning of the body part itself may be uncomfortable, when asking this question, they are referring specifically to where the probe currently is being placed.

Some clinics will use an ultrasound tech to perform their ultrasound imaging.  At Lake Washington Sports & Spine, all of our studies are personally performed by the physicians, Dr. Chimes and Dr. Hyman.  One of the reasons we do it this way is that our physicians primarily view the ultrasound as an opportunity to educate their patients, helping patients become more aware of their bodies and how their structures influence their function and discomfort.  We encourage patients to ask questions, and they are welcome to bring friends, family members, and members of their treatment team with them.  We've had patients bring their physical therapist, personal trainer, or chiropractors to join them at the visit, which is a fun and educational way to make sure everyone on the team is on the same page.

Ultrasound Guided Procedures

While there are a number of different procedures performed in the office at Lake Washington Sports and Spine, the most common is a cortisosteroid injection, the so-called "cortisone shot". We encourage patients not to refer to these as cortisone shots though, because almost all injections are corticosteroid injections, and this does not help distinguish different injections from one another.  It would be analogous to referring to a surgery as a "scalpel surgery"- while this is technically true, it would not distinguish a small bowel resection from a breast reconstruction.

The most relevant information for any injection is two factors:
1. Where the medication was placed
2. How it got there

For example, we may refer to an injection as an "ultrasound-guided subacromial bursa injection."  This means that the injection was targeted to a very specific location within the shoulder (the sub-acromial bursa), and how we know how we targeted the injection (using ultrasound-guidance).   We specifically like to know if imaging was used to guide the injection, which dramatically increases the likelihood that the needle was actually where we thought it was.   For injections that don't use guidance, some use the term "blind" injections, since you are not directly visualizing the needle tip.  We usually refer to blind injections as "landmark-guided", meaning that the clinician used touch sensation to feel for the intended location.

The exact procedure will differ depending on what the body part is and what structure is being targeted, but the next paragraph will give a general idea for what to expect when having one of these done in our office.

The doctor will apply some gel to the skin and place the ultrasound probe over the area and scan it to localize the target. After this is done, the gel will be cleaned off and the skin will be cleaned with cleaning solution. At this point, the doctor will then inject numbing medication into the skin using a very thin needle.  To the extent that there is much pain during a procedure, the numbing is usually the worst part, although it is not particularly painful.  It causes a burning that lasts on average 8 seconds, and is usually significantly less painful than a blood draw or flu shot.

After numbing the skin, more gel is then applied and the probe is used to visualize the target. Once the target is adequately visualized, another needle is inserted and directed towards the target. Once the needle has reached the target, the medication is then injected. Often patients will feel some pressure in the area, but it should not be especially painful. Once the medication is administered, the needle is removed, the skin is cleaned off, and a Band-Aid is applied.

Patients will often ask what they are supposed to expect after the injection. Most patients will come off the table feeling at least some level of relief. Typically this is due to the numbing medication that was injected along with the steroid, which takes about 8 seconds to take effect. How long the numbing lasts for is variable depending on the patient, but can last anywhere from 2 hours to forever. The steroid medication works more gradually and often can take about 2 weeks before its peak effectiveness. 

It is not unusual for patients to feel relief for 2 hours or so before having the pain return. This is completely normal, and we advise patients to ice regularly and monitor how they are feeling until we see them for a follow up, normally about 2 weeks post injection.

The post-injection follow-up is important.  The injection is part of the overall treatment plan, but is not a substitute for other parts of the treatment, which will nearly always involve an exercise prescription, and may also include physical therapy or chiropractic care.  At Lake Washington Sports & Spine, we strongly believe in the need to "Rehabilitate beyond the Resolution of Symptoms," and a major focus of our aftercare is to make sure patients not only feel better, but also know how to prevent recurrences, and know tactics to bring their symptoms under control if they have a recurrence.

Who profits from Obamacare? It's not patients, and it's not physicians

This link from the NY Times highlights an important point about current health care changes - they are shifting money AWAY from care, and TOWARD support of infrastructure

Physician salaries are going down, and accordingly, so is the incentive for talented people to go into medicine, or stay in medicine.  Physicians are retiring early, sometimes as early as in their 30s.

On the other hand, administrator salaries are increasing, and outstrip that of physicians.  According to this NY Times article, the average hospital administrator makes 43% more than the average family physician.  Does that make sense to you?

It's important to remind patients- buildings do not take care of patients.  People do.

The Power of Choice: Lake Bell, Bill Simmons, Rick Gottlieb, and why patients should care about the Long Tail

I was listening to a fantastic BS Report Podcast with Bill Simmons, where he was interviewing the actress Lake Bell about the upcoming movie "Million Dollar Arm".

For those not familiar with the movie, it's a true story of how a baseball agent/scout (played by Jon Hamm) travels to India and arranges a contest to find young Indian cricket players to come to the USA to play baseball.

During the course of the interview, Bill Simmons was noting Lake Bell's interesting career, where she initally had a traditional Hollywood actress pathway of some marginally-successful runs on TV shows and movies, despite being clearly immensely talented.  She has found a new pathway to success, through things like the Emmy-winning web series "Children's Hospital."

Bill asked her at one point in the interview if Lake was interested in "getting on real TV."  Lake gracefully laughed that she actually preferred being on "fake TV."  This was a fascinating conversation for several reasons, which I'll highlight here:

1. Lake very appropriately realized that Hollywood was not savvy enough to take advantage of her talents, and she sensed a market inefficiency.  In particular, she noted that only a small % of movies are directed by women, even though they do a high % of movie ticket purchases.  FiveThirtyEight had an excellent blog post about this a few weeks ago, noting that this is a true inefficiency - Hollywood would do better financially if they took the women's view into mind more.

2. Lake had one area of particular passion, which was voice over work.  She noted that there is an enormous bias that has men do the vast majority of voice over work, and she struggled to find such work as a woman.  She took a brave and pro-active approach to correcting this- she made her own independent movie about a woman struggling to get voice over work, called "In a World" which parodies the ubiquitous movie trailers that begin with that phrase.   Check out the very funny trailer here.

3. A super important point here- Lake is VERY successful.  She is not on a network TV show, but she doesn't WANT to be on one.  Instead, she's on an Emmy-winning web series, directing her own movie, about to come out in a big studio movie, recently married, and happy.  She created her own pathway to success.

4. What's incredibly ironic is that this line of questioning is coming from Bill Simmons.  For those not familiar with Bill Simmon's back story, he is often cited as the single most successful individual who has parlayed non-traditional media to create an empire.  He started writing a small web column called "Boston Sports Guy" back in 1997, when there really wasn't such a thing as a web column.  He created a great product, and eventually moved up the ranks through ESPN.  He has been called the "Most Influential Man in Sports Media" by his competitors at Sports Illustrated, and ESPN made him the editor in chief of their influential Grantland website.  In full disclosure, Grantland is my favorite website, and I'm a huge Bill Simmons fan.
     So, what's incredibly ironic is that if there was one human being on the planet who should appreciate that success shouldn't be defined by having to participate in traditional products, it's Bill Simmons.  

Yet, he fell into the trap of assuming that there is only one pathway to success.

Segueing .... in the excellent book The Long Tail, Chris Anderson notes that the trend in the current economy is to offer people choice.  The long tail in the title refers to the shape of a Pareto distribution (see picture above).  The concept in the book is that in the past, consumers had limited choice, and the bulk of sales occurred on the left side of the graph.  For example, the vast majority of books sales were the top 20 best-sellers, the vast majority of record sales were on the Billboard Hot 100, etc.

However, because of services like Amazon.com, ITunes, and (obligatory Microsoft reference) Bing search, consumers have access to far more choice, corresponding to the "Long Tail" on the right side of the curve.  And we LOVE it!

For example, I grew up consuming traditional media.  I read my local newspaper everyday (the Trenton Times), listened to Top 20 radio, and watched The Cosby Show and Facts of Life just like everyone else.  It was ok.

Now, I consume media I really enjoy.  I read my medical websites, but also enjoy Grantland, FiveThirtyEight, but also websites for my favorite niche sport, Mixed Martial Arts.  I listen to lots and lots of Podcasts, which is my favorite form of media.  And I hardly watch TV or listen to radio.  It's a completely different way of consuming media, and I vastly prefer it.  Choice is simply better.

This applies to all walks of life.  I love Chipotle.  That said, I am really glad that Baja Fresh and Qdoba exist.  I love that we have a choice.  Even if you go to Taco Bell, they've had to improve their game because of the competition created by Chipotle.
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So, what the heck does this have to do with healthcare?  Well, in every other facet of life, the trend is to embrace the Long Tail, and offer consumers choice.  But the trend in healthcare is in the OPPOSITE direction, to limit choice.  This is not good, and as a consumer, this is not what you want.

One popular model is that idea of a "narrow network", where a large employer or insurer will contract with a limited group of providers, and the consumers will have to use the provider that is within that narrow network.  This, in my opinion, is definitely not in the best interest of the consumer.

I'll give a very specific, real example of how this hurts patients.  On Friday afternoons, I perform my spine procedures at the Overlake Surgery Center in Bellevue.  When I perform procedures, in the operating suite next to me there is another physician who is also performing spine procedures.

He's a great guy and a great physician.  He is so awesome, in fact, that I am going to advertise on his behalf on my blog- his name is Llewellyn Packia Raj, MD.  While I suppose he is technically a competitor of mine, I don't view him that way.  I view him as an amazing, compassionate physician, with great technical skill and wisdom.  I sincerely want him to be successful.  I'd gladly see him as a patient, and would send a loved one to see him.

It is my personal belief that for some patients, Lew will be a better choice, and for other patients, I will be a better choice.  While I think we are both very good at what we do and have some overlaps in skills and personality, I don't think we are equivalent. 

So the question is- who gets to make that choice?  The consumer, or some central agency defining a narrow network?

To me, this is obvious.  The consumer, in this case the patient, should make the choice.  That should be their right, and helps lead to a better fit.

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For the final leg of this blog post, I'll comment on a time I deliberately chose to escape a narrow network, and how happy it made me.  When I moved to Pittsburgh, I needed to establish a relationship with a new dentist.  My dental health plan had a narrow network, so I was looking for a specific dentist within that network.

I happened to have a patient who was a brilliant periodontist, and he was someone I also related to on a personal level and trusted.  I asked him who I should see, and he recommended a great general dentist named Rick Gottlieb.  

Dr. Gottlieb was out of my network, but my friend said that Dr. Gottlieb was so good he'd be worth paying cash to see, and gave me some anecdotes on how this would save me money in the long run.  This was a big leap of faith for me- I had never willingly paid cash for something for which I insurance, but I trusted his advice and saw Dr. Gottlieb.

I am so glad that I did!  Rick was far and away the best dentist I had ever seen, and I consider him the best clinician I've ever been to.  I found the experience exceedingly pleasant (..... how often to people say that about going to the dentist!), and I felt confident about my dental health.  I thought it was the best run office I've ever been to, and I've used it as a model when I think about how Garrett and I should run our office at Lake Washington Sports & Spine.

In terms of cost- I think my friend was right.  By helping educate me about my long term dental needs, and helping prevent expensive long term periodontal care and other advanced procedures, I am likely going to save thousands of dollars in the long term.  Now, from an insurer's view, they may not care.   They don't care about savings 15 year downstream, and they are willing to be penny wise, even if it's pound foolish.

But here is an even more important point that is lost in the cost-savings debate- I really like Rick as a person.  That means something to me, and it has value.  Rick and I were social acquaintances when I lived in Pittsburgh.  I don't know that it quite reached the level of "friend", but it was meaningful to me, and I knew very clearly that he cared about me as a person and was rooting for my interest, beyond me merely being someone who provided him income.

And I think that this is something that is getting lost in medicine in all of the discussions of cost containment, narrow networks, meaningful use, and similar blather.  Medicine, at it's core, should be about the relationship of the patient and their physician.  Like all relationships in life, you can make a best guess, but ultimately finding the right match is a give and take process, but when you find that match, it's wonderful.

To that end, I encourage physicians to take a stand and fight for patient choice.  There is some risk in that process- you will lose some patients.  But I am ok with that- even more than that, I embrace it!  If someone chooses to see a great physician like Lew Packia Raj instead of me, that is their right, and more importantly, that frees up my schedule to find a patient who is an even better match for me.

...... I can just see the movie trailer now - "In a world, where patients have a choice ....."

Wonderful link about the power of being mindfull

I absolutely love this link on the Huffington Post about the power of being mindful.

I love my current patient population.  I work with some incredibly thoughtful, creative, and active patients.  One common trend I see, however, is that because they so talented, they are often spread thin, and they have too many responsibilities.

I certainly relate, and one of my main motivations for leaving academia was to create a simpler life for myself that focused on what I considered really important, which was family, health, my dog, nature, exercise, and kindness.

I think there were some key elements the author hit that I think are essential for health:
1. Stay on task.  We can't actually multi-task.  Very smart people can give the illusion of multi-tasking, but multi-tasking creates a drag on efficiency, and it's exhausting.

2. Allow your mind to wander.  Build time into your day to do nothing.   Practice meditation to really embrace that nothingness.

3. Get outside and walk.  This is the greatest gift my dog Bucky gives me (..... besides his love, of course) - reminder that the way we are biologically designed to discharge our autonomic nervous system is by getting outside and walking.  While Bucky may be more animated when he starts getting fidgety from a lack of exercise, humans have the same autonomic reaction.  We need that discharge to recalibrate our system.

4. Enjoy the moments and reflect.  I find this especially enjoyable living in the Pacific Northwest.  Living in such a lush environment with water, flora, and mountains is beautiful.  Take time to enjoy it.  It's such a privilege to be around so many bright, thoughtful, and varied people.  Express gratitude for living in a world where you can engage with them.

Embrace simplicity!