Love- the secret ingredient in patient care!

A few years ago, I was flying home from a conference where I was teaching musculoskeletal ultrasound, and I was fortunate enough to sit next to a very kind woman who had moved to Pittsburgh from India a few years earlier.  She had been an engineer in India, but since coming to the United States, her primary focus was raising her 12 year old son, who was a child prodigy already taking college classes.

She related to me a story of how one time her son was upset that her mom made her dinner every night rather than going to restaurants.  I thought her response was very sweet, and changed the way I think about things:

“I explained to him that when you go to a restaurant, no matter how good it is, they were making that meal for a generic person.  When I make dinner for you every night, I am making dinner for YOU.  Every decision I make, whether it’s how firm to make the rice, or much coriander to use in the seasoning, I am making that decision because I want you to be happy.  Most importantly, there is one ingredient that I can give you than no restaurant can give you, and that’s love.”

I was obviously touched.  I think back to that kind woman often when I am taking care of patients.  One of the things I most love about working in a small physician owned practice like Lake Washington Sports & Spine is the love that our team can put into the care of each patient.  Being small, this empowers us to customize the patient experience.  Whenever we make a decision, we are making it for YOU.

Welcome to our family!

Meet the Team: Jami Schmitt

To help our patients meet members of the Lake Washington Sports and Spine Family, we will roll out some short interviews with our team members.  Up first, the great Jami Schmitt, our Medical Assistant extraordinaire:

What is your role on the Team at Lake Washington Sports & Spine?
My role in our team at LWSS is to assist with patient care. From greeting and rooming the patient to assisting with referring them to facilities that are convenient for them. When they have extra questions about care, I do my best to answer them and return phone calls as soon as possible. I like to make the patients feel comfortable and welcomed to the office. They should always know we have their best care in mind while helping them.

How does working for a small, physician-owned practice contribute to the family environment at Lake Washington Sports & Spine?
Working for a small physician- owned practice contributes to the family environment in many ways. One, since we all spend so much time together and the office is like a second family we, as a team, become closer. I feel that there is open communication and we all feel "safe" to talk to one another. In regards to patients, I feel that they feel more welcomed by coming to a small practice rather than a large facility with multiple doctors and staff members. Here we are able to be more personal with our patients. They can feel safe coming to the clinic and know they are receiving our full attention with their care. Since we are not part of a large corporation, we are able to get to know the patients on a more personal level. They seem to open up more when they feel comfortable with the staff and know that their doctors care about them.

What are some of the "little things" you like to do to improve the patient experience?
Some of the "little things" I like to do to improve patient experience is to make sure they know what the plan is before they leave, to make sure the patient is clear about the next step in their care. If they need prior authorization for imaging or therapy, I like to make sure they know what to expect before leaving the office. Making sure the patient knows where to go for imaging or therapy and has all referrals they need and contact numbers is helpful. If the patient has a "special request" and wants me to look into information for them, I try and complete it before they leave and, if not, try and call them by the end of the day.

What part of patient care makes you the happiest?
The part of patient care that makes me the happiest is when you see the joy on a patients face when their pain has improved. A few of our patients have come to us after huge car accidents where they suffered from many life changing injuries. You learn a lot about patients at the first visit and to see how they improve over time and how their mood improves truly makes me happy. I enjoy seeing our patients make progress and return to activity they were able to do before they were injured.

Many patients have never heard of PM&R or Sports & Spine Rehabilitation before.   What kind of patients do you meet who wish they had come to Lake Washington Sports & Spine earlier in their care?
Our sports patients, many whom don't know what type of doctor to go see.  Typically, they have seen their primary care or physical therapy, who then refer them here. I have found that many patients are unaware of all that we do here. Many have been pleasantly surprised to learn that we are able to use diagnostic ultrasound, nerve tests like EMGs testing, or guided injections like epidurals and ultrasound-guided joint injections.  

Creep

CREEP

CREEP:

- Creep refers to a material property, specifically the tendency for something to become distorted

- If you squeeze something for a short period, it will snap back into place

- If you squeeze something for a longer period, it will deform, and take time to go back into place (see, for example, the picture below of the cleaning wipe container that I squeezed)

- If you hold something in a deformed position long enough, it may permanently deform

This can happen to different structures in your body- e.g., the lumbar disk

- It is important to move on a regular basis to prevent this deformity

- You may need to perform specific exercises in a specific direction to mold tissue back into the correct place

To give yourself an example of how this may affect you in real life, pull back on your index finger so that it is an extended position, and then hold it in that position.  At first it may be a little bit uncomfortable, but as you continue to hold it in that position, it will hurt more.

I very commonly see this occur in patients who sit at their desk all day- the hunch forward, and this shortens the tissues in the front of their body (the "anterior chain") and stretches the back of their body (the "posterior chain").  This can cause significant spine pain, and needs to be reversed with postural control exercises that stretch the anterior chain and strengthen the posterior chain.  The specifics may vary with each patient, but the concept remains the same.

Bulgarian Squat

The Bulgarian Squat is a more advanced exercise- I'd make sure you can do a regular lunge and belt squat before trying.  When the front leg is forward more, it helps activate the gluteus maximus more, which is generally good.  It also helps stretch the hip flexor of the rear leg.

BULGARIAN SQUAT:

1. Stand in front of a chair

2. Place right leg onto chair, with the top of your foot flat against the chair

3. Left foot should be 2-3 feet in front of the chair

4. Slowly lower your body so that your butt moves downward, but not forward.  You will be doing a lunge with your left leg.  You should feel a stretch in the front of your right thigh (your right hip flexor), and you should feel your left buttocks and thighs contracting.

5. TIP: pay attention to the movement of your left knee.  It should move straight up and down, and not deviate side-to-side.  If you find that you are struggling to keep your left knee stable, move slower, and don't lunge as deeply

6. TIP: Concentrate on sitting back, rather than bringing your upper body or shin forward

7. Repeat for 10 repetitions

8. Switch sides

Do 3 sets of 10 repetitions for each side

Belt squats

This is another one of my favorite exercises- the Belt Squat.  It's a particularly good exercise to help activate the gluteus maximus muscle, which many patients have trouble activating

INITIAL PROGRESSION:

- Place a fat man's belt just above the knees

- Initially, started seated in a chair, with your hands on your belly

- Rotate knees outward, so that the outside of your knees are always pushing against the belt (external rotation)

- Stand up, focusing on pushing your thighs outward against the belt.  Pay particular attention to when you are sitting back down to not rotate your thighs inward

- As you come up from the squatted position, imagine that you are squeezing a $1000 bill between your butt cheeks, and don't forget to push against the belt

- Repeat for 10 repetitions, 3 sets

SQUAT PROGRESSION:

- Squat by sitting backward.  Do not let the shins move forward, try to imagine sitting back in a chair.  It often helps to have a rope or belt wrapped around a pole in front of you to help maintain balance.

Great feature in the AARP about our approach!

This article is from about a year ago while I was still at the University of Pittsburgh, but highlights the approach that Dr. Hyman and I use at Lake Washington Sports & Spine, integrating exercise prescription with advanced technologies like musculoskeletal ultrasound to provide the best possible care for sports injuries!

http://pubs.aarp.org/aarptm/20120405_PR?pg=17#pg17

Ice Ice Baby!

I'm about to give away a trade secret that could potentially put me out of business .....

Patients need to use ice more often!  It's one of my most frequent recommendations, but I find that patients tend to blow it off, waiting for the "real stuff" that costs more.  In my experience, for musculoskeletal injuries, frequent use of ice is often the most significant interventions for improving function and outcome.

When I was in medical school, I remember one of the doctors I was following recommending "moist heat" to patients with an injury, and I still hear patients come in having had that as a recommendation.  One would think, based on this recommendation, that there is a large literature supporting the use of moist heat.  There is not.

For example, here is an article discussing the benefits of ice for the calf (http://www.ncbi.nlm.nih.gov/pubmed/12492271), and a subsequent article showing the lack of efficacy in using moist heat (http://www.ncbi.nlm.nih.gov/pubmed/19827506).

So why is moist heat recommended so often?  The same reason that baseball managers used to focus on batting average instead of on-base percentage- it just became part of the orthodoxy, and no one thought to question it.  Moist heat often feels good at time zero, so following it out over time to see if it makes a difference is not intuitive.

Before I completely poo poo moist heat, I would note there is some evidence of using moist heat immediately before activity (see, for example, http://www.ncbi.nlm.nih.gov/pubmed/11805451), so there is a rule for using moist heat before physical therapy.  I would argue, however, that in most cases that a warm up of full range of motion exercise (e.g., long slow lunges or deep squats) is a preferable warm up.

The more common question I get from patients, though, is "I'm in pain, what medication should I take?"  In another blog post, we'll talk about how pharmacologic management of musculoskeletal pain is almost always the wrong choice, but I usually recommend that the "medication" of choice is ice.  When asked "should I use ice or heat?" the answer is essentially always ice.

How should you use ice?  My normal recommendation is to make an "ice pillow" as per the directions below:

1. Take a high quality gallon size zip lock bag
2. Fill it about 1/3 of the way with ice cubes (crushed ice is even better, but I wouldn't sweat it if you don't have crushed ice)
3. Press out the remaining air, and tightly seal the bag
4. Wrap the redundant plastic around the remainder of the bag
5. If you have a skin condition or something that alters your sensation (e.g., diabetic peripheral neuropathy), then you should wrap the ice with a towel.  For the vast majority of patients, though, it is safe and preferred to apply the ice directly to the injury.
6. If you can, apply some form of wrap to hold the ice compressed against the site of injury.  For example, you can use an ACE wrap, or if it's in hard to compress area like the shoulder, putting it underneath tight fitting clothing (like a compression short or Under Armour shirt) can help hold in place.
7. Use for at least 20 minutes.  In practice, I recommend doing something that occupies your thoughts for 20-30 minutes (e.g., paying bills online, watching TV).  No major harm in doing it for a few extra minutes- most people tend to under ice anyway.

If you want to take your icing to another level, a cold compression device like the Moji is even better.
http://www.gomoji.com/?kw=moji&gclid=CILS0K7sorgCFUbhQgodCW8ARQ

If I have time, I may do a full review on the Moji at a later date.  In  short, it's a well designed device to help apply ice and compression at the same time.  I particularly love the Moji knee, and use it myself.