The Reasoning Behind the “Dreaded” Follow-Up Form

Imagine you planned a fancy evening at a well known, highly acclaimed five star restaurant.  You told the waitress you wanted a steak but refused to tell her the type of cut you desired or how you wanted your meat prepared.  The chef could give his/her best guess at what your preferences are, but in many ways he/she would be flying blind, so to speak. 

And I’m almost certain you would never do this! In order to have the best restaurant experience you know you would have to give the chef some clues, some extra information, in order to get the best result. It is the same with our doctors here.  Dr. Chimes and Dr. Hyman have spent years training, practicing and meticulously designing the method in which they treat their patients, the one that garners the highest success rate. They have both found that having their patients fill out a follow-up form, allows them to have the proper “clues” they need to give the best care possible. In other words, this follow-up form allows them to “cook you the best steak”. 

Many patients believe that just because they filled out the form a couple weeks prior means that nothing could have changed since their last visit and another form would prove inconsequential.  That, however, is often not the case.  If one is experiencing pain, it can manifest itself in different ways and in different areas of the body and these changes can be discreet. Filling out the form as completely and honestly as possible allows the doctors to detect any changes that at first may appear insignificant but to the trained eye may hold some deeper truths.

Of course, in the end, the choice lies with the patient about whether or not the form will be filled out.  Just remember, leaving out this information will impinge the doctors in the same way not mentioning you like your steak well-done will impinge even the best chef.  We want you to have a five star experience at Lake Washington Sports & Spine and it starts with that (no longer) dreaded follow-up form!

Healthy Competition: How having a great partner makes everyone better!

Today, I saw one of my favorite patients. She is a 60 year old female rock climber who is back in action.  I was making my list of "What are things right about you" (... see http://lakewass.blogspot.com/2014/01/whats-right-with-you.html for why we think this important), and she touched upon something really important.  She mentioned how she has a great peer group of rock climber and mountaineers, and they serve as a source of inspiration for her.

This made me think about the importance of healthy competition.  As I've alluded to in one of my earlier posts about my twin sister Jill (http://lakewass.blogspot.com/2014/01/jill.html), I've been spending a lot of time thinking about my friend Jim McLean, who passed away 6 years ago.  When he died, our mutual friend Jack Rigg said something very kind to me, which was "the essence of friendship amongst men is rooted in competition, and I've never met male friends who better epitomized that than you and Jim."

I know that I feel really fortunate to have that type of relationship with my practice partner Garrett.  It certainly helps in that Garrett and I have known each other for over a decade before we started practicing together and had a professional friendship as a starting point.

It also helps to have a partner you respect and who inspires you.  That can affect technical issues, certainly.  For example, I performed an ultrasound-guided viscosupplement injection this morning, and I modified the technique based on tips I've learned from Garrett over the past 6 months.  

It can affect innovation.  For example, Garrett and I have been pioneering new techniques in the treatment of Achilles tendinopathy, and it helps to have your partner join you while performing the procedure.  

It can affect communication.  Both Garrett and I will reflect with one another on conversations we've had with patients.  Some of that is improving on negatives, and see if different approaches may have worked better.  Most of our conversations are positive .... "let me tell you about this wonderful patient I just met.  We had a great visit- let me tell you what was so wonderful about them, and why I think they will do well with us."

It certainly affects my sense of fulfillment.  When Garrett and I were entertaining the possibility of partnering together, we had a series of long conversations to make sure we shared a similar vision of what we wanted to accomplish.  We both have a common goal, recognizing that "Patients who want the best possible care need doctors too."  We'll work our way through the process of coming closer to that vision every day, but the starting point is making sure we share a vision.  We do.

As an example of that vision, yesterday we closed the office for a few hours to have a dietitian speak to our team.  It was a great experience- helped us understand more about nutrition, both for our patients, but also for our team.  As Garrett and I reflected back on the experience, we thought about whether it was consistent with our practices vision of "Helping people be the best possible version of themselves every day, using the musculoskeletal system as entry point to better understand themselves."  Absolutely!  We felt a great source of pride as we left the office yesterday, literally hooting with joy. 

Sometimes with medicine, life can be oppressive and negative, and there are certainly changes in health care that are concerning (..... Centers of Medicare and Medicaid Services- don't think we don't notice what you're doing!), but I think so long as we stay true to our vision, we'll get through the changes.

Patients ultimately are going to demand better care, and they know it when they see it.  Having a partner you respect to serve as a source for inspiration is part of the "secret sauce" that will make sure we continue to grow and get better.

Video explaining why discogenic low back hurts

This is an oldie but goodie- a video of me explaining why discogenic low back pain is painful

http://vimeo.com/80855880

Try to ignore the extra chins- this was when I was 30-40 lbs heavier

In this video, I reference the ActivAided back brace I patented with my partner Kelly Collier- http://activaided.com/

To learn more about Kelly, check out this interview: http://www.alphalab.org/blog/interview-with-kelly-collier-ceo-of-activaided-orthotics/

Walking the dog- why being a clinician-owner matters

One of my favorite morning rituals is walking my dog Bucky before work every day.  It's a chance to bond with my boy, to get some light exercise, gather my thoughts, and start the day with some energy.

I also admit it's one of the times I check my work email.  This morning, while walking Bucky, I received an email from one of my physical therapy colleagues at 6:30am, about a patient who was struggling .....

So I called him.  For the next 20 minutes, we discussed the patient, our common concerns, learned from each other's perspective, and also learned about how we can better team together for other patients.  It was helpful.  Bucky approved.

Later this same morning, I had a pre-work discussion with someone who works on the business side of medicine, and he commented about how the national trend is clearly for physicians to leave private practice and become employed physicians, and I was the first person he's met in the past 4 years who went in the other direction.

The reason for that trend is because physicians are scared by the crushing forces of the Accountable Care Act, the Center for Medicare and Medicaid Services, and "Big Medicine" in general.  What I told this gentleman is that I am scared too, and this may be in part why I am having conversations with physical therapists at 6:30am, why I am having a meeting with him at 7:30am, and why I ultimately will do a better job with patients.  I don't have any guarantees, and my success depends on me simply being bettter.

One of the mottos we have at Lake Washington Sports & Spine is that "People who want the best need doctors too."  I've seen the trends of big medicine, and how that drives complacency.  When you don't feel like your patients are "your" patients, but are part of a "systems" patients, you treat the patients the same way you treat a rental car.

When you own the business, you take a call from a colleague at 6:30am.  You meet with business people to learn more about the community need.  You reset the Keurig at your office to make sure that the coffee doesn't spill while they get ready for their appointment.  You strive to be better.

Meet the Team: Nala

Introducing Nala, our Ambassador of Adorable!

Q. Nala, what is your primary role at Lake Washington Sports & Spine?

A. Roof, roof

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Q. Our Dog-lish is a little bit shaky. Are you ok speaking in English?

A. Not a problem.  I'm bi-lingual

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Q. What breed are you?

A. Cockapoo- 1/2 Cocker Spaniel, 1/2 Poodle

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Q. Does that mean you don't shed?

A. That's correct

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Q. As "Ambassador of Adorable", what do you actually do at Lake Washington Sports & Spine?

A. Officially, I greet patients who want to be greeted, bring positive energy to the practice, and help maintain a sense of calm to help facilitate better care.  On a practical level, I mostly nap.

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Q. Do you actually think you make a difference in improving health care outcomes?

A. My humans tell me that I do.  I am not a pooch to quote the literature too often, but I do like to remind Garrett and Gary about the research showing that involving a dog in therapeutic practice does lower sympathetic drive, lower blood pressure, and improve outcomes for patients with pain and/or anxiety.  But I find that walking around and looking cute seems to drive home the point without having to act like Cliff Claven spouting facts left and right.

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Q. What about patients that don't like dogs?

A. We welcome everyone.  We have a system in place where we can make a note to that effect in the chart, that way we make sure that you don't feel like your personal space is invaded.  I'm here to spread joy and good cheer, so I promise I won't cause you any agitation.

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Q. Any suggestions for those who want to learn more about the health benefits of involving a dog in their medical care?

A. Sure thing.  I recommend the book "The Power of Wagging Tails" by Dawn Marcus.  We have a link to it right here-http://www.amazon.com/dp/1936303124?tag=lakwasspospi-20&camp=213381&creative=390973&linkCode=as4&creativeASIN=1936303124&adid=051JRSTAD1W1T3J9QW5N&&ref-refURL=http%3A%2F%2Fwww.lakewass.com%2Flwss-endorsed-products.html  

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