Lifestyle Change- the "Secret Weapon" for great health outcomes

I saw a patient today who impressed the heck out of me, and he gave me permission to tell his story.  I'll call him Fred for the purposes of his story, to protect his anonymity.

Fred's a middle-aged, high functioning executive, referred to me because of numbness in his hands and feet.  On examination, I picked up some findings concerning for compression coming from his neck.

I also expressed to him my concerns that he was undergoing some of the lifestyle changes I see in some of my most wonderful patients, where they are feeling health consequences from the complexity of their lives.  Fred is what I would consider "hyper-competent"- he's very smart and thoughtful, charismatic, a great people manager, and just gets stuff done.  As a consequence of his hyper-competence, he has the "reward" of getting more and more stuff to do, which does give him emotional satisfaction, as well as more money.

But it comes with a cost.  As we reviewed some of the symptoms I see in patients with too much complexity, some patterns emerged.

First, he has sympathetic overdrive.  The sympathetic nervous system is part of the autonomic nervous systems that handles the "fight or flight response", and Fred is always primed and ready for action.  Some negative consequences:
- heart arrhythmia
- resting heart rate over 80
- difficulty "shutting his brain off"
- trouble sleeping, replaying conversations in his head from earlier in the day
- muscle tension
- tinnitus (ringing in the ears)

He also has some signs of hypogonadism (low testosterone):
- fatigue
- lower energy levels
- decreased libido
- sleep apnea
- some days hard to focus and concentrate
- less frequent morning erections
- still has morning erections, not sure if it's every day
- harder to obtain orgasms than before

I told Fred my preferred approach is to focus both on the focal (his neck), and the global (Fred as a human being, rather than as a collection of body parts)

We imaged his neck, and sure enough his cervical MRI demonstrated some disk disease affecting his nerve roots and touching on his spinal cord

I also ordered a comprehensive hypogonadal assessment, which showed:
- low testosterone
- high estrogen
- elevated glucose

I discussed with him that the body is in a constant battle between being anabolic (building up) and catabolic (breaking down).  You need both, since you need catabolism to healthily remodel tissue.  But his system was out of whack, and was in the process of breaking down from the load of complexity in his life.

So we put a plan in place.  To Fred's credit, he bought in 100%.  (.... I was afraid that he would insist on buying in 110%.  That would have made things worse - I needed him to resist the temptation to do too much- I didn't want him doing the mathematically impossible).

I am so impressed with Fred.  Changes he's made:
- changed his diet to a 1:1 protein:carb diet, using tracking software to stay accountable
- used propranolol 30 mg at night to help with sympathetic overdrive
- started meditating at night to help with sympathetic overdrive and sleep
- prioritizing sleep
- modifying job to allow his brain to be less intense
- drinking less coffee (needs less now that he sleeps more, and excessive coffee was increasing his sympathetic overdrive)

The next major step for him is getting him to be in compliance with the American College of Sports Medicine exercise guidelines, particularly in regards to aerobic conditioning

I may eventually perform some injections in his neck, but Fred has already seen how lifestyle changes have made a huge impact in his well being, is costing him less money (less medications!), and will make any spinal procedure I perform on him more effective

Fred- thanks for being an inspiration!

Meet the Expert: Brian White, DO- particular focus on patient satisfaction

Meet the Expert: Brian White

For our next feature, we are interviewing Brian F. White, DO my co-author on the article "Patient Satisfaction Surverys: Tools to Enhance Care or Flawed Outcome Measures?" in the December, 2013 issue of PM&R the journal of injury, function, and rehabilitation.

Gary:

First off Brian, thanks for participating in this Q&A session. It's a privilege to have you here. From a standpoint of introduction, can you tell us about your background, and your journey in becoming a physician.

Brian:

Thanks Gary, it is a real pleasure to be involved in the fantastic work that you and Garret are doing at Lake Washington Sports and Spine.  In regards to my own background, when I graduated from high school a career in Medicine was pretty far from my mind.  I attended the University of New Hampshire, initially as Mechanical Engineering major, but during my junior year decided to complete my degree in Business Administration.  At that time, I was not thinking of pursuing a career in engineering, or medicine for that matter. 

I had been an alpine ski racer in high school and when I began my studies at UNH I envisioned competing on the UHN alpine ski team, unfortunately, as a ski racer I was not competitive at the Division 1 level and stopped ski racing after my sophomore year.  As part of training for the ski team, I became involved with the UNH cycling team which at the time was a regional and national collegiate cycling powerhouse.  I ended up living at the US Olympic training center in Colorado Springs as part of the National Team Development program for three different winters and while I competed for UNH we won the US National Cycling Championship title. 

Gary:

I know that you were involved in both skiing and cycling.  How did you make the transition from skiing to cycling?

Brian:

Once I stopped skiing during my sophomore year of college, I transitioned to cycling fulltime and for the next several years hardly ever got on snow.  In order to take my cycling to the next level, I moved to Boulder Colorado, initially in 1992 to train for Olympic trials, and then on a permanent basis in 1994. 

For various reasons cycling was a good fit for me as an athlete, a much better fit than alpine skiing had been.  I competed at Olympic trials in 1992 and 1996 as well as more than a score of National championship events, finishing in the top 20 on multiple occasions.  I also represented the US National Team in many International events and wore leader’s jerseys in the Tour of Venezuela as well as the Tour of Panama.

Gary:

I also know that you have had some success with coaching, both skiers and cyclists, I believe your former athletes were National Champions and even an Olympian.  How did you move from athlete to coach?

Brian:

One of my main cycling training partners in Boulder, Peter Davis, had been a ski racer at the storied Burke mountain academy.  Given my background in alpine racing, he suggested that I get involved with coaching youth ski racing as an off season activity.  He introduced me to a friend of his Matt Lyons, who was the Program Director at the local ski team.  We met and discussed my involvement in the program and I began coaching 9 and 10 year olds the winter 1994.  Although an unplanned diversion in my life, I took to coaching and was able to combine the understanding of elite athletics I had learned as a cyclist with my prior knowledge of ski racing.  This combination of skills proved quite useful as a ski coach and I ended up coaching full time, six days per week, for the next seven years. 

Ultimately I developed a cycling team in association with the Eldora ski racing program, one of my athletes, Ian MacGregor, went on to win the US national road championship in 2004 and 2005, and another, Timmy Duggan, won the US professional national road championship in 2012 and was also a member of the 2012 US Olympic cycling team that competed in London.  Ian has retired from cycling and since has gone on to co-found Skratch labs with physiologist Alan Lim.  In another selfless act that continues to make me swell with pride, Timmy and Ian developed a non-profit organization to help young athletes get funded to further their own Olympic dreams; Just Go Harder.org, check out their web page, and more importantly, make a donation.

During my time in Boulder, even more important than success as an athlete and a coach, was the meeting of the Head ability coach at Eldora, Susan Holes, who eventually agreed to become my wife in 1998 and then the mother of our two sons.  As fate would have it, we were first introduced to each other by the same training partner who suggested that I get involved with coaching young kids.  I suppose that sometimes it is better to be lucky than good.

Related media:

Daily Camera Article Boulder on Timmy Duggan 6/30/12

The Gazzette article on TimmyDuggan Colorado Springs 8/18/12

USA cycling website, Timmy Dugganbio

 Just go harder website

Skratch website

Gary:

So you went to UNH and obtained a business degree, competed as a cyclist at the Olympic Trials level both domestically and internationally.  Then you coached skiing and cycling with some success, how did this pathway during the 1990’s lead to your current career as a Physician?

Brian:

Susan and I were married in 1998 and decided that developing a more long term profession was in order to facilitate building a life together and planning for a family.  To that end I enrolled at the University of Colorado and pursued a second degree in Biochemistry.  I considered a few alternative professional pathways, but given my history in athletics and coaching, Medicine was really the best fit and best way to use my prior skill set to give back  

I ultimately began Osteopathic medical school at Midwestern University – AZCOM in the late summer of 2000.  I continued to coach skiing during the first year of medical school and continued to compete as a cyclist into the second year of medical school.  Medical school was very challenging, but I found that leaving the life of an athlete was an even more challenging; it was very difficult to give up that way of life and the intensity and singularity of mind it provided after so many years.

Gary:

More specifically, how did you decide on Physiatry?

Brian:

During medical school, like most medical students I struggled with the decision of which specialty to pursue.  I eventually narrowed it down to orthopedic surgery and Physiatry.  In the end I chose Physiatry, in many ways guided by my beliefs and the experiences I had as an athlete.  I experienced several significant injuries as a cyclist, in fact in 1997 I missed the entire competitive season due to a recalcitrant Achilles tendionopathy; this lost season was especially disappointing given the success I had during the 1996 season.  

When I was injured, surgical debridement of the tendon was offered as a treatment option, an option I ultimately chose not to pursue.  This desire to avoid surgical intervention drove my recovery process as an athlete for this as well as other chronic musculoskeletal injuries I suffered over the years.  Given the non-surgical pathway I had mapped out for myself as an athlete I thought that pursuing a musculoskeletal care pathway that minimized surgical options as much as possible would be the best pathway for me advise to my patients; to this end I choose Physiatry over Orthopedic surgery. 

Gary:

I had a similar experience, though at a lower level of competition.  When I graduated from the University of Wisconsin in 1995, I was training for an Ironman, and tore my right PCL in my knee.  I ended up spending the summer between college and medical school rehabilitating my knee.  My personal experience with rehabilitating this injury is what led me to choose PM&R as a career as opposed to Orthopedics.

Brian:

It is very interesting to hear you describe a similar early story and tying your personal desire to avoid surgery if possible with your ultimate decision to pursue Physiatry over Orthopedics.  I know many Physiatrists who were would be Orthopedists but ultimately choose Physiatry as their life pathway. This includes several of our mutual friends such as Ethan Colliver, Marla Kaufman, and a host of other notable physicians.

Gary:

Getting back to the line of thought regarding the pathway that brought you to where you are today.  We initially met in Cooperstown when you were an Intern.  I had completed the Internship at Bassett two years prior. We met again at Kessler where we were both residents. Tell me a bit about your experience with Bassett as well as at Kessler.

Brian:

Sure, as you note we had a similar training pathway with me following two years behind you at the Bassett Internship program and then again at the Kessler PM&R residency program.  After graduating from medical school in 2004, I completed a Columbia University associated Rotating Internship at Bassett Medical Center in Cooperstown, NY.  It was a challenging but wonderful year in Cooperstown. I learned a lot about medicine, made many friends, and continued to train along side one of my medical school classmates, Ethan Colliver.  My wife and children made many friends and despite the long hours and stress involved in Internship, we had a great year, it was good for me as a growing physician but more importantly it was a very good year for our family.

I left Cooperstown and again followed you to engage in the rigorous, academic residency at the Kessler PM&R program in NJ.  While at Kessler I was exposed to many great musculoskeletal attending physicians such as Gerry Malanga, Greg Mulford, Jeff Cole, Todd Stitik, Gautam Malhotra, and Pat Foye among others.  I also had the benefit of excellent mentors such as Steve Kirshblum and Susan Garstang.  Further, the Kessler program also afforded me the good fortune of meeting like minded and very gifted musculoskeletal colleagues in residency such as yourself, Jim McLean, Casey O’Donnel, and Chris Visco.  Chris and I were residency classmates and two of our other Kessler class of 2008 classmates, Rich Dentico and Ron Karnaugh, also did post residency fellowships and chose to pursue a career as musculoskeletal Physiatrists; it was a great bunch of talented individuals to be mixed together with during our formative training years.  All of these individual provided direction to my education and career pathway, and more importantly remain my close friends to this day. 

I left Kessler to pursue a Fellowship year at the University of Massachusetts in Worcester, MA where I furthered my knowledge of EMG and musculoskeletal medicine as well as developing an interventional skill base.

Your question regarding Cooperstown and my time at Bassett I think can be best answered by where I live and practice now. When it came time to select a job post fellowship, I gave my wife the choice of pursuing a position in San Francisco or returning to Bassett Medical Center in Cooperstown; she chose Cooperstown as the place to grow our lives together and to raise our sons.  We have been here ever since and so far have been quite happy with our choice. 

Gary:

You describe a bit of a convoluted pathway toward you current career as a musculoskeletal physiatrist, given my personal pursuit of a PhD in Anatomy as part of my own medical pathway, I can see value your unique process.  Is there anything special you think that you bring to the table in treating patients that you might not have in your bag of tricks had you pursued a more traditional pathway to Medicine?

Brian:

Yeah, it was a bit of a road getting here, but life is about the journey much more so than the destination.  I believe that this unique and protracted pathway to Medicine has afforded me many unique tools to bring to bear in the treatment of my patients.  Graduating with a business degree provides an insight into the business aspect of Medicine and the requirements to run a successful business.  Competing at an elite level has given me an understanding of what it takes to be successful at a high level and of how hard I can push my body and mind in the pursuit of excellence.  Coaching high level athletes helped me to develop the capacity to teach and nurture individuals to push themselves to attain goals that they once did not think possible.  All these are qualities I use on a daily basis in the course of providing care to my patients.

I had the good fortune of recently being featured in the quarterly edition of CORE which may be an interesting read for your readers.

Gary:

Let’s switch gears a bit.  Tell us more about patient satisfaction surveys. For those who don't know much about these surveys, they sound like a great idea, but you argued that they may actually be harmful for patients. While I obviously agree with you (since I was your co-author), that may not be apparent to most people. Why are patient satisfaction surveys harmful?

Brian:

As you mention, you and I wrote an in-depth opinion piece on the subject published in the December issue of the PM&R Journal.  I would encourage your readers to review the article for themselves and get a more informed perspective. (Gary's Note: full access to article only available for PM&R Journal subscribers.  Please contact Gary if interested)

There are many problems with patient satisfaction surveys.  These surveys are marketed as a tool to grade healthcare quality but are deeply flawed.  First, they are not particularly accurate measures of what they purport to evaluate.  Second, the measures these surveys do evaluate do not equate to improved healthcare.  So in the end these surveys are a poor measurement of data that is not relate to the quality of healthcare provided. 

A big flaw is that patient satisfaction surveys ask the wrong question.  The goal of medical care is not to engender satisfaction, but rather to improve health and function of our patients; satisfaction surveys miss the point.  What we should be doing is looking at how we can better engage our patients to further their personal goals for health and function rather than look to see if they are satisfied with us or not. 

There are not a lot of scientific studies on the topic, but those studies that do exist actually demonstrate that high patient satisfaction correlates with poor patient outcomes.  This may, at first glance, seem counter intuitive but this unexpected result is likely related to what physician behaviors and activities engender patient satisfaction and what physician behaviors foster better patient health; these two sets of behavior are often in direct opposition to each other.  

As we noted in the article we co-authored, the best study to date on clinical outcomes and patient satisfaction scores demonstrated that the patients who were most satisfied with their physicians died at a much higher rate than those patients who were relatively unsatisfied.  A further point we made in our article was to note the moral inappropriateness of using satisfaction scores to evaluate physicians, as is well described in the article we referenced by Labig. 

  

Unfortunately these surveys aren’t just a benign waste of time, but rather are misguided tools. In their application, they are often used to manipulate physician behavior, often in ways that might not be best for either the patients or the doctors.  The unintended consequences of these surveys are potentially great and argue against their use. 

The patient-physician relationship is not a symmetric one.  The physician brings to the table a set of knowledge and insight that the patient does not possess and then uses this insight for the benefit of the patient rather than leveraging the inequality in the relationship for personal gains.  As physicians, we use our skills for our patients benefit rather than for our own good despite the frequent sacrifice on our part required to do so.   Our role in the relationship is not to engender a fondness for us, nor to get our patients to like us or feel a high degree of ‘satisfaction’.  Rather our role is to selflessly care for and guide patients on their road to improved health and function.  However, if we were to focus on getting patients to ‘like’ us, we would often make decisions counter to the real goal of helping patients improve.

So this brings us back to the prior thought that measuring a patients’ satisfaction with their physician is looking at the wrong factor and in doing so could very likely alter the relationship in a manner that is harmful to the patient.  As improving patient welfare is the goal of physicians, engaging in satisfaction scores is the wrong thing to do.

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Gary:

For a small private practice like what Garrett Hyman and I run here at Lake Washington Sports & Spine, how would you advise we improve the patient experience? Are there methods that would work better than using commercial survey tools? For example, would simply asking patients directly for their feedback be more helpful?

Brian:

I think that there is a cluster of features that help define the patient experience in regards to clinical quality.  The first two aspects directly tie to the physician, in this case Garrett and yourself, and what you bring to the table.  The second two aspects apply to the patients and what they bring to the table.  The quality of the clinical experience lies in the interplay between theses facets of this relationship and both parties need to have responsibilities to, and expectations of, that relationship.

Gary:

So part of the relationship is the responsibility of the physician and part is the responsibility of the patient?

Brian:

Exactly, the first set of features in this relationship puzzle relate directly to the physician.  I see two big items that the physician controls.  The first is development and fostering of a caring relationship and the second is striving to continue ongoing development of clinical excellence.  

At the heart of the patient physician relationship is the relationship itself; this is often the key to clinical excellence.  In order to care for patients, you must first ‘care’ about them, and directly engaging them is a fundamental component of the process of caring.  To that end physicians need, as your question suggests, to directly engage their patients and discuss their needs in a proactive manner as a starting place for maximizing patient care. 

However, although fostering a relationship based on compassion and caring provides a starting point, this is not enough. You and Garrett need to continue to expand on your already considerably clinical skills.  Pursuit of clinical excellence needs to be the second step in this relationship pathway. 

When you and I were in residency, one of our mentors, Dr. Kirshblum, often talked about the three ‘A’s’: Affability, Availability, and Ability as the key to excellence as physicians.  The two components I am discussing here as the province of the physician within the relationship is really another way of stating the three ‘A’s’ to excellence as Dr. Kirshblum taught us years ago.    

The second set of features comes from the patient, but as physicians you can help teach and mentor the patients in these components.  The first is management of expectations, and the second is embracing personal accountable for health and outcomes by the patients themselves.

I think that appropriate expectation management is especially important.  As we care for an ever aging patient population there are real, as well as perceived, limitations on what people can do.  The limits of human ability is always expanding, but that said, there are limits and sometimes what a patient desires for their healthcare outcomes may not be realistic; we need to counsel and educate them about what is reasonable, we just need to do so in an optimistic and positive manner.

For example, I often counsel my patients with back pain, that their desire for complete, permanent eradication of their lumbar pain while engaging in any activity they desire may be unrealistic.  However, addressing underlying factors effecting the development of their pain and having a goal of increased function in an age appropriate fashion is usually very realistic. 

People tend to be disappointed, complain, and have reduced satisfaction when their expectations are not met.  As such, if their expectations are not obtainable in 99% of the circumstance, they will end up disappointed 99% of the time.  We need to set high goals, but obtainable one that can be achieved with discipline, hard work, and the patient’s full engagement in the process of achieving health and improving function.

This brings me to the next patient driven aspect.  Patients need to be accountable for their ultimate health and outcomes.  As an athlete, if I didn’t train, I was the one who did not succeed; I was responsible, there was no one else to blame.  We can control our efforts, the time we put into our training and the attitude we bring to the training environment, but we can not control the outcomes; control of outcomes is an illusion.  In this vein, we need to teach our patients to focus on what they can personally address, the controllable factors, and try not to get hung up on what they can not address, the uncontrollable factors.  As a coach, and with my own children, I teach that your personally controllable factors are: the time you put in; the effort you are making; and the attitude you bring to the task.  This perspective has wide spread utility in healthcare, especially healthcare intimately directed by small practice physicians such as Garrett and yourself. 

Gary:

That sounds great, be realistic and take responsibility in your own healthcare, do you have an example?

Brian:

Sure, let’s look at a patient that would be common in both your practice as well as my own.  Let’s look at low back pain.  When we look at a clinical issue such as back pain we know that there are many factors that are involved in a complex interplay of genetics, phenotype, environment, injury, etc.  For back pain we know that obesity and smoking play a large role as does age and gender.  We also know that strength, flexibility, and neuromuscular patterning also play a role as does daily activity, personal biomechanics, and ergonomics. 

Some of these factors, for example genetics, gender, and age, are not modifiable, so we need to teach patients to try not to get too caught up in worrying about these issues; they can’t change them anyways.  Other factors are modifiable and patients need to be counseled to fully engage these factors.  Are the patients aggressively trying to get their weight down to a BMI <25?  Have they stopped smoking? Are they doing a daily home exercise plan?  Are they avidly addressing their deconditioning?  Are they engaging in activity that requires inappropriate duration or intensity of activity for their body and age?  Have they modified their expectations to include reasonable goals?  And so forth. 

In all of these examples, you and Garrett can directly improve the quality of patient care by keeping the patients focus on modifiable, controllable factors, the time that the patients are putting into these issues, the effort they are applying to make changes, and the attitude that they bring to the process.  This effort on your part will potentially have a much more lasting impact that any particular intervention or medication. 

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Gary:

For you or your family, which would you prefer for a better patient experience- a small independent practice, or a large practice that is part of a system or Accountable Care Organization?

Brian:

For my family, my primary concern would be excellence of care. To that end, I would prefer to see the components discussed above brought to bear for the benefit of my family member.  I would like to see care provided by a physician with demonstrated excellent clinical skills and academic knowledge and an obvious desire to continue to develop and improve their knowledge base and acumen.  I would like to see this physician provide care within a compassionate, concerned relationship with an eye toward an end point of great care for my family member. 

Care such as this could be provided in many settings, this would include small independent practices as well as larger organizations.  However, I think that a small independent practice is better positioned to give this type of care.  In the small setting, the patient typically has direct access to their physician and the goals of the practice are more in line with the goals of the individual patient.  In larger organizations, even with the best intentions by individual physicians, often the organizational goals are more aligned with the overall care of a patient population rather than an individual patient.  This bigger picture, population driven focus of healthcare in a large organization works well for the management of demographic data but not necessarily for any given individual patient. 

When caring for an individual, we get back to the keystone word ‘caring’; I think that the small physician centric independent practice is better positioned to provide that ‘care’.  This focus on direct patient relationships and ‘caring’ can happen in larger organizations, but I think it is more difficult.  In a small practice such yours, because you have both direct authority over care and direct responsibility for the patient relationship, I think that you can be more responsive to individual patient needs and in most cases provide better care.

At the end of the day, healthcare is about two people in a closed room having a private, intimate conversation.  One of those two people brings a deep knowledge about medicine to the discussion and the other person brings a deep knowledge of their personal problem.  After a private discussion and evaluation, the two people come up with a plan and then leave the room.  What happened inside this room is ‘healthcare’. Everything else in the system exists to support that private conversation and patient-physician relationship.  The closer we can get to this idealized situation the better it is for patients.  In general, I think that at this point in time, the small independent practice is best positioned to provide for and support this private interaction.

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Gary:

Do you think physician ownership of a medical practice, as opposed to a medical practice run by an administrator, makes a difference in a quality patient experience?

Brian:

I think that in general medical care should be directed by physicians, both for the individual patient as well as for organizations and policy.  This need for physician control and direction holds true at a local level for a small practice such as yours but also expands upward to control and direction of larger healthcare organizations and even to state and national healthcare policy objectives. 

To use a sports metaphor, many great coaches were not great athletes themselves, but they were nearly always good athletes.  How can you coach and direct a team or an individual athlete if you do not ‘know’ the game.  When I coached alpine skiing, I was a better coach than I was a ski racer.  But I had ski raced at a high enough level to have some insight into the ‘game’ and by competing at a much higher level as a cyclist, I knew what it took to compete on a National level and beyond.  By combining those two skills along with some other personal skills, I developed into a good coach, much better than my personal history of ski racing would have suggested.  But the important point is that I had been a ski racer. 

I think that it would be very tough to coach any sport that you had not played yourself and it would be very hard to help an athlete be successful at a high level if you hadn’t been at a high level yourself; how could you understand the process or mindset without the experiences yourself?  Extending this metaphor, the direction and management of medical care must be via physicians.  How can non-physicians directly lead or direct healthcare without the background that the process of becoming a physician and obtaining Board certification affords?

I think that a natural career pipeline for physicians is to practice for 15 – 20 years and be mentored in leadership during that clinical phase of their careers.   Following this phase they can have a leadership / administrative role for 10 – 15 years leading into retirement.  This is a natural flow that allows for development of a deep understanding of patient care, healthcare process and delivery, as well as development of leadership skills.  All while directly engaged in the relationship and pursuit of clinical excellence that we discussed above.

To have non-physicians in a role of supervising, directing, or controlling physicians is a mistake.  Non-physicians’, that includes mid-level providers and nurses, do not have the same ‘buck stops here’ experience with medical care that physicians do, as such, they are not positioned to evaluate or direct physicians in the execution of patient care.  This is much the point of our point-counter point article on patient satisfaction scores.   I make a strong point on the importance of physician control and leadership of healthcare, but we must also remember that other players perform unique and useful tasks within the patient care pipeline and we need to respect and support them in the course of their filling those support roles.  The non-physician colleagues can play a very important and much needed role as our allies, but not as our leaders, ‘owners’, or ‘bosses’.

Gary:

What does your vision for better health care in 5 years look like?

Brian:

I think that the tea leaves on this issue are in really muddy water at this point in time.  The current trials and tribulations of the ACA and the obvious public distain for much (but admittedly not all) of the contents make any forecasting very difficult.  Further obscuring the future pathway is that the pendulum has swung very far towards the business / administrative side of healthcare.  It is crazy that people with business degrees are in positions to tell physicians how to run their clinics, that administration is having a say in the schedules of residents and fellows during their training, that in many large healthcare organizations there is one administrator for every 3 or 4 physicians.  The inappropriateness of these and many other things are being noticed by those outside the ranks of physicians and I believe that the pendulum will swing back toward physician drive patient care as the cornerstone of health care, the question is when.

As a nation we are also going broke providing healthcare in the manner that we currently do, so things must change.  We have an annual GDP of about $15 trillion in the US and medical care expenditures of more than $2.2 trillion.  That can’t keep happening; we simply can not afford this amount of cost over the next 15 or 20 years.  It is a fact that this expanding expenditure will get cut, but the question is where to cut? 

A large part of the problem is the almost complete lack of national discussion on the real source of these runaway costs.  Physician salaries make up only 8% of the total healthcare costs, so even if every physician in America worked for free we would still spend nearly $2 trillion per year on healthcare in the US.  So, obviously targeting physicians is the wrong way to go, even if only for pragmatic reasons that chopping doctors will have minimal to no effect on the cost problem. 

So where to address things?  My personal belief stems back to the above mentioned patient centered aspect of care; personal responsibility.  Modifiable factors are the biggest cost in healthcare in America.  Obesity and smoking combine to directly tie to >50% of all healthcare costs in America. In other words, if everyone in the US had a BMI <25 and no one smoked, we could move toward a future with healthcare costs <$1trillion per year; now that is a significant difference. 

The escalation of healthcare costs is really a demand side economic problem and as a nation we continue to attempt to address the issue by making supply side regulations and attempting to change payments in order to change the slope of the supply curve.  But supply is not the problem, demand is the problem.  In most large hospital systems the top 100 utilizers of emergency department services (the 100 patients who use the ER the most) spend a wildly disproportionate amount of the healthcare dollars in those systems.  I do not have an article to cite, but I have heard it stated that overall 10% of the patients spend 90% of the healthcare dollars. 

Until we address the demand curve for healthcare, the US healthcare expenditures as a percentage of GDP will never get ‘fixed’.   The great news is that if we can get politicians on board and decrease the disproportionate input that ‘big’ medicine has on the system, and focus on the quality of care issues you and I discussed above, then we can find a solution.   But there is almost no discussion on a national level regarding this issue; instead our national and state leaders continue to throw regulatory requirements into the marketplace that make healthcare more expensive all the while ignoring patient responsibility for cost control and their own personal health.  We must move on a national scale toward the above noted components for excellence, with a national focus on excellence in physician directed care and on patients having realistic expectations and taking personal responsibility for their healthcare and outcomes.

There are several well known national voices that have espoused a future of medicine in the model of Wal-Mart or the Cheesecake factory.  They envision large corporate entities providing homogenized, albeit acceptable (but not excellent), healthcare to the masses.  This vision is deeply flawed because of it continues to focus on the supply side of the healthcare equation while lacking in the much more financially salient demand side of healthcare in the US. 

Further, is shopping at Wal-mart a better retail experience than shopping at a local merchant?  Is it better for the community at large?  Is it better for the workers?  I would ask what community has seen its local population benefit from the invasion by Wal-Mart and the subsequent decimation of local retailers. Does eating at Cheesecake factory offer a better meal or quality of product than could be provided by local chefs using local or regional products in a small to medium volume format?  If you are looking for a quality dinning experience would you rather eat at Cheesecake factory or at The French Laundry or Blue Hill at Stone Barns (look them up)?  Or, if you are looking for less financial challenging quality food, I would suggest that the Panini sandwich at your local deli is both higher quality and lower cost than a similar lunch at the Cheesecake factory.  What community has seen an expansion in the quality of local food when a Cheesecake factory opens up in the local shopping center? 

These giant organizations offload their profits away from the local community, pay relatively lower wages than would be making by the owners of local establishments, and degrade the quality of product in terms of both product and the quality of relationship available.  This corporate homogenization does not improve the retail experience or the dinning experience, and I do not think corporatization will benefit the healthcare experience. 

So the future is murky, but I think that there will always be a role for small physicians groups providing outstanding clinical care and forming lasting and quality relationships with their patients and communities.  Excellence never goes out of style, so I think that you and Garrett have a bright future.  

Interview with the Experts: Lisa Huynh, MD

We are starting a new feature on our blog called "Meet the Experts."

We are going to start with Lisa Huynh, MD, who is my co-author on the
recent article "Get the Lowdown on Low Back Pain in Athletes"
published this month in the American College of Sports Medicine Health
& Fitness Journal (link requires ACSM membership)

Lisa worked with me as Chief Resident at the
University of Pittsburgh Medical Center, and starting in July will be
starting at Stanford University in an Interventional Spine Fellowship.
 Amongst other things, Lisa was the very last resident I taught at the
University of Pittsburgh, and it was such a privilege for me to work
with her.

I've invited Lisa to give her perspectives on low back pain in
athletes, her practice philosophy, and her general thoughts about
Sports & Spine Rehabilitation.

Gary: What sparked your interest in treating low back pain in athletes?

Lisa: As discussed in our article, low back pain is the second most
common reason people see their doctors.  Therefore, it's important for
all physicians to understand the different etiologies of back pain and
how to treat them.

Athletes are a unique set of patients.  As dedicated as they are to
their sport, they are equally dedicated to healing after an injury in
order to return to play as quickly as possible.  This makes them
intensely motivated, which is welcoming as a physician.

I recall early on in my training treating a female college volleyball
player who had persistent low back pain for over a year.  She had been
through generic physical therapy programs and tried oral medications
with no relief.  I helped diagnose her with an annular tear, which had
been previously missed.   We performed an epidural steroid injection
and prescribed a course of extension-based physical therapy.  On
follow-up, she was back to playing volleyball and was pain-free.  That
was a great feeling!

Gary: You have perspectives as an athlete yourself and as a physician.
Why do you think it's important that athletes with low back pain seek
out care from a specialist who is familiar with the particular needs
of athletes?

Lisa:  As a physician, we learn and treat a variety of medical conditions
and see a diverse set of patients.  However, athletes are a unique set
of patients, which require specialized care.  As an athlete myself, I
would want a physician who understands not only an athlete's mindset,
but also the demands of his or her particular athletic activity. This
enables the physician to better tailor the treatment and
rehabilitation regimen to help heal and prevent further injuries.

Gary: One treatment that you touched upon in the article was the
Mechanical Diagnosis and Therapy (McKenzie) approach to assessing a
directional preference and centralization of symptoms.  My experience
is that this is frequently overlooked in patients with low back pain, even when seen by other spine experts.  Why is this so important in an assessment of patients?

Lisa:  The McKenzie approach is based on finding the directional
preference (lumbar flexion or extension) of which back pain and
radiating pain is relieved.  By determining a patient's directional
preference, you can better narrow down their pain generator, which
ultimately helps guide their physical therapy program.  At a basic level, for example, for patients that have back pain and leg pain worse with lumbar flexion, they
should participate in an extension-based program.  For those that have
pain worse with lumbar extension, they should participate in a
flexion-based program.  The overall goal of this approach is to move
pain from the legs and centralize it to the back, with eventual
dissipation of the pain.

Gary: Another great point you touched up in the article was annular tears
as a common cause of low back pain.  I find that many patients are
told that they have "chronic muscle strains" or "mechanical low back
pain", when they actually have annular tears.  What tips do you have
for recognizing an annular tear, and how do you use that insight to
guide treatment?

Lisa:  Typically, symptoms of an annular tear include a vague pain
located at midline of the back.  Pain is typically worse with bending
forward, coughing, sneezing, and prolonged sitting.  Oftentimes
patient may complain of stiffness in the morning or can be seen
shifting their weight from side to side while sitting.  It does not
typically radiate down into the buttocks or legs like it does with
disk herniations.  Since pain is typically worse with bending forward,
prescribing an extension-based physical therapy program would be most
appropriate.  If pain persists despite more conservative measures,
consideration can be given to a fluoroscopic-guided epidural steroid
injection.

Gary: Since you and I haven't worked together for about a year, it's
helpful for me to gain from your perspective of what was helpful from
I had shared with you as a clinician. Did I teach you anything useful
that you still use?

Lisa:  One of the greatest things you imparted to me was lifestyle
medicine.  Many times, patients come to us for a quick fix such as a
"magic pill" to make their pain go away.  And while it may be easy to
write a script for medications or therapy, these often do not help in
the long run.  By educating the patient and providing them with the
tools to change their mindset and lifestyle, we not only help to
improve their acute injuries, but can also prevent further occurrences
down the road.

I also continue to educate them on the difference between strategy and
tactic, as you have taught me.  Strategy is having an overall plan,
whereas tactics are specific, well-defined tasks that help to
accomplish an overall goal.  So rather than telling a patient to lose
weight, I continue to encourage them to participate in at least 30
minutes of aerobic exercise at least 5 days a week according to ACSM
guidelines, use walking sticks if needed, and sign up for
myfitnesspal.com to track their progress, amongst many other tools.

Gary: It has been such privilege for me to be part of your development as
a physician and person.  As you are evolving your personal
patient-care philosophy, how would you define your vision and
approach?

Lisa:  I'm just starting out so I'm sure that my vision and approach will
evolve over the years.  However, my personal patient-care philosophy
is one that empowers the patient to take charge of their treatment
plan of care, because that is what will ultimately motivate them to
improve.   When I first see a patient, I want to find out what their
overall goals are, what they think their limitations are, and what
tools they have to accomplish their goals.  Utilizing that information
allows me to develop a treatment plan WITH the patient so that we are
BOTH in agreement on how to achieve his or her goals.  I find that
patients are more inclined to complete tasks and stay motivated when
they have had direct involvement in their treatment plan.

Gary: I'd like to extent a great thanks to Lisa Huynh, MD.  She is a
spectacular physician, and I look forward to checking in with her to
see how her perspectives develops in the coming years.

Vertical integration- one of the great medical lies

Something I've never heard from a patient "Thank god for a phone tree!"

.... I saw one of my favorite patients yesterday.  She was initially referred to me for neck pain, which we've treated successfully, but I also picked up an untreated concussion, which we've been working through.

She is super compliant, super motivated, and just super in general.  She also has a medical condition that I picked up, but is outside of my domain of experience, and really needs to be follow-up by her primary care physician ....

Which would be great, but she's been trying to get a hold of her primary care physician for the past 3 months, and can't reach a human being.  Her primary care physician is part of a large health conglomerate, and she is stuck in what I call "phone tree hell."

The solution is pretty easy- I work with some wonderful primary care physicians who are independent, and will be happy to see her, and treat her like family.

So the solution is pretty easy ... what's the problem then?  Vertical integration.

Vertical integration is the idea that if we take take all the different aspects of medicine and put them under one roof, we will have one-stop shopping, and a one-stop solution.  Another way of framing this issue is making the argument that medicine benefits from an economy of scale, and that by creating incentives to make medical practices bigger, we will prevent inefficiencies and improve care.

That has not been my experience, and it has not been the experience of my patients either.  One particular intervention that most vertically integrated organizations love using a phone tree, or central call system.  The thought is that it will improve efficiency and limit staff.

Let me ask you, the reader, how your experience has been with a phone tree?  Delightful?  Fabulous?

My experiences have always been awful.  I once had a patient who worked for Comcast's phone tree system, and he told me that their internal metrics for their call center were spectacular, even as they had to rename parts of the company XFinity because Comcast was nationally synonymous with horrible service (see here for more details).  What I was told was the Comcast scored their operators on two criteria - whether they were able to upsell, and how quickly they got off the phone.  It's easy to see why this would be valued within the accounting department, and hated my customers.

And this is exactly why we prioritize having an actual person at our phone, and having that actual person within a short walk of both Dr. Hyman and myself.  It's just one more detail that leads to true customer service.

Big health care systems - for people who wish their health care was more like the cable guy!

What is your fitness age?

This is a really fun video with my good friend and colleague Chris Visco, who runs the Sports Medicine program at Columbia University in New York

http://www.youtube.com/watch?v=T7Wk2rYJLYg

The fitness calculator the video references can be found here: https://www.worldfitnesslevel.org/#/

I decided to try a little experiment- see what my fitness age is now, as a 40 year old living in Redmond, and compare it to how I was as as 38 year living in Pittsburgh.  The results?

Now- my actual age is 40 (.... or as my nephews/niece may say, 40 and 2/3), and my fitness age is 33

Back in Pittsburgh a few years ago, my age was 38, and my fitness age was 54

Wow- much bigger difference than I anticipated.  Even though I am 2 years older now, my "Fitness Age" is 21 years younger.  To what do I attribute the difference?

1. I exercise more.  I always believed in exercise, but I was only getting exercise in 2-3 times/ week before, and that may have been generous.  I now exercise every day, at minimum walking my dog Bucky for 30-60 minutes/ day, and often biking to work or hitting the gym

2. I don't drink alcohol anymore.  I was never a heavy drinker, but in retrospect I didn't metabolize it well, and I might as well have been drinking fruit punch or cola for all the calories I was taking in

3. I weigh a lot less, and lost 6 inches off my waist

4. I am much happier in my work life.  I found many things satisfying in both jobs, but I have far fewer sources of dissatisfaction.  Much of that I attribute to running my own practice, and having a partner I respect and I know is rooting for our mutual success.

My prediction when I moved to Redmond was that I was going to be adding 10 years to my life.  Looks like I aimed low.

I need a medical adminstrator STAT!

I have flown hundreds of thousands of miles in my time as a physician, and I've always wondered if I would ever get called into duty on a flight ..... there's a first time for everything

The day began with a kiss goodbye for my girlfriend and feeding the dogs.  My girlfriend has been out of town on a consulting gig, so the few moments I had to kiss her goodbye may be the only 5 minutes I see her for several weeks.  I am out of town for 3 days as part of a leadership position for the AAPM&R (www.aapmr.org), the main parent organization for the field of PM&R.

I get on the airplane, and I start profiling.  As someone who is 6'3" and 230 lbs, I always hope that I am seated next to a 4' Hawaiian girl.  Most of the seats are taken, and I do see one opening ... next to a guy who looks to be about 5'10", 265 lbs.  Nice guy, and he is pleasantly in his own space jamming to some Beats headphones.  We make some pleasant small talk about the sound quality of his headphones (he likes them), negotiate over elbow room without much confrontation, and then settle in for the flight.

I start reading my book of choice on the IPad- "Fightnomics" by Reed Kuhn.  Interesting read, where he uses statistical techniques to help analyze fighting, similar to the concepts Bill James pioneered in baseball, and has been spreading to other sports like basketball (e.g., this great article at Grantland).

This is a topic of great interest to me, both as a Mixed Martial Arts fan, and as a mathematics/statistics fan.  Bill James, and his intellectual progeny at the Baseball Prospectus, demonstrated that using more sophisticated statistical techniques could help baseball teams win more games.  I think the message of this is that often heard is that "Big Data"- the idea of collecting massive amounts of data and hiring statisticians to look at it- can solve problems that otherwise would not be apparent.

That's true ... but it also misses a lot of what was Bill James's real genius.  He didn't advocate for sophistication or numbers, he simply advocated for asking good questions and looking for simple approaches to answering basic questions.  For example, one of his biggest insights was that measuring On Base Percentage was a much more meaningful way to characterize a batter's offensive output than Batting Average.  There is nothing complicated about On Base Percentage - I literally was calculating mine as an 8 year old- but Bill James realized that asking the right questions was important.

It was also important to not get hung up on stupid details.  For example, one of his big insights was realizing that "clutch hitting" is essentially unmeasurable.  It may be real, but trying to build offensive strategies around "clutchness" don't work, and was often used as a way to validate someone who actually wasn't that valuable.  

This is important because we often get hung up on details that don't matter, or in fact are harmful.  I think about this with medicine all the time.  My colleague Brian White and I, for example, recently published a Point-Counterpoint article where we are argue that popularly used Patient Satisfaction surveys are harmful, primarily because they change physician behavior in a way that leads to 25% higher mortality, more patient expenses, and higher hospitalization rates.  The question of "how could it hurt?" with data is that, with the wrong data, it could hurt a lot.

The debate in medicine is whether usage of Big Data better parallels sports analysis, where the Big Data has clearly helped, or is Big Data like the stock market, where people have arrogantly used Data to cause market crashes because they overestimated how well they really understood the consequences of the data, as outlined in Nassim Taleb's wonderful book the Black Swan.  I say it's a debate, but it's not really, since the Affordable Care Act (aka Obamacare) has already made that decision, ruling for Big Data.

Which brings me back to a lady on the plane .....  I was thinking all these thoughts as I started to nap.  One of my great gifts in life is that I am great at napping on a plane.  As the plane lifted off, I put away my IPad and dozed off.  The flight attendants bumped my feet a few time (... which was my fault, since they extended into the aisle), but I got in a solid 45 minutes of napping.

I eventually awoke to take a bathroom break.  I was still in a sleepy stupor, my mind wandering from thoughts of my girlfriend to thinking about whether leftys have a competitive advantage in Mixed Martial Arts (.... they do), when I noticed that the woman in the seat behind me was passed out.

She was lying on the seat, with a very white face.  She had a bit of belly, and looked to be about 3-4 months pregnant.  The excellent flight attendant was in the process of getting some oxygen, and it turned out that the guy with the Beats headphones was an army medic.

As a physician, one of my first thoughts was assessing whether I could be helpful.  I think for the things I do every day- treating Achilles tendinopathy or herniated disks- I am amongst the best in the world, and there are certain things I know nothing about (pediatric hematology, for example).  This was somewhere in between.  I deal with patients passing out after injections with some frequency, and I've dealt with athletes passing out.  

I gauged the situation, and Russell the Army Medic had things under pretty good control.  I tapped the flight attendant on the shoulder, and let her know "this is outside of my main area of expertise, but I am a physician, and I am happy to help in any way I can."

The experience gave me some flashbacks to 2000.  I had finished my PhD, so I was technically a "doctor", and was returning to my clinical med school rotations to finish my MD.  Because I spent three extra years working on my PhD, many of the interns and residents I worked with on clinical rotations were former students of mine, whom I had taught Anatomy.  As a courtesy to me, some of them would refer to me as "Dr Chimes" in front of patients.  I appreciated the thought, but I always asked them not to, because I felt that saying the word "Doctor" in front of a patient implied a knowledge base that I simply didn't have then.

It's always been striking to me since how others seem so willing to insert their credentials, even when they are substantially less qualified than I was at that stage of my life.  I think I correctly assessed my ignorance back then, but I did have some allied credentials- I had a PhD in a medical field (anatomy), had completed 3 years of medical school, had at that point seen hundreds of patients.  There are some non-physicians who certainly can understand more than physicians in certain circumstances - Russell the Army Medic has certainly treated far more gun shot wounds than I have - but I've had so many experiences in the past 10 years where people with essentially no medical training has insisted that my knowledge as a physician was trivial in comparison to their experiences.

One such woman interjected while Russell and I were triaging the downed pregnant lady.  She spoke up and said "I too work in the medical field, and ..." and gave her 2 cents.  This is always a delicate situation.  On the one hand, I want to be open to hearing what she has to say, because she may have some useful information, and I was well aware of the boundaries of my ignorance.  On the other hand, I couldn't tell if she just felt like interjecting out of some sense of self-importance.  I'd like to think that my comment "I'm a physician, but this is not my main area of expertise" helps create a clear boundary of what my strengths and limitations are.  Saying "I too work in the medical field" doesn't really help very much.  

Russell manned the oxygen, and I assessed her skin turgor and coloration.  She was dehydrated, and had a vaso-vagal episode from coughing.  We positioned her legs to give her better blood flow, without letting her uterus put too much pressure on the blood coming back from her legs.

She got better.  She needed to lie back for the remainder of the flight, and the rescue team took her out for an IV.  She did fine.

As I thought about the episode, it led to a few thoughts:

1. Did it make a difference that I was there?  Yes.  Russell did a great job in oxygenating her, but she was not getting blood to her brain, and she needed her legs repositioned.  He may have figured this out eventually, but I helped keep her from going into shock.

From an emotional standpoint, she made a point of letting me know it made a difference.  Once the color returned to her face, I spent 10-15 minutes letting her know what I thought was going on, talking to her about how it impacted her future son, and giving her reassurance.  I think the fact it was coming from a physician carried some weight with her, and I think that emotional weight was earned.

2. Did Russell make a difference?  Yes.  He had a better skill set for the initial triaging, and he and the flight attendant set up the oxygen quickly

3. Did the access to a physician over the phone make a difference?  No, but I am glad it was available.  The flight attendant asked if she should call, and I told her she should.   I thought we had things under control, but I also recognized this was outside my main area of expertise, and I was happy to hear other thoughts.  Ultimately, our ability to see what was going on in real time was more relevant to her care.  I'm glad we had back up if things got out of hand

4. Did it make a difference that this was Alaska Airlines?  I think so.  My entire experience on the flight was exceedingly pleasant, and it was always clear the safety and comfort of the patient was the #1 priority.  I don't know that the same would have been true on US Airways or United Airlines

5. Did the woman who spoke up and said "I too work in the medical field" help?  No.  She didn't really do any harm, but she was distracting, and if she wanted to help, it would have been more useful for her to have given parameters of what she knows, and what she was observing.  For the most part, she was benign.

HOWEVER, her instincts were horrible.  I want to give her the benefit of the doubt, but I think she underweighed the cost of her being a distraction, and overweighed the usefulness of her insight.

It happens to be a particular pet peeve of mine, because when it comes to medical decision making in the "Big Data" era, I think that everyone feels like they should have a voice, and the voice of physicians is just another voice in the crowd.

There is a stereotype of the A-hole physician who is arrogant and doesn't listen to anyone else, but while that stereotype has some elements of truth, I think it is incredibly overstated, and it's severely minimizing the role of physicians in health care.  I think that as a group, physicians are better than most in recognizing the boundaries of their knowledge, and that is in part because we are so used to working with content expert in other domains.  I know I don't know as much about Neurosurgery as my surgical colleagues, and I know this because I talk to surgeons all the time.  My physician patients get this too- they are amongst my best patients in recognizing that I have special knowledge based on my experience.

This woman who spoke up- I don't think she gets it.  She was surveying a situation that was attended to by an army medic who has expertise in triaging critical situations, with back up from a physician next to him, and a specialist in flight-related medical issues over the phone.

On another level altogether, I think more to the BIG DATA question, and how this applies to medicine.  While I've never been called into duty on a flight before, there's a reason that they ask "Is anyone here a doctor?"  They don't ask if there is a Hospital Adminstrator, or an Insurance Adjuster, or a Health Plan Adminstrator, or Electronic Health Record Specialist, or any of the myriad of people who contribute to health systems, but don't actually deliver health care.

Because, the bottom line is that when you are a pregnant woman who collapses on a plane, it's comforting to know that there is a physician there who is rooting for you.