ActivAided in the News- Kelly Collier: "Saving the World, One Back at a Time"

This is a great news story about Kelly Collier, who worked with me to develop the Recovery Aid back brace by ActivAided.  I'm the physician mentioned in the story- Kelly and I met when we were both working in Pittsburgh

Some highlights from the story:
"Inventor Kelly Collier first connected with Innovation Works to build her business skills. She had just finished a dual degree in materials science and biomedical engineering from Carnegie Mellon. As part of a class project -- and with guidance from a physician recognized as an expert on spine care and sports medicine -- Collier developed a device to ease back pain. With the makings of a prototype, she then faced challenges with business development. 

"It was hard to convince people to believe me," recalls Collier. "And to get people to believe that this product was going to work the way I said it was going to work."

She attended free public sessions and applied for Innovation Works' AlphaLab program, a business accelerator that funds entrepreneurs with a $25,000 investment and provides intense business mentoring. Collier then obtained additional funding from Innovation Works as her business, ActivAided Orthotics, grew. The RecoveryAid garment is now sold online and through medical supply companies across the country.

"The product works really well," says Collier. "My goal was to try to save the world one back at a time." 

Edge & Spoke: Lessons learned from a great local business

As small business owners, we here at Lake Washington Sports & Spine like to observe the success of other small businesses (even outside of medicine) as models for how to treat our patients.

One such business is my bike shop, Edge & Spoke in Redmond.  Edge & Spoke has recently rebranded from their prior name, as the former store manager Brian "Venny" Venable purchased the shop in early 2014.  

I like to think of Edge & Spoke as "my bike shop."  As a cycling enthusiast, it's nice to have a shop that you think of as your home base.  I've lived in other communities where I did patron a local bike shop, but did not feel a kinship with the management.  Rather, they just happened to be the bike shop closest to where I lived.  I don't feel that way about Edge & Spoke.  To me, they feel like part of my cycling family, and I know that if I have a cycling need, they are where I will go.  

Here are some lessons I've learned from Venny and his team about how they do business, and hope to bring to our business at Lake Washington Sports & Spine:

1. Sales through service:  

      I first met the Edge & Spoke team one year ago when I first moved to the Redmond/Bellevue area.  I was looking for a new commuter bike for my 8 mile ride to work.  I already had a nice road bike and a serviceable mountain bike, but I wanted a bike that could handle the weather, hills, and night conditions in the area.  Because I was planning to ride the bike frequently, I set a high budget for what I was willing to spend.

     At every other bike shop I went to, I found that the sales people were focused on selling me something as close as possible to the upper end of my budget.  I didn't mind that approach necessarily, since I was open about my budget, but it was clear their sales algorithm was designed to maximize profit.
     I had a very different experience when I met Mason at Edge & Spoke.  He spent about 30 minutes interviewing me about the specifics of my needs, asking thoughtful questions about the details of my commute, and the specifics of which route I was taking to work.  He then made a point of DOWNSELLING me to a bike that was about 2/3 of the cost I what I was willing to spend, but he thought was a better fit for what I needed.
     He then spent about an hour fitting me on the bike.  It was the most thorough fitting I've ever had on a bike, and included swapping out some parts to make the bike a better fit.
     A year later, I can say that Mason's advice was correct- I love the bike he recommended, and it's added greatly to me enjoying my bike commute.  I also appreciate that he placed my needs ahead of just making a sale.  The next time I needed to make a bike purchase, they had earned my loyalty, and I made a point of only shopping with the Edge & Spoke team.

     As a small business owner, the lesson that was emphasized to me was that the best way to make a sale is emphasizing the need of the client.  By placing the needs of the client first, you build brand loyalty.

2. Know what you are- don't try to be too much.   

     I enjoy watching cooking shows.  On shows like "Restaurant Impossible," one of the key points that they make is that it's a mistake to have too large of a menu.  Rather, have a smaller menu you know well, and make sure everything you sell is great.
     At Edge & Spoke, they primarily sell Specialized brand bikes.  At first I was surprised that they didn't sell 20 different types of bicycles.  However, when the Edge & Spoke team shared their logic, it made sense to me.  The strength of the shop is that they are a small, intimate shop that provides the best service.  By limiting their scope to fewer manufacturers, that allows them to be great at everything they sell.  Specialized is a great company with a diverse line that meets nearly every cycling need, so they wouldn't gain much by having the comparable bikes from other manufacturers like Cannondale and Trek- it would really lead to duplication of inventory.
     By staying focused, it allows the team to be experts on all things Specialized.  I've been in the store several times when the team has been talking to a customer, and they were able to give very specific details about the Specialized supply chain, things like "they over-ordered on the 2013 model, so on March 3 that model should be available at discount."  By narrowing the market, the Edge & Spoke team is able to provide better service and value on what they do sell.

     This made me realize that as a small business owner, we need to make sure everything we do is great.  At Lake Washington Sports & Spine, we try to stay true to our vision to "Keep People Active" using our expertise in sports medicine and being great in our use of musculoskeletal ultrasound and exercise prescription.  That also means that we can't be great at everything, and recognize that if we can't be great, we are better off referring clients looking for something else elsewhere.

3. Sweat the small details.
     I remember when I purchased my first bike at Edge & Spoke, Venny offered me a free branded water bottle.  I told him I didn't need one, since I had plenty at home, and then Venny told me about the thought and product testing they did to find the best water bottle on the market.  So I took one, and he was right- it's a great water bottle.  

     This is a small detail, but it also gives insight into the way Venny thinks.  Many places blow off details like which vendor they should use for their water bottle, but this is clearly something he put thought into.  Also, he was excited to share the product to make me happy- by giving me a free water bottle, he made was not making any money.  He was simply trying to make me a happier customer.
     The take home as a small business owner- when you show your customers that you are rooting for their happiness, you build loyalty.

4. Engaging customers as partners.
     Part of Edge & Spoke's commitment to their clients is 1 year of maintenance.  This is beyond the industry standard, and I can personally validate this is something they stand behind.
     Since I ride my commuter frequently, I've had to bring it in for small adjustments three times (which is to be expected).  Every time I brought in the bike, the team has welcomed me and always started by asking me if I am enjoying the bike.  That struck me as such a positive way to view the encounter- they could have viewed me coming in as unpaid labor, but they prioritized my happiness over their labor.
     One of the repairs they did is something that I think that Edge & Spoke could have considered "user error" on my end- I bent the front derailleur while shifting too aggressively.  One of the mechanics, Jack, looked at it, and asked Venny to help him out since it was a more complicated repair.   I think that Edge & Spoke was within their rights to charge me for the repair since it was my fault.  Instead, Venny repaired it, and promised that if his repair didn't work, he'd swap it out for free.
      His repair worked great, and I've ridden hundreds of miles on the repair without a problem.  That said, Venny built up a ton of loyalty from me by engaging me as a partner and treating me in a reasonable manner.
      As a small business owner, that is the biggest take home for me.  Venny treats me as a partner, and has made it clear to me over multiple encounters in the past year that he wants me to love my cycling experience.   Similarly, as a physician, my number one priority is that I want my patients to stay active and love what they are doing.

Lake Washington Sports & Spine wants to congratulate Edge & Spoke on their rebranding, and thank them for helping Keep People Active!

Strategy vs Tactic: Synonymous? No. Complementary? Absolutely!

Many of us (myself included) have undoubtedly used the words strategy and tactic interchangeably at some point in our lives.  Whether it’s in an intense game of Monopoly, on the soccer pitch, or while ironing out the most successful business model, strategies and tactics are crucial components.  These words, however, are not synonymous; they are complementary! Strategies and tactics are meant to work in tandem in order to achieve one’s goals (whether it be driving your opponent to bankruptcy in Monopoly or becoming the top sports medicine clinic in the area) and one cannot work effectively without the other.  So let’s hash out those differences…

Strategy, is identifying clear, broad goals that advance the person or organization. Tactics are the specific methods a person or organization will employ in order to achieve that strategy. Going back to the Monopoly example (because, let’s face it, it’s a GREAT game), if the goal (and therefore strategy) is to force the opponent into bankruptcy, a tactic might be to buy all of the orange properties because it’s been found that players land on those most often and generate the most revenue for their opponent.   

To help clarify the distinction, here are a few other examples:

Strategy	Corresponding Tactic
Invade Normandy	Tanks, Infantry, Battle Plan
Get out of Debt	Budget, Pay off Credit Cards
Exercise More	Hire Personal Trainer
Eat Better	Work with Dietician
Spend more time with my children	Commit to getting out of office by 5:30 pm
Be more mindful	Meditate for 30 minutes before bedtime

Choosing to look at a more relevant example that we see here often at Lake Washington Sports & Spine is the common strategy to “lose weight”.  Losing weight is the overall goal for the person, but unless specific tactics are designed to achieve that strategy, there will be disorder and ultimately failure in achieving weight loss.  If the strategy is to lose weight, one might say a tactic is to hire a personal trainer, commit to seeing them twice a week and cutting out sweets from his/her diet.  On the flip side, it is important to note that one cannot have tactics without strategies.  If this were the case, the person would have no big picture, no goal to strive toward. 

The reason why this important to us here at LWSS is because all of our patients’ treatment plans are based on the balanced relationship between strategies and tactics.  Patients often come into our office with a strategy, a larger goal they wish to achieve.  Dr. Hyman and Dr. Chimes are the ones who advise and prescribe different tactics that will help the patient reach his/her goals.

To help make an even stronger point is the realization that when patients fail to reach their goals, it’s usually because of tactical errors, rather than strategic errors. To use a parallel example, why do people hire accountants?   Is it because they need help with strategy or tactics?  Certainly the accountant can offer strategic advice (like lowering the total amount that you pay in taxes every year), but the main benefit of an accountant is helping on the nitty-gritty tactical details, such as taking advantage of certain deductions, or making purchases before after January 1 because of changes in the tax code.

Similarly, patients benefit from physicians the most when they utilize physicians for tactical advice.  As Lisa Huynh noted in her Meet the Expert interview, the thing that separates the good doctors from the great doctors is their ability to give specific, deliberate, and actionable advice on tactics to achieve your goals.  That is what we strive to do here at Lake Washington Sports & Spine, and we think it’s part of the “secret sauce” that makes for a better patient experience.

Dead Pro Wrestlers- finding the best comp

The great FiveThirtyEight blog has an interesting link today about professional wrestlers dying at a young age, inspired in part by the death of the Ultimate Warrior, Jim Helwig, at age 54.

As the blog posts notes, professional wrestlers have been known to be dying young for quite a while.  The Ultimate Warrior's death was startling because he had just been inducted into the WWE Hall of Fame as part of the Wrestlemania 30 tribute a few days earlier, and that he had given a speech about legacy that in retrospect was prescient of his upcoming death.

The observation of wrestlers dying young has been documented for years.  Deadspin has a Dead Wrestler blog, and there is a decent (not great) book about dead wrestlers written by the author of the blog called The Squared Circle: Life, Death, and Professional Wrestling.

There is not much disputing that professional wrestlers die at a young age.  The big question is why.

I have a unique insight since, as far I know, I am the only practicing MD/PhD in the world who seriously contemplated a career as a professional wrestler.  When I was a junior in college at the University of Wisconsin, I was trying to decide which pathway to pursue.  I wanted to be a pro-wrestler, but I realized that while I was big by normal human being standards (at that time, I was 6'2.5" and 215 lbs), I was small for a pro-wrestler, so I gave my 6 months to learn how to perform a moonsault.  For the uninitiated, a moonsault is a standing back flip off of a 5 foot platform.  Even after 6 months working into a gymnastics pit, I kept landing on the back of my neck, so at the urging of my gymnastics coach I gave up my dream as a wrestler and went to med school.

But I kept following wrestling, and kept seeing my childhood heroes die young.  I read the stories about how they were linked to steroid usage- NY Post columnist Phil Mushnik has made a career of pushing this theory- and assumed it was true.

However, now that I am practicing physician who treats athletes, I am pretty sure this conventional line of thinking is not true.  I do not think anabolic steroid usage is the main reason wrestlers are dying young.

In the specific case of the Ultimate Warrior, Jim Helwig, he died of cardiovascular disease.  It is certainly possible that he developed hypertrophic cardiomyopathy from anabolic steroid usage, but that was not specifically listed as his cause of death, which would provide a more direct linkage.

There are a few key things that I think will help understand why wrestlers die young- pro wrestlers have the combined lifestyle of two groups- bodybuilders, and stand-up comedians.

What pro wrestlers have in common with bodybuilders:
- anabolic steroid usage
- weight lift a lot
- large, muscular physiques

What pro wrestlers have in common with stand-up comedians:
- on the road all the time
- shift of the natural body clock (staying up late, getting up late, with frequent time shifts)
- frequent alcohol use
- frequent use of downers
- frequent substance abuse
- extreme personality types

What I would love to see the author of the FiveThirtyEight blog is run a similar data set with both body builders and stand up comedians.  I think he will find that stand up comedians die at a young age, in a way that is comparable to Pro Wrestlers, while bodybuilders do not.

Just as a quick comparison:
The FiveThirtyEight blog used Wrestlemania 6 as a starting point, which took place in 1990, and found that 12 of 36 participants are now dead.  Of note, three are women, who likely didn't use anabolic steroids (Miss Elizabeth may have- she was living with Lex Luger at the time, who used all sorts of drug cocktails).

Let's compare that to comparable events for both bodybuilders and stand up comedians in 1990.

The pinnacle of body building is the Mr Olympia show.  Wikipedia has a list of the top 14 for the 1990 Mr Olympia show, won by Lee Haney.
- Frank Hillebrand died of a heart attack at age 45
- Andreas Munzer died of multi-organ failure at age 32
- I cannot find data on Mike Christian.  For the purposes of this discussion, I will presume he is dead.

There obviously may be some measurement error related to reliable reporting, but that is 3 out of 14 bodybuilders dead, or 21%, as compared to 33% of the wrestlers from the same time frame.  I'll admit that that is more bodybuilder deaths than I was anticipating, but still not quite comparable to wrestlers.

Looking at stand-up comedians- I am struggling to find a comparable Wrestlemania or Mr Olympia type event that would make a good comp.  If any readers have a good comparable event, I would love their feedback.  I've looked for a comprehensive list of comedians who appeared on HBO Comedy Specials in 1990, but couldn't find such a list.

Just as an example, though, here is a brief list of contemporary comedians who died young:
- Richard Jeni
- Mitch Hedberg
- Bill Hicks
- Greg Giraldo
- Bernie Mack
- Chris Farley
- Sam Kinison
- Patrice O'Neil
- John Candy
- Phil Hartman
- John Ritter

My impression, semi- quantitatively, is that the list of stand-up comedians is more similar to the pro wrestler list than are the list of bodybuilders.

A few years ago, I heard an interview with Craig Shoemaker, discussing the suicide of his close friend Richard Jeni.  Shoemaker's theory was that Jeni's body was messed up from years of never having a normal sleep schedule.  That is consistent with my clinical experience- one of the worse prognostic signs for patients is an abnormal sleep schedule, and lifestyle factors (particularly drug usage).

So what do I think is going on clinically?

I think we are dramatically over-estimating the risk of anabolic steroid usage, and dramatically underrating the risk of things like alcohol, muscle relaxants, abnormal sleep schedules, frequent travel, and hanging out with people who have similar lifestyle habits.

I hope we are focusing on the right issue.

Finding a great match!

One of my favorite movie scenes is from Miracle on 34th Street, where Kris Kringle let's a customer shopping for Christmas presents know that if they can't find something at Macy, he'd recommend a competitor (this link is grainy at off-sync a bit, but you get the idea).

I think one of the clear messages is no service provider can be all things to everyone, and so if you are not able to provide the service requested, often times the best customer service is no service.

The relationship between a patient and their doctor is first and foremost a relationship.  Much like dating, there are subtleties that make a relationship work, but also times the fit isn't ideal.  When that is the case, it's best to recognize the lack of fit, so that the patient can find someone who fits their needs and style.

Another analogy is the world of burritos. In our area, you can get a great burrito at Chipotle, Baja Fresh, Qdobo, and a myriad of other places.  Chipotle is my personal favorite, but I am glad that I have a choice.  I'd hate to have a system that mandated uniformity.  Variation is good.

In healthcare, that is true as well.  I have some colleagues I respect greatly who have different practice styles.  My practice style could be summarized as a musculoskeletal root-cause analysis, but with dogs in the office, and a graduation ceremony with maracas when you get better.  It's not the right choice for everyone, and I am ok with that.  I don't want to be good for anyone- I want to be great for a subset of patients, and help other people find a great fit with someone who meets their style.

One of the things that helps an efficient market is choice and transparency.  As my partner Garrett Hyman noted, the recently released Medicare billing data doesn't really add transparency- it mostly adds a lot of noise to true signal.  On the other hand, I think this blog provides transparency.  One of the main reasons I like to blog is that it offers patients a free "test drive" to my style and way of thinking.  For example, my personal diagnostic approach is rooted in thinking through a differential diagnosis, and my blog post on Differential Diagnosis explains how I think.

An additional part of this transparency and choice is freedom of choice for referral sources.  As I continue to work with colleagues, they start to develop familiarity with what I do well and what I don't do well, and that can help coordinate a good fit for the patient.

For example, many referral sources like to refer to me because they know I do a very thorough biomechanical assessment, give feedback on exercise, have expertise in diagnostic musculoskeletal ultrasound, and that I am skilled with both ultrasound-guided and fluoroscopically-guided injections.  For patients looking for that approach, I am a great fit.

Conversely, I do not prescribe oral medications for musculoskeletal conditions.  I don't think they work in the long term, and I think their usage gets in the way of more effective treatment approaches.  I have evidence-based and experience-based reasons for this philosophy, and this not a negotiable part of my practice style.  For patients looking for oral medications as part of their treatment, I am a horrible fit.  My preference is that patients understand this as early in the process as possible, preferably before the first encounter even.

Bottom line- great care starts with a great match!  Sometimes that great match is going to Gimbels instead of Macy's.  Patients should have the right to have a choice

Why physicians also need patients to be OUR adovcates

This recent blog post at the Daily Beast does a really nice job summarizing the challenges to being a physician.

I don't find my job as a physician miserable, but I used to.  To be more accurate, I used to find being a physician a mix of both the incredibly rewarding and completely unsatisfying, and I suspect that is true of most physicians.

In order to optimize my happiness, I had to make a dramatic shift, and that was leave my former job and large corporate medicine in general, and join a great partner, Garrett Hyman, who is invested in our mutual happiness as a tool to improve patient care.  The Daily Beast above highlights how that this is not the norm- physicians feel increasingly obligated to join large corporations as employees because of the burden of compliance with regulations.

Unfortunately, I know some friends and colleagues who are resigning mid-career because of the misery of being a physician in the current climate, and that is both unfortunate and expensive.

The Daily Beast article touches on some of the burdensome frustrations of being a doctor and how this hurts patients, but I'll give another specific one- Meaningful Use.

Meaningful Use is a requirement of CMS (the Centers for Medicare and Medicaid Services) that verifies that not only are we using an electronic medical record (EMR, or EHR for electronic health record), but that we are using it in a "Meaningful" way.  To get physicians to comply, they withhold part of our payment, and then give it back if we jump through the appropriate hoops.

Last year, I lost $8000 because of Meaningful Use penalties.  I actually met all of the criteria, but because I switched jobs last year, I was not able to present the data to CMS in the format they required.  It was basically an $8000 tax because of a logistical quirk of switching employers.  Very frustrating and expensive, but it is what it is.  These days, it is not uncommon for physicians to just have to "suck it up" and take on these kinds of costs as part of the cost of doing business.

One of the criteria this year is that we have secured communications with patients via our EMR.  Now this is where the logistics of CMS becomes super annoying.  I am very clearly in the upper 1% of physicians in terms of electronic communication.  For most visits,  I send patients a secured-email summary of their visit, along with pertinent articles and links to our blog on related topics (e.g., this article on the use of suspension straps, where I have photos and instructions on how to perform the exercises).  This very clearly meets the intent of the requirement, BUT because I am sending this information outside of my electronic medical record, it doesn't count.

So I have a choice- use an inferior alternative that pays me more, or take the penalty and communicate in a way that I know patients prefer.  I choose to take the penalty.  But it comes with a cost- $8000 this year, and the costs escalate over time.

The number of these criteria are not small.  For example- we do NOT get paid to counsel our patients about exercise.  Rather, we get paid to CLICK A BUTTON that says we did.  It's an important difference.

This button pushing is pretty miserable, so why do I refuse to give in and be miserable?  Because I perceive that I have a choice.  Garrett and I have decided we are going to live by our mission statement, which is KPA- Keep People Active.  If something helps patients KPA, we do it.  If it doesn't KPA, then we don't.  That choice is the difference between being happy and being miserable.

Now, what should a patient do?  The thing I'd recommend is become your physician's advocate.  It's all about the golden rule- treat others the way you'd want them to treat you.  If you want your physician to be free to listen to you, guide you along your journey of being more active, vote in ways that free us to be YOUR advocate.

Because good doctors are disappearing, and it's accelerating.  I'd hate to be having this same conversation in a few years when you can't find a doctor to take care of you.

The fundamental hypocrisy of CMS, ACA and Big Data

There is a great blog post today at Five-Thirty-Eight about mammography.  In the post, they discuss the pros and cons of mammography, and I think it provides a fair and thoughtful balance.

There is one quote in the post I want to discuss:"One of the central assumptions of economics is that more information cannot generate worse decisions. Mammography clearly provides more information. The problem is that contrary to our typical economic assumptions, it seems hard for doctors and patients to ignore this information. Once a tumor is detected, we want to treat it."


I think this a great point the authors make - we should not assume that more data necessarily generates better decisions.  In particular, they are saying that sometimes both patients and physicians need to be protected from themselves, because they make poor decisions because they have too much data.

Simplifying it further- more data can lead to bad decisions, especially when people act on it inappropriately.

This then leads to the fundamental hypocrisy of the Affordable Care Act (the ACA, or Obamacare) and CMS (the Centers for Medicare and Medicaid Services).  They are very expensively creating a major shift in health care to create bigger and bigger data sets, with the idea that this "Big Data" will lead to better decisions. 

As a patient, this should feel condescending and infuriating.  Basically, the politicians and the administrators behind the ACA and CMS are saying that patients and physicians do not have the discipline or wisdom to use data appropriately, but they do.  They are willing to dramatically but how much money they are willing to spend on things like MRIs and mammograms, and shift that money toward making people collect data on behalf of CMS and the ACA.

So, how do you want your taxpayer money spent?  Would you rather your doctor and you come to a mutual discussion of whether you need a mammogram, or do you want that decision taken away from you, and have money spent forcing doctors to push buttons to collect data for use by the ACA and CMS.

As an example of how ludicrous this use of Big Data is seen by the shift to ICD-10.  ICD stands for the "International Classification of Disease", which is a list of diagnoses.  Every time we see a patient, doctors need to assign a diagnosis according to ICD.  The current version of ICD is called ICD-9, and the government has forced a very expensive shift to a newer, much larger system called ICD-10, that has a much longer list of diagnoses.

ICD-10 is ridiculous- it's overly complex and creates far more noise than signal.  This link gives a list of several of the stupider codes.  My favorite is that there are 3 different codes for health effects of walking into a lamp-post- whether it's the first time you walked into the lampost, a repeat encounter, or a secondary complication of walking into a lamp-post.

What the advocates of Big Data are proposing is that patients and physicians working together are not wise enough to use the data from mammography appropriately, but adminstrators and politicians will be able to make brilliant insights because they know which sub-type of injury you have from walking into a lamp-post.  Does that make any sense to you?

There is another word for this hypocrisy- arrogance.  There have NOT been any studies that have shown this shift to big data will help, and it's very expensive.  And it explains why doctors are increasingly literally pushing buttons instead of talking to their patients.

Patients- there is an alternative.  Think about who within the health care systems is most aligned with your interests.  Is it the politicians, the administrators, the insurers, or your physician?  We physicians do not like what is happening, but unfortunately we have not been successful lobbying to protect the interests of patients.  Patients need to speak up and protect those who are trying to protect you.

Help physicians help you.  Speak up.