Ultrasound Case of the Day- Ganglion Cyst

Today's case focuses on a ganglion cyst of the wrist.

This is the class bump to the back of the wrist that can form as a "wear and tear" injury.  In the olden days, these were typically treated by smacking the cyst with a Bible.  Bible smacking still works (sometimes), but we can also use ultrasound to help treat the cyst in a less brutal manner

I chose to show this image both because:1. It can help show patients the techniques Dr. Hyman and I use for treating different conditions in a more accurate and less painful way

2. It highlights an advanced technical point for other clinicians learning to use ultrasound

The ganglion cyst is the large black area highlight by the yellow area.  It appears large and black because the sound waves from the ultrasound machine penetrate easily through water, so it does not reflect back signal (as does the underlying bone)

The blue and red arrows are pointing to the extensor tendon of the ring finger.  This is the tendon that would help straighten out the ring finger if the finger was bent.  You can see a series of white parallel fibers that are extending from left to right across the screen.   One of the great strengths of ultrasound is that it is a MUCH higher resolution than an MRI.  On an MRI, then tendon would like like a simple black line, but using the ultrasound we can see the individual collagen fibers at a much higher level of detail.

The green arrow points at the underlying joints in the wrist (called a carpal joint).  This is an advantage of looking at the cyst under ultrasound - in this particular case, we can see that the cyst is very clearly NOT in continuity with the joint.  This has significance in terms of risk of infection or other complications

For this specific patient, we drained the cyst using ultrasound guidance.  In the past, we used to perform this procedure the way most doctors still do, which is feel around and just stick a needle into it.  The reason we use ultrasound guidance is to make sure we are not inadvertently injuring other structures (e.g., the carpal joint or the extensor tendon).  I can also do a detailed refinement called a fenestration, where I create multiple small holes in the cyst, which helps prevent the cyst from reforming.

Finally, a technical point for aspiring ultrasonographers- you may notice that the tendon immediately below cyst (the red arrow) is brighter than the tendon that is not beneath the cyst (the blue arrows).  This is an artifact called "through transmission."   What happens here is that the computer processor used by the ultrasound machine works under the assumption that the tissue density is uniform throughout the width of the ultrasound beam.  However, because the sound waves passing through the cyst have very little resistance, the computer processor will make everything deep to the cyst appear more bright (called hyperechoic) than it actually is.

One of the quirks with ultrasound is that because it shows so much detail, it is prone to artifacts that, in the wrong hands, can be misread as pathology in the patient.  This is why Dr. Hyman spend so much time travelling across the country working with other physicians to learn more about the nuances of ultrasound

Congratulations, Tony!

As part of our business culture, Lake Washington Sports & Spine supports & encourages our staff members to chase their dreams and become the best versions of themselves. We're proud to announce that Tony, medical assistant extraordinaire, was accepted into the DPT program at UNLV!! We'll be sad to see him leave the LWSS team, but we are so happy he is on the path to achieving his career goals! Go Tonyyyyy!!

Nutrition: 9 easy ways to get your fruits and vegetables

March is (drum roll...) 

NATIONAL NUTRITION MONTH!  

We asked our go-to nutritionist, Chelsey Ocean, to offer some simple tweaks to help add more fruits and vegetables to our diets.  For more information about Chelsey & the services she offers, visit her at www.myfoodexpert.com

9 easy ways to get your fruits and vegetables

Chelsey Ocean, MS, RDN, CD, CSSD

We all know that fruits and vegetables are healthy for us and you may even know 5-7 servings of fruit is what you should aim for on a daily basis. But how can you pack all those healthy servings in one day? See below for some easy tips to get those fruits and vegetables in your diet.

Breakfast

• Add spinach, kale and/or celery to a fruit based smoothie. It may turn the smoothie green, but with the sweetness of the fruit you will never know where that green color is coming from!

• Make a parfait with 0% plain Greek yogurt, fruit, nuts, cinnamon, mix and serve
• A chicken sausage, egg white scramble with mushrooms, onions, and peppers makes a high veggie protein meal

Lunch

• Use romaine lettuce leaves to make deli meat sandwiches or wrap your turkey burger with in a lettuce blanket
• Take a cantaloupe, cut in half, remove seeds and serve inside a scoop of tuna mixed with salsa
• Add cooked or pureed cauliflower, peas or squash to mac and cheese

Dinner

• Use spaghetti squash instead of noodles and serve with turkey meatball, marinara or parmesan
• Make a salad with at least three colors of the rainbow: red, green and purple (tomato, romaine lettuce, and purple cabbage)
• Make a mixed berry blend of strawberries, raspberries and blueberries sprinkled with vanilla extract, cinnamon, cardamom and clove serve as a sweet after dinne

The Health Cost of Complexity: the concept of Time Debt

This link from the Harvard Business Review does an outstanding job explaining the concept of "Time Debt."

One of the most common problem I run into with patients is that they have too much on their plate, and this leads to health consequences.  When the body is in a perpetual time debt state, the sympathetic nervous system kicks in, which is something physicians call "sympathetic overload."

The sympathetic nervous system is designed to handle our "fight or flight" response.  This is an appropriate response to being chased by a Tiger, or dealing with the occasional busy work deadline.

However, we as human beings were NOT meant to be in a state of constant "fight or flight," and our body does not handle it well.  Persistent sympathetic flow can lead to agitation, weight gain, poorly healing injuries, heart attacks, and death.

There is a great scene in the movie Parenthood, where Steve Martin's character Gil is confronted with a list of things he needs to do.  His wife asks him if he has to do something, and Gil responds "my whole LIFE is have to."

That sense of HAVING to do things is what drives the sense of Time Debt stress.  What I advocate patients do, to prioritize their health, is to re-evaluate the "Have to" items in their life.

This can often lead to some challenging decisions- you may need to re-evaluate your entire life.   When I was in the my late 30s, I realized my life was filled with too many "Have tos" in my life, which led to my decision to leave Academic Medicine, move across the county, and start prioritizing my own health.

Simplifying your life is not easy to do.   However, just because it is challenging to embrace simplicity doesn't make the concept less important.  It makes embracing simplicity MORE important.

Accountability: How to Achieve Your Goals

As we are approaching the annual “spring forward” this Sunday, I have begun reflecting on New Year’s resolutions.  Maybe it’s losing the extra weight they put on over the holiday season, maybe it’s training to run one 5K per month, or maybe, like me, they are planning on taking a graduate school entrance exam (MCAT here I come!)  When reading through your resolutions list, many may sound like the ghosts of resolutions past.  How many times have each of us said “Now THIS is the year that I do [enter resolution here]!”?  And yet, as late spring rolls around, our running shoes have collected dust, our pantry is filled with unhealthy snacks that we are not keeping track of, and our study supplies are packed away in storage.  We start to make excuses – “I’ve been overwhelmed with a project at work”, “I was busy with my kids”, “I don’t have the money for a gym membership”, etc.  These excuses allow us to relapse into old habits and forget the resolve we had in January.  I mean, there’s always next year, right??

Now for some of us (myself included) there comes a point when we desperately want to break away from this cycle and finally achieve these New Year’s resolutions, becoming the better versions of ourselves. When that time comes, accountability is a major asset.  Simply by having another person, whether it’s a couple of people, or your entire list of Facebook friends list aware of the goals you have set for yourself makes it a lot harder to skip that morning jog, opting instead for a muffin at Starbucks. 

Personally, I am absolutely guilty of “recycling” my resolutions.  I have found that accountability has become my ultimate sidekick, the most powerful tool that keeps me going.  Take the MCAT (the medical school entrance exam), for example.  I have told anybody who will listen that I plan to take the infamous exam at the beginning of this summer.  I have explicitly set up a study schedule and I text my mom every night after I’m done with my session.  If I don’t text her, she usually texts me (she’s very on top of her game.  Go Mom!)  Although I don’t want to disappoint myself by doing poorly on the exam, I certainly don’t want to disappoint her (or any other friends who have been patient and unwavering in their support through this journey). 

This same idea can be applied to the different treatment options that Drs. Hyman and Chimes recommend to their patients.  If 30 minutes of daily exercise is what the doctor ordered and you know that there might be days when the devil on your shoulder tells you to skip the gym and stay in bed, enlist a friend to come along! First of all, you’re much less likely to flake out on a friend than you are on yourself.  Second, the exercise will be much more fun with a friendly face right there, pounding the pavement with you, in turn, making it more likely that you’ll form a healthy new habit!  If one of the treatment recommendations is tracking your food intake, whether on paper or in a food tracking app like www.myfitnesspal.com, send a copy of each day’s intake to somebody, such as your spouse, your nutritionist, or personal trainer.

Another way to be held accountable is to have money on the line.  Spending $300 to take the MCAT definitely makes me only want to take it once, and that motivates me to stick to a strict study schedule. In regards to exercise, one can sign up for a paid class or a personal trainer.  It is much harder to miss a workout when you know it will cost you a $70 training session or a $25 exercise class.  Knowing that there is money on the line certainly makes each of us more likely to follow through.  You probably would not skip out on your massage appointment; so don’t skip out on your workout! 

Whichever method of accountability you choose, the doctors and staff at Lake Washington Sports and Spine are here to support you on the path to achieving those New Year’s resolutions and becoming the best version of yourself!

Ceasing Medicare Contract: Frequently Asked Questions

What Underpins Our Decision?

Our decision to stop contracting with CMS is based upon the simple premise that we wish to provide the best, unfettered, unobstructed care.  Care influenced only by what will best serve the patient.  We feel that CMS (and to a lesser extent, other insurers) continue to evolve and create policy with the goal being cost control, at times under the guise of improving quality.  

A very significant, though secondary reason, for discontinuing our contract with CMS is that the finances do not make sense.  Cuts in payments in many cases mean that our business liabilities exceed our reimbursements.  Our business certainly cannot sustain this trend of increasing costs and diminishing returns.  We aim to take control of and stabilize our financial circumstances, so we may continue to serve the sports medicine needs of the Eastside and greater Seattle community for many years to come.

What Does the Evidence Say?

It is a misnomer that scientific data, or "Evidence-Based Medicine" (EBM), is always available to guide us, the medical providers.  Even in the best of circumstances, when well-designed research studies are available to guide us, this is "evidence-informed medicine" -- meaning that one has to carefully interpret the research and apply deliberately as appropriate to the unique circumstances of an individual patient.  Moreover, CMS has manipulated the interpretation of data, selectively favoring research that restricts access for patients and conveniently disregarding research that favors promising techniques.  As cutting edge clinicians, this limits our toolbox for helping patients.

What Can You Do?

We would advise you to learn more about the evolving changes in healthcare and the risks posed to you as the healthcare consumer.  Then write your local, state, and federal representatives to express your opinions.  This impacts you, now, and your children and grandchildren in the future.

We also advise that when it comes to money and health that you budget for total health cost, which includes health insurance premiums, ancillary health insurance payments (copays, deductible, co-insurance), gym membership, and food.  Many patients only consider health insurance premiums and are caught off-guard by these other predictable expenses.

Can You Still Receive Medical Care from Us?

Yes.  Though you would have to sign some official paperwork consenting to receive treatment from a non-contracted Medicare provider, we would be happy to treat you in so long as we are the best fit to assist you.  We accept cash for our professional services.  Our goal is to restore you to optimal function as quickly as possible.

What if I'm Referred to Another Provider?  Can I Use My Insurance?

It depends.  If the provider to whom you are referred is a contracted provider through Medicare/CMS, then you may use your insurance.

Opting out of Medicare

Following a long period of deliberate contemplation, we, the physicians of Lake Washington Sports & Spine, have decided to cancel our contract with the Center for Medicare Services (CMS).  This will take effect as of April 1, 2015.  

As board-certified Sports Medicine providers, with the primary mission of keeping people active (KPA!), we cannot in good faith continue this relationship as our mission no longer appears to align with that of CMS.

To clarify, this means that Drs. Hyman and Chimes will no longer process Medicare insurance claims in our office as of April 1, 2015.

We'd like to explain our decision, at least in brief.

The Medicare trust account is underfunded.  This is well established.  The fund is expected now to be depleted by ~2030.  Over a period of years, CMS has set in process several measures to reduce healthcare payments to providers caring for Medicare beneficiaries, or to eliminate coverage altogether for some effective and well-established services.  

For example, one spinal injection called a therapeutic cervical facet joint injection is no longer covered, despite its effectiveness for many patients.  Other procedures that show promise such as prolotherapy and platelet-rich plasma (PRP) injections for refractory chronic tendon and joint problems are not covered, while CMS continues to cover steroid ("Cortisone") injections even in light of very limited evidence to support them.  These policies make no sense, not for sports medicine providers, nor sports medicine patients.

Despite the many additional years of highly specialized training required to perform nerve testing, spinal injections and musculoskeletal ultrasound (above and beyond that necessary for our Board certification), CMS is reducing reimbursements for these services in dramatic fashion: nerve testing has been cut by >50%, >60% in cuts for certain cervical spinal injections and 2015 will bring cuts of nearly 75% on ultrasound guided injections.  In the past, physicians have absorbed the small incremental cuts in payment, but, because these cuts are so dramatic, the payments now in many cases are insufficient to cover the cost of doing business.

New similar policies are set in place each year.  These global policies are most certainly designed to limit access to care, deliberately to reduce costs.  

Our primary goal is to provide the absolute best care for patients who choose to seek our professional advice, and to restore those patients to optimal function using the best possible tools at our disposal.

And so therein lies the conflict.  We are focused on caring for and improving the health and wellbeing of our patients and our community.  CMS's goal is to reduce healthcare dollar spending in the United States. 

Additionally, Medicare has been hiring bounty hunters called RAC's to review charts to look for errors in coding (and medical coding is unnecessarily complex) to charge physicians with fraud, and fine hundreds of thousands of dollars or in some cases send physicians to federal prison.  So not only is CMS reducing our reimbursement, but it is placing physicians’ billing practices under a microscope, looking to recoup millions of dollars and to criminalize and make examples of physicians.  While we are certain that our clinic's practices would hold up to the greatest scrutiny, we would rather not continue on this booby-trapped playing field.

We are confident that this decision will positively influence our patients, and will more than ever, align patient and physician goals.  We recognize that our decision may cause anxiety or angst for some of you.  Should one wish to continue to treat in our clinic on a 'cash pay' basis, yet have concerns about ability to pay, we ask that they please contact us to discuss these concerns.  We will do everything possible to ensure patients receive the care they need.

For additional reading, please refer to : 
http://lakewass.blogspot.com/2015/03/ceasing-medicare-contract-frequently.html

http://lakewass.blogspot.com/2014/05/how-obamacare-forced-two-tiered-system.html

http://lakewass.blogspot.com/2014/04/promoting-mediocrity-through-medicare_10.html