We 'Believe in Magic' at LWSS

At 46 years old, I crave Disney Magic as much as anyone.  I still vividly recall the effervescent energy of several cast members during a visit with my then fiancée, now wife Rachel, 20 yrs ago.  Their warm smiles and cheery voice coupled with an “I’d hug you if you were 10 and under” body language smoothed the path to a world of fairy tale and make believe.  One almost couldn’t help but ‘Believe in Magic’ after a close-up encounter with a cast member, whether street sweeper or manager.  I remember saying to Rachel, “How do they do it?  To a person, the energy is so positive, the commitment to the guest so genuine appearing, the willingness to serve…. they create a mood-elevating environment.” 

Soon after as I began working as a physician in a group private practice I learned about the Disney Institute.  My physician group hired a law firm to train us in principles similar to those taught at the Disney Institute or Ritz Carlton Leadership Center.  Their program taught us that 5 Star Service is never attained, but is always aspired.  The idea is that while you may deliver an experience that is “5 Star-esque,” there is always opportunity to do even better.

Our medical center, Lake Washington Sports & Spine, the professional business I started 4 years ago, operates on the principle of always striving to be 2% better.  And we operate on Positive Psychology principles, suggesting that in medicine we stand to learn much from the highest functioning among us.  Our mission is to “KPA” or keep people active.

The feedback we routinely receive reflects our intentions.  Our patients not only appreciate getting measurable results (i.e. returning to their desired physical activity) but they enjoy this improvement in a unique medical practice culture; for example, a live person, rather than automated phone tree, always answers the telephone, and we deliberately prioritize the patient over the population (as compared to large healthcare systems, the government or insurance industry), and we celebrate our patients’ recovery with a whimsical graduation ceremony.

My family and I just left Walt Disney World.  We spent one day in the Magic Kingdom, another in Epcot, and the final day at Animal Kingdom.  Unfortunately, it seems that Disney has misplaced the magic. 

How so?  Did the rides work well?  Yes.  Was the food adequate?  Yes.  Was the park clean.  Yes.  Were the attractions first rate?  Yes.  Well, what then?  Where was the Magic lost?

The cast members.

More specifically, Disney has allowed to disintegrate its culture of training excellence, and so this gives the customer the appearance that the magic was lost in the cast members.

Not present during our Disney visit were the routine and common interactions between guest and cast members that would elevate the mood, and so lighten one’s weary, having-stood-an-hour-in-a-line-to-enjoy-a-90-second-ride, feet.  During prior Disney visits, when the ‘magic’ was flowing, instead of heaviness or fatigue of one’s tootsies, one enjoyed a lightness of presence akin to being proverbially swept up by Alladin’s Magic Carpet.  Disney distinguished itself from other amusement parks based upon its service culture and ability to deliver a superior experience.  No longer.  Not for me or my family.  Walt would be disappointed. 

Specific examples of falling short you require?  As an extrovert and as someone with a keen ‘energy sensor,’ I routinely try and make eye contact and exchange greetings with those around me.  The Disney cast members would rarely make eye contact, their collective countenance was at best disinterested, and they rarely did exchange a big-hearted greeting.  Their energy was flat.  This energy was present in nearly all the staff I encountered.  In those staffing the rides, the attractions, the food courts/carts, and the custodial team.  The difference in animation of the Disney cast members was very clear.

I believe only once did a cast member approach one of my young children (ages 13, 10, and 6) and ask about their experience or try to engage them in a moment of Disney magic.  And this person was our handsomely paid private Disney tour guide. 

Did my family enjoy our days at Disney World?  Yes.  Walt Disney World states that they endeavor to help guests create memories that will last a lifetime.  I know my kids will remember their first backwards rollercoaster ride on Expedition Everest (I’m sure not a brainchild of Walt Disney).  Isn’t it backwards, however, that they may not know or remember in 20 years if that ride took place at Walt Disney World in Orlando or Six Flags Great Adventure in New Jersey?  Shouldn’t every child leave Walt Disney World with a love of Mickey Mouse and friends, asking for Mickey ears rather than a Star Wars light saber?  Perhaps the Magic has been lost to a new Walt Disney Company mission of earning dollars over earning lifelong raving fans?

My guess is that this is a top down leadership issue, and that the leaders of the company are more caught up with demonstrating profits to shareholders than they are interested in continuing Walt Disney’s passion for bringing the Magic to people’s lives.  A watered down mission dilutes the team culture very quickly.  The absence of cast member “Believe in Magic” enthusiasm is reflected in their quality of work.

Interestingly, we can draw parallels to what is happening right now in healthcare where the primary drive is to control costs, not care for people.  Government officials and insurance industry administrators and executives consistently invoke the buzzword “quality” in the same sentence when describing their aims of “expanding coverage and cost control.”  It is well understood that you can strive for two of three, but not all three, when speaking of accessible, high quality, and low cost health care.  Likewise, at least in days past, Disney rightly focused on two things:  providing excellent (high quality) staff training and customer experience, and ‘magical’ amusements and attractions.  And for this, they charged a premium.  The admission/ticket costs to spend a day in one of the Disney parks has always been expensive relative to other amusement parks, and now the price exceeds $100 per person per day.  Some have written articles about how Disney has priced out the middle class (https://www.washingtonpost.com/news/business/wp/2015/06/12/how-theme-parks-like-disney-world-left-the-middle-class-behind/). 

But just as healthcare systems have had to drop their focus on quality to focus on cost containment and access, Disney has dropped its focus on bringing out the ‘magic’ in each of its cast members through the once singular Disney training program, in order to concentrate on generating higher corporate profits. 

While I find this sad, my father-in-law shrugs it off, believing that all things are destined for change.  In our world of caring for active people, we see it as a glaring opportunity to serve a community of people who want and deserve excellent consultation with a wonderful team and top-notch physicians.  I suppose it does follow that Disney’s mediocrity merely makes room for the next magical visionary whose mission is our enchantment.  Perhaps that’s Elon Musk with SpaceX?  I’m sure the void in magical experiences will provide a ‘carpe diem’ moment for one so motivated entrepreneur.  And I, a self-described fairy tale fanatic, may be first in line.

Opinionated on Opiates and the Treatment of Pain -- Independent and Strong Sports Medicine Physicians and Our No Opiate Rule

President Obama just allocated $460 million to states to bolster resources to treat opiate-abuse disorders.  The goal apparently is to reduce opiate-related deaths, which are on the rise, especially amongst middle class whites.

I disagree with President Obama and his advisors when it comes to managing opiate-related concerns.  This is throwing money at the back end of the problem, tantamount to pouring extra water on an already extinguished house fire while an arsonist is next door dousing surrounding homes with gasoline and carrying a lit match.  Soon you're gonna have a bigger problem with which to deal.

The problem is opiates are catastrophically overprescribed.  This practice stems from the pharmaceutical industry led movement that began in the 1990's. I recall enjoying what seemed to be weekly free lunch provided for by a pharmaceutical company peddling their opium-derived drug.  A well-paid physician stood in front of me lecturing on the drug while my free boxed lunch set off 'triple point' endorphins as I ate my delicious sandwich, chips and chocolate chip cookie, pocketed between 1 and 10 shiny new drug-logo pens, and naively sat marveling at my having 30 additional minutes of free education as a school-loan supported medical student in New Jersey  that bolstered the idea that "pain is a "vital sign" to be measured routinely and monitored over time by your doctor at every visit like your temperature, heart rate (pulse), respiratory (breathing) rate, and blood pressure.  Pain is not a vital sign.  It cannot ever truly be a vital sign.  A vital sign must be objectively measured, by a reliable and trained health care provider or medical device.  Pain is subjective, and only measured by patient report. 

Opiates are reportedly prescribed to treat pain by physicians or other licensed non-physicians. 

Sadly, I report that I also fell victim to the influence of Big Pharma.  My 'retrospectoscope' now clearly places my naive self in the very center of the problem.  I am fortunate to be a reformed opiate prescriber.  Our office does not prescribe opiates.  I am often asked by colleagues how we can 'manage' to not prescribe opiates as they admit to wishing to stop prescribing them as well.  I would bet that a clear majority of physicians would choose to stop prescribing opiates entirely if they felt it was moral and ethical to do so...the problem is we were taught otherwise to more aggressively treat pain and prescribe opiates even if unsupported by evidence.  Taking opiates carries the risk of addiction, pseudoaddiction, tolerance, gastrointestinal side effects, impaired brain function, and as we know from well publicized media reports, death from opiate overdose.  Great financial windfalls are enjoyed by Big Pharma, and a growing illegal black market triggering many patients treated for seemingly legitimate concerns to divert some or all of their medication for cash.

In an era proscribing to adhere to 'Evidence-Based Medicine' I should point out that the pain research supports a clear absence of functional restoration for opiate users.  This means that persons taking opiates for pain do not demonstrate improved function in their daily life -- perhaps most importantly and objectively measurable, they do not return to work at higher rates than non-opiate users with pain.  As would be expected, opiate users do report higher quality of life scores.  Opiate drugs contain the same active ingredient as opium (same as heroin) and when they bind to our cell opiate-receptors provide one with a sense of euphoria.  We can probably agree that we're likely to rate our quality of life fairly high at a moment of euphoria?!!!

Opiates treat suffering moreso than pain.  Suffering ensues when pain is associated with a decline in function (e.g. inability to work or play), loss of control, and/or a decreased quality of life perception.  Opiate triggered euphoria transiently solves suffering.   What a wonderful concept for the cancer patient on her deathbed, or the battlefield wounded who may not survive his injury -- we can alleviate suffering at such a critical time.  However, pain is not suffering.  Pain is our bodily response to physical or psychological distress.  We need to experience pain to inform how we manage and hopefully cure such physical or psychological distress.

Nowhere is the distinction between pain and suffering more evident than in sports medicine.  Athletes overall are very high functioning individuals motivated to get better to return to their sport.  When they present to me relatively early on following injury, they typically have pain that resolves in a predictable manner with activity modification and therapeutic exercise.  They then return to play and their pre-injury high level of function.   Suffering may develop in the athlete unable to cope with their functional decline and/or if the athlete perceives a loss of control or decrement in life satisfaction.  Fortunately, most athletes have a wonderful capacity to heal and often have strong coping skills and positive life outlook.  This helps most athletes avoid pain-related suffering.

I have learned quite a bit about pain and suffering through my own personal experience.  I had spinal surgery for a disc herniation and nerve damage in 2007.  I dealt with high levels of pain before surgery and more mild-moderate levels of pain following surgery.  However, I escaped the realm of suffering.  I did not once use opiate medications before or after surgery.  How (or why) one might ask?  My pain did not transition to suffering due to my deep understanding about what my body was going through.  I did not feel worried or anxious as most people do because I knew why my body hurt and why my leg was weak and numb.  I understood my surgical and non-surgical choices. 

I can understand why physicians and other health care providers might wish to prescribe opiates to patients who present with suffering.  I think we are easily drawn to be overly empathic in the face of suffering, wanting to use our anti-suffering killer miracle drugs, readily losing objectivity and forgetting that opiates are not indicated for non-malignant pain (i.e. terminal cancer).  But unfortunately on some level we ignore our oath to 'first do no harm.'  We often treat our own anxiety, because it is easier to sign an opiate prescription than to recognize, diagnose, and treat suffering.  I don't know how to treat suffering in a brief office visit...but I'm very adept at recognizing it.

I agree we need resources directed towards treating these needy and suffering individuals who now are most often treated with opiates.  Funding should be directed to the training of additional mental health providers who are expert in recognizing, diagnosing and treating suffering, and appropriate public health messaging.  Teach people the difference between pain and suffering. 

While I entertain a discussion on the topic of opiates and the confounding health messaging by the pharmaceutical industry, our government, and the media, I am reminded of what I believe to be the true definition of health care:  health care is what happens in a closed room between a physician (which, by the way, comes from the Greek word for 'teacher') and a patient.  Health care does not happen in the local, state or federal legislature, in the boardrooms of pharmaceutical or medical device manufacturers, or in the offices of media executives -- that is where power is heralded.  Let us be transparent and clear.  In an age where more doctors are employees of hospitals or large health-care systems than self-employed, and more often considered merely interchangeable and 'evidence-based guidelines' technicians or line-workers, health care consumers are at risk of losing the opportunity to have individualized medical care provided by unconstrained independent thinkers.  As my fabulous partner and famously independent thinker, Gary Chimes, often chirps, "people who want great medical care deserve doctors too."

Meet the Team: Natalie Hoyte!

Welcome to the team! Can you tell our readers a little bit about your role at Lake Washington Sports & Spine (LWSS)?
Thank you! My role as a medical assistant is to help make each visit with Dr. Hyman go as smoothly as possible, from gathering information at the start of each visit, making sure appointments stay on schedule, helping to draft referrals, setting up equipment for procedures, drawing blood for PRP injections, and serving as a liaison between Dr. Hyman and patients by helping to answer any questions or concerns patients may have related to their care.

So far, what is your favorite part of working at LWSS?
There are so many things to love, it is hard to say! First, I enjoy the culture of this office and the sense of community I already feel with the entire team- this is a small office and we are all driven to learn and become 2% better, every day. For example, it is a part of our office culture to never be afraid to ask questions, and to encourage providing feedback so that others can learn and improve their role in the practice. I also like that I can always count on doing a post-work workout in the office lobby with Laura and Elianna, or swap stories about the many hobbies and activities that we all pursue outside of work. Most of all, I love how much new information I am learning each day. I plan to continue my education and further my healthcare career by attending a graduate program to become a physician assistant, and the doctors undoubtedly take special care to teach me things that will help me when I become a medical provider, whether it be teaching me what they are looking at in an ultrasound, explaining the reasoning behind their medical approach, or encouraging me to study my anatomy and keep asking questions.

The LWSS mission is to KPA- Keep People Active. Can you explain how that mission guides the day-to-day care that the doctors provide?
Both Dr. Hyman and Dr. Chimes are very active in their own lives, and it is clear that they care deeply about helping their patients lead active lives as well. In my short time working at LWSS, I notice that the doctors take the time to address all factors that may be influencing a patient’s condition, including the patient’s lifestyle and activity goals. The doctors spend significant time educating patients about their given condition and treatment options, and they take the time to explain their thought processes throughout the diagnostic process, so that patients can have an active role in their own recovery. Dr. Hyman and Dr. Chimes offer treatments that can help patients get back to activity, rather than just masking the source of pain. Both doctors have faced their own fair share of injuries, and it is clear that they strive to be the kind of providers that they would have liked to see when going through their own recovery processes.

How do you personally align with the KPA mission?
One of my favorite ways to stay active is to get outdoors and take a hike! I love exploring nature and reaching new vantage points. I am always rejuvenated after getting to spend time outdoors, and this past summer I hiked the John Muir Trail, which is a 210 mile hike that goes from Yosemite to Mount Whitney, the tallest mountain in the contiguous states. I took 20 days in total, and completed the journey just one step at a time! In the short days of winter, I like to stay active by rock climbing at the gym or strength training so I can improve my climbing abilities. Most importantly, I want to take advantage of the capabilities of my body, which is an incredible system that allows me to experience the world in amazing ways.

What are the advantages of being treated by an LWSS physician vs. a physician in a large organization?
The advantage of being treated by an LWSS physician is that, unlike physicians working in a large system, Dr. Chimes and Dr. Hyman have significantly more control over what kind of care they can provide. They have the autonomy to offer PRP and prolotherapy injections, for example, which many larger organizations would not be able to offer due to insurance restrictions. The doctors can choose to have longer patient visits, which would otherwise be impossible in a larger organization where ‘productivity goals’ stipulate how many appointments the physician must have each day. Since it is a smaller office, it is also much easier to get a short-notice or same-day appointment, which could otherwise take months at larger practices. Also, it is pretty special that you may get to visit with Bucky, Nala, or Winnie, the lovable dogs that frequently keep company at the office.

Ok, now a little more about you! What are 5 fun Natalie H. facts?
Few people in my adult life know this, but growing up I was known as the “llama girl.” At one point I had four llamas and twenty-two sheep!

In college I discovered that one of my passions is helping others get outdoors to experience the wonders and rejuvenating power of nature, so for three years I led backpacking and kayaking trips through my university’s outdoor center.

My goal for 2016 is to ride my bike more, and this summer I would love to go on a multi-day cycling trip; there are so many beautiful places in the northwest, and traveling by bike would be challenging, but more efficient than hiking!

If I had to only cook with one spice for the rest of my life, it would without a doubt be garlic. I love it so much that once, in an attempt to convince others of its ultimate plant superiority, I made a roasted garlic apple spice cake. Suffice it to say that by the end of the evening, the cake had been devoured and I was left with only crumbs.

I love to cook, and if I could have one super power, it would be the ability to conjure up any plant food at the snap of a finger- I could cook the freshest of meals and I would never have to grocery shop again.

Viscosupplementation

What is Viscosupplementation?

Viscosupplementation is a procedure that is often utilized by the doctors at Lake Washington Sports & Spine, mainly for patients who suffer from osteoarthritis of the knee.  Osteoarthritis (also called degenerative joint disease) is mechanical wear of cartilage and bone within a joint and often limits patients’ abilities to remain active.  Since our goal at Lake Washington Sports & Spine is to Keep People Active, any procedure that helps our patients maintain their level of physical function is a great tool in our belt. 

Viscosupplementation (also known as hyaluronic acid injections or hyaluronan injections) involves injecting a lubricating fluid into a joint (most commonly in the knee, which is the only joint that has historically been covered by insurance, but it can be helpful in other joints as well).  Hyaluronic acid is an important component of the joint fluid in healthy joints and is found in lower concentrations in osteoarthritic joints.

What is it like to receive a viscosupplement injection at Lake Washington Sports & Spine?

Both Drs. Hyman and Chimes typically recommend that their patients receive a series of three injections over the course of three weeks (one injection per week).  The patient will come in at their regular check-in time and fill out a follow-up form.  As always, we recommend patients wear athletic clothing to the appointment (shorts are particularly ideal).  The doctor will perform the injection under ultrasound guidance to make sure that the hyaluronan is accurately placed into the joint space.  There is a chance that patients will start feeling benefit after the first injection, but typically, maximum benefit is gained after all three injections have been completed. 

Doctors’ recommendations post-injection:

1.       Ice the injection site if patient is feeling any local tenderness

2.       Continue any mild to moderate cardiovascular exercise routine

3.       Avoid any High Intensity Interval Training (HIIT), weight training or resistance training for the first 48 hours after the injection

4.       Call the office with any other questions/concerns that may arise

The benefits of viscosupplement injections can be felt for between several months and a year, but of course, these numbers vary greatly between patients.  It is possible for the series of injections to be repeated; usually our doctors and insurance companies require at least 3-6 months between the first series and the second.   Additionally, it is important to understand that viscosupplement injections are not substitute for total joint replacement surgery if a patient’s osteoarthritis is severe. 

What if I have osteoarthritis in areas OTHER than the knee?

Currently, the use of viscosupplementation is FDA approved to treat knee arthritis only but it has been shown to be beneficial when used in other arthritic joints such as hips and ankles.  As a practice that focuses on delivering “pure medicine”, our doctors do not want patient care to be restricted by insurance companies, and therefore we offer competitive direct-pay pricing for viscosupplement injections not covered by insurance. The doctors at Lake Washington Sports & Spine will make it clear if they feel viscosupplementation is the best method of treatment, whether or not it is covered by insurance. 

If you are suffering from osteoarthritis that is keeping you from participating in the activities you love, we recommend you call our office and set up a consultation to see if viscosupplementation is the right choice for you!

Graduation Ceremony

Graduation: high school, college, completion of treatment?

The Graduation Wall

Have you ever been to a clinic where they have a ceremony to commemorate your success? Better yet, a clinic that celebrates when you don't have to schedule another appointment?  

Here at Lake Washington Sports and Spine, we believe it’s crucial to recognize our patients' dedication and determination to get back to being active. Our graduation wall represents the collective achievements of every patient who has completed treatment and returned to the activities they love.

The Sights & Sounds of an LWSS Graduation

Our whole office pauses for a moment to recognize your success! At graduation, you write your name on a sticky note, then slap the note on our graduation board while performing an exercise that utilizes your rehabbed body part.  As you post to the board, the LWSS team cheers and shakes maracas in celebration. But wait, it doesn't end there!  Once you walk to the end of our hallway, you press the "Emergency Affirmation" button and are congratulated with a “swag bag”.  Celebration, gifts and a body back-in-motion, who doesn't love that!? 

Why We Believe Graduation Is So Important

LWSS is built on the foundation of "Happiness Based Musculoskeletal Medicine", so we always focus on life's positives!  What could be more positive and happy than returning patients to doing the physical activities they enjoy? We recognize that you put the work in and think you deserve the credit!

For patients who are just beginning their journey with us, we hope the Graduation Wall serves as an inspiration and we look forward to celebrating you and your future success!

5 tips to prevent holiday weight gain & stay active

1) Hydrate
H2Oooooohhh yeah! Drink a large (16 oz.) glass of water 15-30 minutes before every meal, especially before hitting a holiday buffet. Water will help you feel fuller, eat less and aid in the digestion process.

2) Indulge in moderation
Deprivation is a recipe for disaster, but so is unlimited indulgence. Find a happy balance and allow yourself 2 or 3 small portions of your favorite holiday treats. For the rest of the meal, stick to healthier options like veggies, lean meats, low fat cheese and fruit.


3) Weigh in
While it’s tempting to reach for elastic waist pants and hide your bathroom scale for the month of December, neither will help keep you accountable. If you see the number on the scale creeping up or feel your favorite pants getting tighter, you’ll likely pass on that slice of pie.

Think you can take an accountability hiatus and start again in the New Year? Neglecting healthy eating habits and exercise during the holidays will only make your resolutions more difficult.

4) Make exercise appointments
Consistent exercise and protected time to de-stress are more important than holiday shopping and gatherings. To avoid making excuses or falling into the trap of being “too busy”, schedule exercise on your calendar just like you would any other meeting. Bonus, you can even set an event reminder alarm to alert you it’s time to get moving!

5) Share fitness with loved ones
The best part of the holiday season is spending time with friends and family, so connect while staying active! Take an after dinner walk with your kids, go hiking with your cousins, attend a fitness class with your best friend, or register for a fun 5K. Make fitness a new part of of your holiday tradition!

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