Natalie's Journey & LWSS Lessons

Nearly two years ago, I took a chance, packed my car with all my belongings, and moved to Seattle, where I had a job interview lined up for a medical assisting position. The interview seemingly went well, and I was confident I would hear a ‘Welcome to the team!’ by Monday. Unfortunately, Monday came and went, then Tuesday, then Wednesday… Somehow, my master plan was not working out as I intended, and I decided I needed to get back to the hunt (job hunt, that is). I sent cover letters and resumes flying out to the ether, and before I could bat an eye, I received a cheery reply inviting me to an interview at Lake Washington Sports & Spine for the next day. That was quick!

The following morning, I fought the unfamiliar Seattle traffic to arrive bright and early, dressed to impress. This interview lasted nearly until lunchtime, and I don’t remember many specifics aside from the fact that I left desperately wanting the job, but woefully aware that I had flubbed it at every turn. I sat in my car worrying over everything I had said and everything I should have said instead… I contemplated calling to explain that ‘I can do better! I can show you! I’m not that anxious of a person!’ (false- I am). While I ruminated over and over on my performance during the interview (how come I hadn’t felt this way after my interview from the week before?) I was saved from going down the rabbit-hole of worry and self-doubt by the ringing of my cell phone. It was Laura on the other end, asking me “Won’t you join our team?!” I was flabbergasted. I was convinced I would not be hearing from them, let alone so soon after the interview. “Holy buckets! Of course!” I squealed, and I was quickly out-squealed by the ensuing clamor of cheering and dog barking in the background.  

The process of becoming a part of the Lake Washington Sports & Spine family is only the tip of the iceberg when it comes to story-telling.  I could write about the time I was convinced I had poisoned Dr. Hyman’s pup Nala with sugary sweets (nope, turns out Dr. Hyman swiped the treats himself), the time Laura scared the britches off me when she popped her head through the ‘pee collection’ window into my office, or the time Dr. Chimes ran around the office all day testing everyone’s grip strength and championing our very own ‘Office Olympics.‘ But these memories are only one piece of the pie. The whipped-cream on top (or ice cream a-la mode) is the accumulation of invaluable lessons I have learned along the way, which I will carry with me for the rest of my life. In no particular order, these are the pearls of wisdom I’ve gained from my time at LWSS:

Lesson #1 (Ok, I lied, lesson #1 is first for a reason): Prioritize. There are only so many hours in a day, in a week, and in a lifetime, so it is crucial to make clear to yourself, and others, what your priorities and values are. Say no if something doesn’t fit under one of your priorities. This time-management tool also helps me weigh what I’d like to get done with what I am actually capable of getting done, and helps me to feel more satisfied with my accomplishments at the end of each day.

Lesson #2: Keep a growth mindset. Through consistent and constructive feedback, I learned to be comfortable with making and learning from my mistakes. I learned that it is important to seek feedback and to continually strive to improve, otherwise one stagnates. I also learned first-hand how valuable it is to work with a mentor who is willing to teach, challenge, and share.  

Lesson #3: Sing and be goofy. “All work and no play makes…” life a lot less enjoyable! Working alongside Dr. Hyman really impressed upon me the value of being goofy, doing the things that bring you joy, and occasionally throwing a nerf ball at your office manager while wearing a superhero cape.

Lesson #4: Bandwidth. This is a phrase we used at the office all day long, and is something that I have now adopted into my personal life. My friends and family will often hear me saying “You know, I’d love to hear your story but I just don’t have the bandwidth for it right now,” or my partner will ask me what my bandwidth level is before launching into a story about the fulcrum load effort of his PR squat press that day. Talking about attention span in terms of bandwidth has proven to be revolutionary in allowing me to be more intentional when talking with friends and family.

Lesson #5: Sweat not sweets. The LWSS Sweat Club (our motley crew of whichever ladies decided to stay late after work to work out in the waiting room) inspired me to actually make the lifestyle changes that I want to see become a reality. Laura and Elianna in particular inspired me with their dedication to their fitness goals, which has encouraged me to pursue my own. Also, the office policy of (generally) not keeping sweet treats around is one that proves quite valuable in my own food endeavors at home; out of sight, out of mind!

Lesson #6: A/B testing. There is value in comparison, and not everything works well. I observed the doctors frequently ‘A/B testing’ their approach to various situations, and I appreciated that they encouraged everyone in the office to practice it as well. A/B testing is the idea of trying out strategy A for one situation, and then trying strategy B in the same situation next time, to help determine which is the best approach. This is a tool that will help me figure out my optimal time management plan, study strategies, or more importantly, my favorite chocolate bar.

All said and done, I cannot thank my Lake Washington Sports & Spine family enough for all that they have taught me over the past two years. These lessons will carry me forward as I pursue my next endeavor of becoming a PA. In the next phase of my career, I can only hope to find mentors as invested in my growth as both Dr. Hyman and Dr. Chimes have been, and a workplace as joyous as LWSS. So long! Merci Buckets! 

The Barre3 Experience

In an effort to better understand the factors that underlie exercise-specific injuries, the LWSS team has embarked on a mission to try a myriad of local fitness classes! Last week, our squad attended a class at barre3 in Bellevue.  For most of us, it was the first time performing any type of barre exercise.  

Notable post-class quotes:

"I was slipping in my sweat!"
"That was wayyy harder than I expected."
"During the first 7 minutes, I was looking around hoping I wasn't the only one sweating so much."
"I ran a marathon 2 weeks ago and that class made me feel out of shape!"

Interested in trying barre for the first time? Here are some tips for success:

1. Know your level of fitness.  If you haven't worked out in quite some time, barre (or any group class for that matter) might not be the best reintroduction to exercise.  We recommend a personal trainer or private lesson to ensure proper form and to prevent injury. 
2. Do your research.  Every studio and class are different!  As a beginner, you'll want to make sure you're signing up for a beginner or fundamentals class and not level 5 advanced.
3. Dress appropriately. Make sure to wear fitting athletic clothing since you will SWEAT. You won’t be wearing sneakers in the studio, so make sure to check the studios policies prior to arrival to see what they require for footwear.  We were required to go barefoot and WISH we all had some special grip socks for balance!
4. Arrive early.  This will give you time to complete the studio's forms, ask any questions, and introduce yourself to the instructor.  Make sure to let them know you're a beginner and make them aware of any injuries you have.
5. Listen to your body: go at your own pace, don't be afraid to take breaks when you need to them, and modify poses that are too challenging.

Final thoughts:

Barre3 was a great high intensity interval training (HIIT) workout.  Even the men felt it would be a great way to build diversity into an existing exercise routine! With winter and skiing/snowboarding on the horizon, barre3 would also be an excellent workout get those quads in slope-shape!  

The Hidden Cost of Immediate Medical Care

My daughter injured her wrist playing soccer a week ago.  Another player launched the ball upward into her extended wrist.  She had immediate pain.  Tears flowed.  I shifted from Dad to doctor mode and assessed her wrist on the sideline.  I had low suspicion for a fracture or severe injury.  She was able to continue playing.   

The wrist hurt more later that day.  She iced, and we applied a wrist brace we had at home.  I counseled her that it was likely a bad sprain and should get better over the next few days.  I asked her to let me know each day how she was recovering.

She improved wearing the brace.  Then the pain came back as she used the wrist more writing at school.  After a week of persistent symptoms, I decided an X-ray made sense to rule out a fracture.

Our busy family schedule didn’t easily allow for a trip to a radiology center during regular Monday through Friday business hours (of course I have the latitude to order the test myself) so I decided that I would take her in for the X-ray on Saturday morning.

I phoned the free-standing radiology group I normally patronize and learned that while they’re open for MRIs on the weekend (both Saturday and Sunday) they do not offer the more simple X-ray service on the weekend — the lion-share of their income is from MRI reimbursements so it likely does not make financial sense to pay an X-ray technician on the weekend.  So I had to find another option.

I thought next about taking my daughter to an urgent care clinic for an X-ray.  I have Kaiser Permanente (formerly Group Health) insurance that promises more cost effective care when using Kaiser providers, and so looked up the Kaiser Urgent Care in Bellevue, open 24 hours.  And off we went.

I’d never been to Kaiser’s Bellevue facilities though I work across the street.  Looks beautiful from the outside.  It’s even nicer on the inside. As a small business owner who has hired contractors to remodel my office space, I stood in awe of the elegant atrium with warm accents like a gas fireplace with couch-like seats that had nearly the feel of a ski chalet.  My daughter said, “Dad, this looks like an airport.”  And I thought, she’s right, this is kind of like the beautiful new atrium at Sea-Tac Airport…but the airport is used 24/7 — I wondered what the foot traffic looks like here on any given week.

And sure enough it was a ghost town.  We walked right up to the Urgent Care reception desk and checked in.  Two kind women were there to serve.  One seemed to be mentoring the other.

We were taken back within minutes — no sooner had I taken my daughter’s homework out of my backpack when we were brought back by a nurse for vital signs.  The nurse then had us go back to the waiting area.  One minute later we were greeted by an upbeat male technician who identified himself as an ER Tech, and taken back into what I expected would be a typical Urgent Care medical office facility.

To my surprise, the facility was a high tech and fully equipped emergency room.  The young man, the tech, told me that this was a fully functioning ER but due to contractual issues with Overlake Hospital (that has another fully functioning and state-of-the-art ER literally across the street), they must call it an Urgent Care.  

My daughter and I sat idle in a room that could accommodate a full Code Blue with oxygen lines and monitors adorning the wall.  We were right across the way from the nurses station (actually all rooms look out towards the nurses station as a deliberate and modern wheel-and-spoke ER design element).  We observed at one point approximately 10 people casually standing around chatting at the nurses station.  There were perhaps two other persons being attended to for what appeared to be reasonable urgent care type issues like cough/flu or nausea/vomiting.  

The ER tech was kind, and after I told him our story, and that I’m a sports medicine physician, he said he’d facilitate the X-ray even before we were to be seen by the physician assistant.  After about 15 minutes an X-ray technician brought us back for my daughter’s wrist X-ray.  Then we met the physician assistant, who performed a very brief history and a nominal examination.  The radiologist had concern for a buckle type fracture of the distal radius (forearm bone), and so the physician assistant got on the phone with a Kaiser orthopedic surgeon on-call.  The orthopedic surgeon kindly spoke with me over the phone and after reviewing the images and the clinical history, he did not think there was a fracture.   Ultimately we decided that bracing her for several weeks makes sense and we were discharged.  

Our experience at the Kaiser "Urgent Care” (in quotes because this is really a fully functional and state-of-the-art ER) was very positive in that we received prompt attention from a number of very friendly staff members and we met my goal of obtaining an X-ray to assess for fracture.  In fact, we surpassed my expectations as I was able to speak with an orthopedic surgeon about my daughter’s case.

My level of worry going in was very low.  My daughter was quite functional, and I deemed her at low risk for a significant injury.  I got more excited about adjacent observations during the visit that might impact cost — both my direct and indirect costs of an “urgent care” visit to an actual emergency room, and the cost to my larger community.

An article (http://www.crainscleveland.com/article/20150708/NEWS/150709836/akron-general-to-build-new-emergency-department-cost-expected-at-35) from 2015 describes a cost of ~$35 million to build a new emergency room in Akron, Ohio.  So I wouldn’t be surprised if that approximates the cost of the Kaiser “Urgent Care” here in Bellevue…again, this facility is literally the neighbor to the adjacent building of Overlake Hospital with a level 3 trauma center ER.

Aside from this being an example of overbuilding and an outrageous, and costly, redundancy in community resources, I find it remarkable that I didn’t even know that such a facility exists given that I work across the street AND I myself have Kaiser Permanente insurance.  As one of Kaiser’s insured, clearly it may benefit me and my family to know about the resources at our disposal.  As one of Kaiser’s neighbors and a community physician who treats others having Kaiser insurance, clearly it may benefit my patients to know about this extraordinarily equipped “urgent care” facility.

So what are the take home messages?  The high and growing cost of your healthcare insurance premiums relates to many things, and one of my concerns is that inter-system competition (i.e. locally, Swedish vs UW vs Overlake vs Virginia Mason) is a consequence of the consolidation of healthcare providers/systems and competing systems often compete on resources.  These resources are costly.  And that cost is passed on to you.  

We all want answers now.  Not only for emergent care, which is a bit easier to define (perhaps by my definition, care that might help you prevent loss of life or limb), but for issues that we know are not emergent but trigger enough concern or anxiety to warrant a visit right now (i.e. is it broken or just a sprain, or will my infection need an antibiotic?).  Let’s face it.  We’re all looking to escape from our anxious thoughts.  One way to do so for a health related concern is to seek attention immediately.  Escalate our urgency to a "fever pitch” (pun intended) and drive to some 24 hour clinic.  Why lie awake all night with anxiety when you can go see someone tonight?  At least this is some of the psychology that underlies patient behavior, and perhaps the more irrational behavior of health systems that more and more are squandering our money!

Did you know? Bellevue has a Farmer's Market!

The bounty of Summer is almost past, but alas Bellevue’s Farmer’s Market goes until October!

Not until recently, did I know that Bellevue has its own farmer’s market! The farmer’s market is located in the parking lot of Bellevue Presbyterian Church, half a mile north of Downtown Bellevue and is every Thursday 3:00pm-7:00pm. Open late enough to go after work for some fresh produce or a light dinner!

The market is slow enough that you aren’t going single file through a gridlock of people, like at Pike Place or Ballard’s Sunday market, which makes it a pleasant way to enjoy a Thursday evening. Being that the vendors aren’t mobbed with people, they are friendly and conversations flow easily.

The goods are mostly seasonal vegetables and fruits: peppers, beans, eggplant, and berries this time of year. My favorite booths are the tomato man and honey bee man. Full disclosure, growing up my father and his friend kept honey bees “for fun” and we actually processed the honey. We eventually moved and weren’t able to take the bees with us, but my dad’s college friend turned the hobby into a business--Cascade Natural Honey. The honey is unreal. This is the honey I grew up on: in tea, on toast, on yogurt, and over cheese. Cascade Natural Honey is unique for harvest varietal honeys; bee hives are placed in areas when pollination of a plant occurs. So “raspberry” honey is made when the bees pollinate the raspberry bushes. Same for blueberry, blackberry, thistle and Baby’s Breath, and sweet clover honey. The Thistle honey is my favorite for its dark flavor profile and being so thick one has to scoop it out of the jar with a spoon!

Bee man, or Cary, introduced me to tomato man who grows a wide variety of heirloom tomatoes, and hence the picture above. The tomatoes range in color from light yellow to striped by red and green! These tomatoes are so flavorful and meant to be consumed shortly after purchase, preferably with a sprinkle of sea salt or flash of balsamic vinegar!

Hopefully, the drool that is beginning to pool at your feet begets a trip to Bellevue’s Farmer’s Market this Thursday! Food this good makes it easier to live the healthy and active lifestyle we strive for. See you there!

Link to the Farmer’s Market: https://bellevuefarmersmarket.org/

But, I don't have the time to be injured!

Through working at Lake Washington Sports & Spine, I have come to realize that being injured is like having a part-time job. Between going to see Drs. Hyman & Chimes, going to physical therapy, doing the home exercises as recommended by physical therapist, and all the traffic in between the hours dedicated to healing your injury can add up fast. Let alone the physical activity you regularly do to stay fit. And no one plans for an injury, so where is that time going to come from? Organization.

As a collegiate athlete, I needed to be organized in order to succeed in both the classroom and at the racecourse. Every decision I made was framed as “how am I going to get this done while maintaining a 9:00PM bedtime? (On the rowing team, practice started at 5:30AM.) From this, I developed habits which have carried into my professional life and make time for, say, being injured.

Pearl #1: Learn to use the crock pot. The praises of batch meal preparation have been sung in most every life-hack article because it is effective. Batch meal making can mean using the crockpot, doubling the volume of whatever you cook this week for the following week, or encouraging your significant other to do so. Aim for recipes that lend themselves to freezing and reheating, like; meatballs, soups, stews, and sauce-based meals. Create variance by changing the main protein, adding quinoa instead of brown rice, or switching out the vegetables. Below is a link to my favorite meatball recipe that freezes and reheats well.

http://abc.go.com/shows/the-chew/recipes/harjeevs-turkey-kebabs-with-green-chili-chutney-harjeev-bhalla

Pearl #2: Clean out the freezer to accommodate for Pearl #1 and recruit your Costco-loving friend or significant other for help.

Pearl #3: Pack your clothes for the following week on Thursday night (or whatever time works well for you). By the time the end of the week rolls around many of us are tired and our motivation has waned--perfect time to do a mind-numbing, low-bandwidth task. I suggest using this time to pick out your work clothes for the following week. I pack all clothing I need for work (socks, pants, undergarments, shirt, belt, etc.) into zippered bags and hang the ironed clothes in my car. This gets me out the door quickly in the morning, which can be a huge timesink.

Pearl #4: Set alarm reminders for when it's time to leave the house/gym for work. Are you one of those people who sit in morning traffic just praying the clock said it was a few minutes earlier? Or how did it take you 40 minutes to get out the door? Set an alarm for when you have to leave in the morning to get to your next stop. The act of finding your phone to turn off the alarm takes you away from whatever you are doing at that moment, making you pause and check-in; what do I need to do to get out of the house in the next 10 minutes? Morning time is often hardest for most people, but this Pearl could also be applied if you need to leave work by a certain time.   

Pearl #4: Look at the following week’s schedule on Wednesday or Thursday. Looking at your schedule well in advance of the next week helps: anticipate when you will be busy and, on the converse, when your time to relax is; what things you might need to do now to prepare for next week; or details you need to pin down (is that tentative lunch cancelled or still on the books)? If you are a calendar user, set a calendar reminder to do this. (P.S. Gmail has a function where they email you calendar notifications.)

https://developers.google.com/google-apps/calendar/concepts/reminders#notifications

(see “delivery notifications”)

http://www.makeuseof.com/tag/reminders-make-google-calendar-incredible-list/

(also great ideas for Gcal users!)

Though these Pearls do require an investment of time up-front as you are trying to create a new habit, with them you’ll be well on your way efficiency - thereby creating more time to dedicate to recovery and taking care of your injury!

PFD's FTW (for the win!)

Yesterday, my father “casually” thumbed through the REI catalog, and asked if I saw anything that piqued my interest. My birthday is coming up and I am certain he is at a loss of how to celebrate it.  However, my brother recently got a new PFD (“personal flotation device” aka life jacket) which I am jealous of; it has such better pockets than mine and looks sweet! My kayaking vest isn’t as cool as my Brother’s--isn’t it always that way?--but from a practical standpoint my life vest works perfectly fine. Or so I thought…

I went into the garage and checked out my life vest. Turns out my kayaking vest was rated up to 90lbs. Mind you, I have had this life vest for 15 years and have gone from pre-teen, to teen, to adult in that time frame. I passed the 90 lbs mark long ago! Gulp, my life vest certainly needs to be upgraded.

My first reaction to this realization was gratefulness. You might find this strange. You might also think I am making a mountain out of a molehill. But last Memorial Day weekend, my father, uncle, and I were fishing in the San Juans and spotted a capsized boat in bad weather. When we pulled up both individuals had a life jacket on, but one man’s life vest was so loose that his head was more than a foot underwater and he was unconscious. Best to avoid making someone do CPR on you.

For those who are wondering, yes, both men are perfectly okay, and I got a fancy, new paddling PDF that is rated for both my weight, kayaking, and waterskiing.

As the weather gets hot, please remember not only to wear a life jacket, but to wear a lifejacket that fits properly, is rated for your weight, and is rated for your activity. I personally have had great service and recommendations from both REI and Evo. It is worth going to talk to someone who can help you fit and choose a life vest that is right for you! Check out the following links for more information and retailers!

http://www.nrs.com/tech_talk/pfdfitting.asp

https://www.rei.com/c/pfds?r=c&origin=web&ir=category%3Apfds&page=1

http://www.evo.com/shop/wake/wakeboard-vests.aspx

Five Year Anniversary of Happiness-Based Medicine

I’m very proud to share that I’m five years in to what started as a gutsy new venture, a happiness-based sports medicine clinic.

I opened Lake Washington Sports & Spine in 2012 when independent private practice physicians were committing mass mutiny and enlisting as employed physicians with large health care systems and hospitals.  In fact, all of my prior partners made that choice.  

I was scared, and knew failure was possible, if not probable.  The first year presented many challenges to developing our happiness based medicine philosophy.  First of all, I had no idea how to run a business, and I made a series of bad choices.  Fortunately, I learned from mistakes, and more importantly, I chose to employ a budding star as my practice manager, Laura Cassidy.  

Several challenges were overcome.  Laura and I struggled together through some bad hiring decisions.  She brought a ray of clarity to my muddy management.  It was so hard for me to fire employees that were a bad fit, but I did.  I learned that finding employees who are the right fit is more charitable than keeping a poor-fit, struggling one.

I contracted with a lousy electronic health records company for 6 painful weeks before cancelling the contract.  We migrated to our present, decent, cloud based platform.  It took 6-8 months to develop competence in this new system, but five years later this was clearly the correct choice.  

I made many frugal decisions, and even so I essentially did not earn any money my first year in practice.  That was a great sacrifice for me and my family, especially when taking into account the opportunity cost of what I would have earned as an employed physician.  I avoided taking on debt whenever possible.  For example, despite some outside pressures and advice to the contrary, I elected to not spend thousands of dollars to convert thousands of paper records into electronic format.

We learned that we couldn’t control the office culture while sharing space, even with gracious orthopedic colleagues.  I’m very grateful to my Bellevue Bone & Joint colleagues for providing me the opportunity to set up shop in their midst.  Their was an element of symbiosis to our practice, though in the end I never felt that I could fully express myself within their office.  We moved into our own office space, taking over ~1800 square feet in the Bellevue Medical Park from the retiring David Ferrin, Internist and Cardiologist.

About 1 year in to the venture there was a second sentinel event (the first being Laura’s hire).  I hit a milestone.  The practice was running smoothly, and I was fortunate to have many patients coming through the door.  I knew part of my happiness-based medicine vision included working with a partner, and so one day I rather randomly and spontaneously elected to post a job opening on a national list-serve — this was against the rules by the way…and the posting was taken down within 2 hours by the list-serve operator.  But the "find-me-a-wonderful-happiness-based-medicine-partner” angels did their job.  My wonderful now-partner, Gary Chimes, saw the post.  Somehow he had checked this list-serve in the time between my post and its removal, and the stars were aligned and he was ready for a job change.  

Gary and I had already known one another for years, and in fact had shared hopes of a type of happiness-based medicine construct while teaching musculoskeletal ultrasound together at the American College of Sports Medicine national meeting.  We courted for 6 months or so over the phone until we were both comfortable that ours could be a sustainable marriage.  He migrated West from Pittsburgh and the next phase of the practice then began.

With Gary’s arrival came an exponential and profound period of growth.  Whereas I have a lot of unbridled energy, he carries the compass and reigns to give us direction.  Gary has mentored me, and our team, and we are stronger, and progressing directly on our journey towards happiness-based medicine.  

Together we designed our KPA mission (Keep People Active).  We believe we have the best sports medicine practice anywhere.  In an area where we have many wonderful colleagues, our differential advantage is our growth mindset, our independence and clear vision of excellent medicine.

Some thoughts and advice:

1. Private practice is hard.  Guess what, so is being employed.  I’d choose private practice over employed practice any day.
2. Being self employed is a must for a physician with a growth mindset.  
3. Deliberate independent thought is critical to the survival of physicians as one of the two primary stakeholders in medicine (primary stakeholders = patients and physicians) particularly in this time of healthcare consolidation and rigorous ACA/CMS compliance requirements.
4. Express gratitude as often as you can.  The expression of gratitude breeds feelings of happiness.  Gratitude leads to joy.  Joy leads to success.