Interview with the Experts: Lisa Huynh, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Vertical integration- one of the great medical lies

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

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

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

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

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

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

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

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

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

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

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

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

What is your fitness age?

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

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

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

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

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

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

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

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

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

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

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

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

I need a medical adminstrator STAT!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Great article on the benefits of full squatting

I love this article, and agree with it

http://www.somastruct.com/5-reasons-to-start-full-squatting/

Some people will struggle with motor control in achieving the squatting routine in the article. For those patients/clients, I recommend using the suspension strap squatting progression we have in our earlier blog post:

http://lakewass.blogspot.com/2014/01/suspension-straps.html

You can also try using the "Belt Squat" as introduction, or combining the belt squat with suspension straps:

http://lakewass.blogspot.com/2013/07/belt-squats.html

The Reasoning Behind the “Dreaded” Follow-Up Form

Imagine you planned a fancy evening at a well known, highly acclaimed five star restaurant.  You told the waitress you wanted a steak but refused to tell her the type of cut you desired or how you wanted your meat prepared.  The chef could give his/her best guess at what your preferences are, but in many ways he/she would be flying blind, so to speak. 

And I’m almost certain you would never do this! In order to have the best restaurant experience you know you would have to give the chef some clues, some extra information, in order to get the best result. It is the same with our doctors here.  Dr. Chimes and Dr. Hyman have spent years training, practicing and meticulously designing the method in which they treat their patients, the one that garners the highest success rate. They have both found that having their patients fill out a follow-up form, allows them to have the proper “clues” they need to give the best care possible. In other words, this follow-up form allows them to “cook you the best steak”. 

Many patients believe that just because they filled out the form a couple weeks prior means that nothing could have changed since their last visit and another form would prove inconsequential.  That, however, is often not the case.  If one is experiencing pain, it can manifest itself in different ways and in different areas of the body and these changes can be discreet. Filling out the form as completely and honestly as possible allows the doctors to detect any changes that at first may appear insignificant but to the trained eye may hold some deeper truths.

Of course, in the end, the choice lies with the patient about whether or not the form will be filled out.  Just remember, leaving out this information will impinge the doctors in the same way not mentioning you like your steak well-done will impinge even the best chef.  We want you to have a five star experience at Lake Washington Sports & Spine and it starts with that (no longer) dreaded follow-up form!

Healthy Competition: How having a great partner makes everyone better!

Today, I saw one of my favorite patients. She is a 60 year old female rock climber who is back in action.  I was making my list of "What are things right about you" (... see http://lakewass.blogspot.com/2014/01/whats-right-with-you.html for why we think this important), and she touched upon something really important.  She mentioned how she has a great peer group of rock climber and mountaineers, and they serve as a source of inspiration for her.

This made me think about the importance of healthy competition.  As I've alluded to in one of my earlier posts about my twin sister Jill (http://lakewass.blogspot.com/2014/01/jill.html), I've been spending a lot of time thinking about my friend Jim McLean, who passed away 6 years ago.  When he died, our mutual friend Jack Rigg said something very kind to me, which was "the essence of friendship amongst men is rooted in competition, and I've never met male friends who better epitomized that than you and Jim."

I know that I feel really fortunate to have that type of relationship with my practice partner Garrett.  It certainly helps in that Garrett and I have known each other for over a decade before we started practicing together and had a professional friendship as a starting point.

It also helps to have a partner you respect and who inspires you.  That can affect technical issues, certainly.  For example, I performed an ultrasound-guided viscosupplement injection this morning, and I modified the technique based on tips I've learned from Garrett over the past 6 months.  

It can affect innovation.  For example, Garrett and I have been pioneering new techniques in the treatment of Achilles tendinopathy, and it helps to have your partner join you while performing the procedure.  

It can affect communication.  Both Garrett and I will reflect with one another on conversations we've had with patients.  Some of that is improving on negatives, and see if different approaches may have worked better.  Most of our conversations are positive .... "let me tell you about this wonderful patient I just met.  We had a great visit- let me tell you what was so wonderful about them, and why I think they will do well with us."

It certainly affects my sense of fulfillment.  When Garrett and I were entertaining the possibility of partnering together, we had a series of long conversations to make sure we shared a similar vision of what we wanted to accomplish.  We both have a common goal, recognizing that "Patients who want the best possible care need doctors too."  We'll work our way through the process of coming closer to that vision every day, but the starting point is making sure we share a vision.  We do.

As an example of that vision, yesterday we closed the office for a few hours to have a dietitian speak to our team.  It was a great experience- helped us understand more about nutrition, both for our patients, but also for our team.  As Garrett and I reflected back on the experience, we thought about whether it was consistent with our practices vision of "Helping people be the best possible version of themselves every day, using the musculoskeletal system as entry point to better understand themselves."  Absolutely!  We felt a great source of pride as we left the office yesterday, literally hooting with joy. 

Sometimes with medicine, life can be oppressive and negative, and there are certainly changes in health care that are concerning (..... Centers of Medicare and Medicaid Services- don't think we don't notice what you're doing!), but I think so long as we stay true to our vision, we'll get through the changes.

Patients ultimately are going to demand better care, and they know it when they see it.  Having a partner you respect to serve as a source for inspiration is part of the "secret sauce" that will make sure we continue to grow and get better.