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.

Sentinel Events for Skiers, Snowboarders, and Mountain Bikers

Ski season is starting here in the Pacific Northwest, so many of my patients are getting ready to enjoy the winter

An important concept with sports like skiing, snowboarding, and mountain biking is a sentinel event, which is a term I use for a small biomechanical mishap that may be a precursor to a more significant injury

The model I base this on is from strokes. If we look at patients who have a devastating stroke, a significant percentage of them have a smaller "mini-stroke" in the month preceding the major stroke. Some patients ignore these mini-strokes because they are either unaware of what happened, don't recognize their significance, or feel a sense of relief that they don't have any long-term disability. This is a shame, because in the period following a mini-stroke, there is a window of opportunity where they can intervene and prevent a more devastating stroke from occurring.

The same concept applies to devastating injuries during skiing, snowboarding, and mountain biking. There are a few common elements of these sports that make them prone to devastating injuries, namely:

A. The body can gather significant momentum

B. Falls are common. High speed falls are common

C. The terrain is inconsistent

D. They require a persistent vigilance to notice changes in terrain so that you don't fall

Prior to having a devastating fall in any of these sports, it's common for the athlete to have a "sentinel event", where they have a smaller stumble that is often ignored. This is a mistake, and athletes should pay attention to these smaller mistakes, even if there is no lasting consequence

For example, a skier may notice that as they become tired, they may not notice a small change in terrain and end up taking a turn more aggressively than they should. They may have a mild fall, or merely require an atypically higher level of exertion

I encourage athletes to pay attention to these sentinel events, they are often a sign of fatigue. Specifically, they can be from two forms of fatigue:

A. Cognitive fatigue. Their brain may not be acclimated to the duration of exercise, so they are paying less attention to the small details

B. Muscular fatigue. They may be using muscles they haven't used in a while, so while their muscles were fine for the first hour of exercise, they are not as efficient after an hour or so

What is the treatment for these sentinel events? Give yourself permission to take a break

This may seem like common sense, but there are a few reasons, particularly for skiers and snow boarders, that may make them less willing to take breaks. The biggest of these is time investment. Especially for people driving to their ski facility, there is a substantial time commitment to even start skiing, so the idea of not "maxing out" their time on the mountain seems wasteful. I encourage these patients to think long term, and taking a short break to prevent a devastating injury is a good use of time and resources.

Big picture - taking a short break following a sentinel event is one of the best investments an athlete can make to prevent permanent disability.

While we can't fix your tight pants, we can fix your frozen shoulder!

This video explains how we can use an ultrasound-guided injection to help fix adhesive capsulitis, also known as a frozen shoulder

Conquer the Halloween Sugar HANGOVER

Raise your hand if you ate too much Halloween candy last night and woke up today feeling sluggish & full of regret.  

Ok, I can't see you, but I know you're out there!  Here are easy tips to conquer the post-Halloween hangover

Drop that candy bar! (or bag, lollie, etc.)

Eating sugar will make you crave more sugar.  Halloween is a holiday, not a holi-week or a holi-month.  Don't allow your one-day indulgence to become a new habit.  You have 100% control of what you put into your body! Make healthy choices today and in the upcoming weeks.Tip- if you are craving sugar, reach for a piece of raw fruit.

Eat whole foods

Adopt a clean eating diet for the next few days (and preferably longer!).  Ditch the processed foods and pick up some real, nutritious foods!  A mix of high-fiber vegetables and lean protein will help your body reset after the sugar storm.

Drink more water

Adequate water intake is essential for the body's function, but it's especially important after a day of indulgence.  Water will help your body process those treats and absorb the healthy nutrients you put back in!

Increase your exercise

Rev-up your metabolism and sweat out toxins with a high-intensity workout.  You'll feel better, have more energy and improve your mood, too!

Get some zzz's

Chances are Halloween festivities and trick-or-treating cut into your sleep time.  Make a point to get to bed early tonight and allow your body proper recovery time.

The MA to DPT Transformation

I’ve been at Lake Washington Sports and Spine since April 2015, and have loved every minute of working here. So it is bittersweet that I will be leaving in late July to start physical therapy school near Phoenix, Arizona. (Know of any hotspots? I have zero experience with Phoenix.)  I have learned so much working as Dr. Chimes’s medical assistant that I am at a loss to put it succinctly into words. However, I can at least try and share some tidbits I have learned through my time at LWSS. The nice thing is that most of these lessons have applications outside the healthcare field. Without further ado, here are a few things I’ve learned, in no particular order of importance.  Maybe I’ll rank them later in honor of Dr. Chimes.

-          Become an expert.

In other words, I want to learn as much as possible regarding physical therapy, the field/specialty I have chosen to pursue. I will never be satisfied, as there is always something new to learn. The biggest mistake I can make is to assume that I know all that there is to know about a given subject. Already I’ve learned about various subspecialties in physical therapy I had no idea existed prior to working at LWSS. I’ll never be an expert in all the specialties, but at least I can be aware of the strengths and weaknesses in order to become a well-rounded, well-informed physical therapist.

-          Admit my knowledge gaps.

This is related to the above point, but an entirely different idea in and of itself. For example, although Dr. Chimes has some experience in all medical fields, he understands and admits that he has definite knowledge gaps. It has been years since he learned about cardiology or hematology, and to further compound the problem, these fields have changed so much in the intervening years. This leaves him in the position that he’s not even sure what he doesn’t know. Did past treatments turn out to cause more harm than good? Are there new diseases that he doesn’t know about? So when patients ask about issues outside of his area of expertise, he gives a clear disclaimer that it is not within his expertise and then refers to another provider who would know better.

What Dr. Chimes is trying to avoid is the Dunning-Kruger effect, which is summed up fairly well by one of the authors during an interview with the New York Times: “… the skills you use to produce the right answer are exactly the same skills you use to evaluate the answer.” In other words, without knowing the skills yourself, you cannot determine whether someone is skilled or not. It then follows, how can you possibly come to an answer without knowing what question to ask? This is a phenomenon I had never heard of prior to working here, but it certainly has shaped how I will treat patients in my future career. I will hopefully get my patients to 100% by focusing on what I know, and referring to, and working with, other healthcare professionals with patients who are beyond my scope of expertise.

-          Know which patients will benefit from my expertise as a physical therapist.

And by extension, and possibly more importantly, when physical therapy is NOT appropriate for a patient. Being able to see patients from the perspective of a Physiatrist, where accurate diagnosis is the name of the game, will help me tremendously as a physical therapist. It is now clearer than ever that I will need to keep an open mind and consider alternate diagnoses if the initial treatment modalities I utilize on my patients do not bring any benefit.

-          Utilize a differential diagnosis process.

Low back pain is one of the most common reasons people go to the doctor. However, there are a multitude of causes for low back pain, and the symptoms often overlap. To compound matters, treatments for one cause are ineffectual for another, or may even make symptoms worse. What I’ve learned from my time here is to tease out the unique features of a patient’s low back pain in order to come to a correct diagnosis. Focusing on symptoms that apply to several possible diagnoses will not help me determine the root cause of a patient’s pain.

-          Be as transparent as possible with my communication.

We have several different iterations of this idea within the office, ranging from a tidy motto to a detailed flowchart/graph. It is never beneficial to be vague with my communication style or vocabulary when talking to another person. Furthermore, not only do I need to be clear with my communication, I need to confirm that the person I am talking to is ready to digest what I’m about to say. Having an disengaged audience can, at best, lead to repetition, and at worst, lead to a complete mishearing of what I have to say.

The above are just a few of the things I've learned while working at Lake Washington Sports and Spine. The effects of these lessons may not even be felt or become apparent for years down the line, but I know that they will only help me in my future as a physical therapist. I cannot begin to express how grateful I am for my time here.