Monday, August 31, 2009

When I am not trying to cure ALS, I am thinking about ways to help improve the quality and affordability of health care. Here are my ideas:

Health Care: Fast, Good or Cheap: Pick Any Two During residency, one of my mentors offered this little adage. “Listen to the patient, she’s telling you the diagnosis”. As congress prepares to begin debate on healthcare reform, those of us on the front lines of health care would do well to look inward and consider the ways in which our actions have contributed to the problem and can help solve it. Our “patient” is the individual we care for in our clinics or hospitals but, in a larger sense, our “patient” is healthcare in the United States in general. And by many measures, that patient is not faring well. The choices we make every day contribute to a system of care that is, far and away, the most expensive in the world yet results in health outcomes that are average at best. In addition, 50 million of our fellow citizens are without any form of health insurance at all. Despite our best intentions, the health care we provide is certainly not cheap, not always good and fast only for a select few. If we are to take our rightful place, where our patients want us to be, as the leaders of health care reform, we must begin by asking ourselves what we can do to bring about meaningful, timely and efficient medical care. I believe the solution lies in radically rethinking what constitutes a doctor visit. The electronic medical record can allow us to achieve that goal. It is a rare patient who has not had the unnerving experience of sitting for over an hour in a waiting room only to be rushed through a doctor visit. Studies show that, on average, doctors listen actively for about 18 seconds before interrupting a patient. Somehow, doctors and patients have come to accept the idea that interrupted visits, “overbooking” and long waiting room stays are a necessary price for quality care. In fact, we cheat our patients and ourselves out of the one chance to truly provide meaningful health care. Furthermore, at the end of these abbreviated visits, patients frequently leave the office remembering only half of what they were told during the visit, and half of this is remembered incorrectly. In the rush to create quality care out of limited time, we can easily succumb to the temptation to order tests, treatments and surgeries when similar outcomes could easily be achieved with listening, explaining and teaching. For example, several thorough studies of non-radiating low back pain have shown little to no overall gain to spine imaging, surgery or long term pain medicine use and yet these treatments represent the “standard of care” in modern treatment. The typical rejoinder to this criticism is that these are the things that patients insist on. My experience has taught me otherwise. In 17 years as a neurologist, I have come to believe that what most patients want from their doctor is understanding and education rather than pills and tests. They want to tell the story of their symptoms and they want us to appreciate its meaning to them. They want their symptoms explained back to them in a way that tells them what is going on with their body. Sometimes they want or need tests or medications or further referrals but many times, once they understand what is going on, they are more than happy to try simple time tested interventions first before resorting to pills and surgeries. When the necessary time to reach this understanding is not provided, patients (and their doctors) often use medicines and tests to fill that void. For example, a patient with a straightforward headache history with no worrisome signs or symptoms comes in asking for a brain MRI to ‘see what’s going on”. Admittedly, our medico-legal climate and the proliferation of “doc operas” on TV have created a climate of fear and expectation of the worst in both patient and doctor. However, many times, after a careful history, a thorough examination and a thoughtful explanation many patients will say, “That makes sense, why don’t we try a few simple things first and I will let you know if it helps or not?” This statement, I believe, is the holy grail of health care affordability. As a neurologist, I have a fairly large population of older patients, many of whom have limited ability to see or hear and, not uncommonly, to even comprehend. It became clear to me early on that I could not hope to provide good medical care for them without giving them a written summary of our discussion. This document explains their symptoms in plain language and outlines some simple interventions I would like them to try to find relief. Sometimes, there are further tests in addition to the treatment recommendations, but the simple recommendations are elevated in importance to the same level as the tests and medications and other interventions I might recommend. With the advent of digitized radiology imaging, I can often paste into this note a representative imaging study to reinforce the message. Any medicines I recommend will have a few lines about common side effects and a dosing schedule and range that starts low and builds slowly emphasizing taking the lowest dose that helps and coming off the medicine once symptoms are better. Any medicine I recommend comes with a printed patient information sheet as well. At the end of this note is a request to talk by phone or at a scheduled return visit to see how this plan has worked. I always type out my request to have the patient call me if he or she has questions or is clearly getting worse. While this may sound like an enormously time consuming endeavor, the truth is, many patients have similar symptoms making it possible to create a file of basic Care Plan building blocks that are customized for the individual patient. This is not, however, the same thing as a boilerplate handout that is too generic to have any meaning to an individual patient. The note I hand to the patient is pasted into our electronic medical record so that our medical support staff can see what I told our patient. This is a vital part of this process as it keeps everyone on the same page and helps our nurses and medical assistants encourage the patient to give the simple recommendations a good try. This extra documentation also serves to support levels of coding that support the time and work involved in the visit. For the most part, my patients have been very happy with this approach. The spouses, children and caregivers are even happier as they too are fully engaged in the process. I end up seeing a lot of their family members and friends. This work takes time. In fact, the note is only the end product of a very time intensive visit. I can only do this work because I have been able to use our electronic medical record to review the chart days in advance of the visit so that none of the visit time is spent pouring through the medical record. This pre-visit preparation allows me to arrange for necessary records and imaging studies to be forwarded prior to the visit. As a result of this preparation, I can begin the visit with a simple question to ask the patient to tell me the story in his or her own words. Then I sit quietly and listen. For most patients, the history unfolds in vignettes and disjointed fragments, usually punctuated by reading from the back of an envelope where notes have been scribbled. Sometimes they bring in a three paged single spaced summary and ask me to read it. I gently encourage them to read it to me, so they can add color and context. This history comes out like a torrent at first but eventually tapers off to, “That’s about it doc”. The drop in the tension in the room is palpable and we can all feel that the stage has been set for healing. I then ask questions from my prior reading and notes I have taken to gather the threads into some narrative. At the end of the history, I ask, “Is there anything else you think is important that we haven’t discussed yet?” Since the advent of Google and WebMD and the like, I have also started asking, “Is there a specific diagnosis you have been concerned about that you want to make sure we think of today?” I never cease to be amazed at the things people come up with that I would never have thought of. But if that question is not asked, it remains the 500 lb. gorilla in the room. In addition to previewing charts ahead of time, I do not “double book” patients or allow my clinic to run late. A patient sitting in a waiting room after the beginning of their scheduled visit is a failure on my part to properly manage my time. If a patient arrives and my staff is busy, I get them myself. The whole of the visit time is simply that important. I am fortunate enough to work at an organization that recognizes the time it takes to do good work and gives me that time. We encourage our patients to be here 20 minutes before their visit so that any paperwork or other details that might cut into our visit time are taken care of. If the patient arrives late, I give them my full attention for the remainder of the time we have and then schedule a make up visit. To do otherwise is to cheat every other patient on the schedule that day. The electronic medical record has also created the opportunity to make every kind of patient encounter more meaningful. For example, I typically call my patients with most test results. This allows me to update the narrative arc of the issue I saw them for in a section of the note called the “Problem List”. Here, a concise summary of their symptom or diagnosis is available for any provider to review without having to plow through the chart in search or an initial note and subsequent phone or office visits. The story of the issue I saw them for is readily available and updated as test results and treatment responses are reported. Our urgent care, emergency doctors and hospitalist find this particularly valuable. These phone visits also allow me to check in on how the simple treatment strategies are working, suggest minor adjustments and provide encouragement. For some patients, their preference is for this to occur through a virtual visit through our secure email system. For others, a return visit works best. What the electronic medical record affords is the ability to provide seamless care to far more patients that the traditional check back visit allows for. Here again is another way to increase the efficiency of health care while sacrificing none of the quality. As for me, this approach has enhanced rather than detracted from my work satisfaction. I can see the appreciation in the faces of patients and their loved ones that they have finally gotten an explanation. I feel that the reasoning skills that led me to this profession are honored and appreciated, rather than my ability to order tests and medicines. And I can see the subtle ripple effect of these teaching notes in the care plans of my colleagues. This administration has touted the electronic medical record as a vital tool in reforming our system of care. Like any tool, it is only as good as the skill and dedication of the user. We must always remember that

August: Miles/Calories/Hours

Total Miles (Swim/Bike/Run): 455 Total Calories: 42,600 Total Workout Hours: 47

12 Mile Family Bike Ride on the Centennial Trail on 08/30/2009

Today was supposed to be a 5 hour ride. Instead we all packed up the bikes and drove to Snohomish to ride along the Centennial trail. Forrest ride with me in his kiddy seat on my mountain bike. We saw horses and sheep and donkeys and stopped to play at a train themed playground at one of the old stations along this rails-to-trails conversion. We then returned to Snohomish for some ice cream and wandering through the antique stores. Probably not the best Ironman training but a wonderful day together that did as much for my soul as any ride would do for my training. Here is a video Laurie made of Forrest and his Dada riding in downtown Snohomish. MapMyTri.com - General Road Cycling: Family Bike Ride Centennial Trail on 08/30/2009 Shared via AddThis video

Saturday, August 29, 2009

13.2 Mile Home to Greenlake Loop on 08/29/2009

The ride at Mt. Rainier I had hoped to go on this morning was cancelled on account of cold rain. I spent the day running errands with Laurie and Forrest and managed to find time to get this run in this evening. Another beautiful late summer evening with all the healthy Seattle folk running their dogs and kids in strollers around Green Lake. MapMyTri.com - Regular Run: Home to Greenlake Loop on 08/29/2009 Shared via AddThis

Friday, August 28, 2009

1 Hour Medgar Evers to I-90 Run Then 1500 Yard Swim on 08/28/2009

Another early morning "brick" workout with a run followed by a swim. I managed to get this done before work but had to cut the swim short as I had a patient to see in the hospital before work. Lake Washington was beautiful in the early dawn light from the I-90 bike lane, a great start to the day! MapMyTri.com - Regular Run: Medgar Evers to I-90 Run on 08/28/2009 Shared via AddThis

Thursday, August 27, 2009

16 Mile Early Morning Ride to Seward and Back on 08/27/2009

Got up early to get a workout in before going on call. The lack of traffic along Lake Washington Blvd was a nice change from usual. The first few miles were a bit rough after yesterday's workout, but I got settled into the groove and finished feeling rejuvinated and ready for the day. MapMyTri.com - Road Cycling - Medium Intensity: Ride to Seward and Back on 08/27/2009 Shared via AddThis

Wednesday, August 26, 2009

7.2 Mile Run (Medgar Evars Pool to Mercer Island and Back) then 2 Mile Swim on 08/26/2009

View Interactive Map on MapMyTri.com Today's workout was typical of what I should be doing from now until early October, a combined run or bike with a swim during most weekdays. The weekends are reserved from one long ride (6+ hours from here out) and a long run then ride combo. Monday is my rest/recovery day. Who woulda thunk I would be looking forward to Mondays! The run was lovely, looking out at the Thistle sailboats racing off Leschi from the bike lane on I-90. Ah, la dolce vita! MapMyTri.com - Regular Run: Medgar Evars to Mercer Island Loop on 08/26/2009 Shared via AddThis

Tuesday, August 25, 2009

30 Minute Run (Madison Park Loop) Plus 47 Minute Roller Ride on 08/25/2009

Another call night so I did as much of Wednesday's 1 Hour ride and 30 minute run workout as I could. I can run with my pager and phone as long as I stay near the house, hence the neighborhood loop, but for a ride, I gotta use the rollers in the basement. Tonight, I watched the DVD of Stop Making Sense by the Talking Heads. Always a sure bet for a high energy workout! MapMyTri.com - Regular Run: Madison Park Loop on 08/25/2009 Shared via AddThis

Sunday, August 23, 2009

13.2 Mile Home to Green Lake Loop on 08/23/2009

Long weekend training run. A little tougher than usual. I don't think I have completely recovered from my 72 mile ride from yesterday! MapMyTri.com - Regular Run: Home to Greenlake on 08/23/2009 Shared via AddThis

Saturday, August 22, 2009

Training for Ironman, Seattle neurologist raises $ for patients

Here is a nice article Monica Guzman at the Seattle P.I. wrote about my ALS fundraising efforts Training for Ironman, Seattle neurologist raises $ for patients

72 Mile Ride Around Lake Washington and Lake Sammamish on 08/22/2009

This is my long training ride of the week. I thought I would expand my usual ride around Lake Washington to take in Issaquah and Lake Sammamish. When I got to Marymoor Park, I hopped on the Sammamish River Trail and then home via the Burke Gilman trail. I felt pretty tired and sore at the end, but less so that earlier (and shorter) rides this summer. I'll take that as a good sign! MapMyTri.com - General Road Cycling: Ride Around Lake Washington and Lake Sammamish on 08/22/2009 Shared via AddThis

6 Mile Run with Forrest on 08/21/2009

Another fun run with our little bunny. I was going to slip out the door on my own as it looked like he needed a nap, but Forrest plunked himself down in front of the door and announced he wanted to come with dada. We had a great time talking about our trip to the park last night and making funny animal sounds :-) MapMyTri.com - Regular Run: Run with Forrest on 08/21/2009 Shared via AddThis

Thursday, August 20, 2009

9 Mile Run then 1.2 Mile Swim on 08/20/2009

The cold that has been running through our home finally caught up with me yesterday. I took a rest day on Wednesday but got back at it today. I did OK through the run (out over I90 and back then up the stairs from Madrona to my starting point at Garfield High). I began to feel my reserves tap out during the swim but managed to get 1.2 miles in. I'm going to try and not push it tomorrow so I can get a long ride in on Sat. and a long run in on Sunday. MapMyTri.com - Regular Run: Run on 08/20/2009 Shared via AddThis

Tuesday, August 18, 2009

Training Ride to Seward Park Then Run with Murphy on 08/18/2009

First workout after the Lake Stevens 70.3. I was stiff at work all day but feel I have made a much better recovery after this race than at Vineman. I rode down to Seward Park and back and felt good on the bike, then a quick transition to running shoes and headed out for a 30 minute run with Murphy. That was a little more of a challenge, particularly the steep hill at the climb. But, I learned there is no hill you can't climb if you have an Irish Setter at your side and Alison Krauss singing with Robert Plant on the iPod :-) MapMyTri.com - Regular Run: Post Ride Run with Murphy on 08/18/2009 Shared via AddThis

Monday, August 17, 2009

Lake Stevens Ironman 70.3 on 08/16/2009

Another 1/2 Ironman distance race. This was to be my race to validate my lottery slot, but I managed to get into the Vineman race. I figured I would run this one for practice. The swim was harder than I expected but my transition to the bike ride went much faster this time. The ride was quite hilly but I managed to post a pretty good time. The run was in weather 15 degrees cooler than Vinemen and that made a huge difference. I really felt much stronger and didn't walk any of it. I shaved about 20 minutes off my Vineman time. Yay! It was so nice to see Laurie and Forrest at the finish. What a sight for sore eyes (and legs) :-) Now for the heavy lifting up to Kona. MapMyTri.com - Regular Run: Lake Stevens Ironman 70.3 Bike and Running Legs on 08/16/2009 Shared via AddThis

Friday, August 14, 2009

4 Mile Pre Race Run w/ Murphy on 08/14/2009

The workout intensity tapers down before a big race. Today called for a 40 minute run. Murphy and I ran a variation of our usual neighborhood course taking in Madison Park, brother John's place, brother Tom's place and back home via Madison Street. Murphy was sagging a bit at the 40 minute mark so I stopped the timer and we walked up Madison Street. Then he wanted to run again! What a trooper! MapMyTri.com - Regular Run: Pre Race Run w/ Murphy on 08/14/2009 Shared via AddThis

Thursday, August 13, 2009

1 Hour Roller Training Ride in the Basement on 08/13/2009

Came home to a downpour and a wife with a cold. I thought I would get my 1 hour ride in with the rollers in the basement so I could watch our little one and let Laurie have a rest. Tried out my new (to me) Zipp 404 aero wheels. Sweet! MapMyTri.com - General Road Cycling: Roller Training Ride on 08/13/2009 Shared via AddThis

Wednesday, August 12, 2009

3000 Yard (1.7 Mile) Lap Swim on 08/12/2009

Another swim before the Lake Stevens 70.3 (1/2 Ironman) this Sunday. I felt stronger in the water tonight. Not having run 10.5 miles just before probably had something to do with that :-) MapMyTri.com - Laps / Swimming Pool: Lap Swim on 08/12/2009 Shared via AddThis

Monday, August 10, 2009

Brick Workout: 2 Hour I-90/Leschi/Madrona Run, Then 1.5 Mile Swim on 08/10/2009

I parked at Medgar Evers Pool at Garfield High and ran for two hours across I90 to Mercer Island, then down to Leschi and Madrona Park, then up the long climb along Madrona Avenue back to Garfield High School. I had to add a few loops to finish the run in time for Lap swim at Medgar Evars. The swim felt great but its a strange feeling to be surrounded by water and still feel thirsty! Tomorrow is a call day so no workout until Wednesday. Then the workouts taper down in anticipation of the Lake Stevens 70.3 on Sunday. MapMyTri.com - Regular Run: I-90/Leschi/Madrona Run on 08/10/2009 Shared via AddThis

Saturday, August 8, 2009

10.5 Mile Lake Stevens 70.3 Run with Murphy on 08/08/2009

I got a few hours off on my call weekend to get a run in. Murphy and I ran most of the 13.1 mile running segment of next weekend's 1/2 Iroman. The run is a double loop with a long hill late in each loop. The good news is that the run follows the lake with some lovely views. Murphy was pretty played out by 10 miles and I had to get back to resume call, so we passed on the last section. At least I know the whole course now! MapMyTri.com - Regular Run: Lake Stevens 70.3 Run with Murphy on 08/08/2009 Shared via AddThis

Friday, August 7, 2009

50 Mile Bike Training Ride: Tacoma to Seattle Ride on 08/06/2009

I worked in the Tacoma clinic today and decided to combine my commute home with a training ride. After a slow start (forgot my jersey and had to buy one at Tacoma Bike) I started out. I then got a little lost in Sumner and did a bit of a loop before finding the road to Milton and then north to the Interurban Trail. From then on it was a pretty straight shot to Boeing field, Safeco Field and then home. Yay! MapMyTri.com - General Road Cycling: Tacoma to Seattle Ride on 08/06/2009 Shared via AddThis

Wednesday, August 5, 2009

7 Mile Elliot Bay Trail Run with Forrest on 08/05/2009

Pushed Forrest in the jogging stroller from the Denali gym at Interbay past the Interbay train yards (always a hit with Forrest!) and then onto the Elliot Bay trail to Pier 70. We had a great time talking about trains and planes and boats and the grain elevator. Laurie got a nice workout in at the gym and we all went out for dinner at Romio's afterward. Another great evening! MapMyTri.com - Trail Run: Elliot Bay Trail Run with Forrest on 08/05/2009 Shared via AddThis

20 Mile Indoor Roller Training Ride on 08/04/2009

Riding of my rollers allows me to get a workout in while I am on call. If needed, I can get to the emergency room or hospital almost as quickly as if I was not working out. This ride averaged 15 MPH, a slow pace except that the resistance device on the rollers makes the ride not unlike a long slow climb. I have been thinking about what an amazing opportunity this lottery win is. The Ironman World championship is the World Series or Super Bowl of this sport. Imaging winning a chance to play for in one of those events! I've also been looking back over my training log. Since April 11 (when I first started tracking my workouts on MapMyTri.com) I have logged 1180 miles and have burned through 117,000 calories! And I still have 2 months of the hardest training yet to go! MapMyTri.com - Road Cycling - Medium Intensity: Roller Training Ride on 08/04/2009 Shared via AddThis

Sunday, August 2, 2009

13.2 Mile Run : Home to Greenlake on 08/02/2009

Yesterday, I rode the 1/2 Ironman bike distance. Today, I ran the 13.1 mile running distance. I ran from Madison Park up past the UW fountain, through Frat row and over to Greenlake and around. I tried out my new Amphipod hydration belt. It holds a 20oz. bottle in a pouch in the small of your back. I really like it, but forgot to put the bungee holder back on and lost the bottle coming back to the UW. Gotta go look for it! MapMyTri.com - Regular Run: Home to Greenlake on 08/02/2009 Shared via AddThis

Saturday, August 1, 2009

55 Mile Training Ride: Lake Stevens Ironman 70.3 Bike Course on 08/01/2009

Thought I would preview the Iroman 70.3 (1/2 Ironman distance) bike course. There are two long hills and a bunch of rollers in the double loop. The hills and the heat were a real challenge, but it felt good to get familiar with the course. I won't have a chance next weekend as I will be on call, and the weekend after is the race (August 16th). MapMyTri.com - Road Cycling - Moderate Hills: Lake Stevens Ironman 70.3 Bike Course on 08/01/2009 Shared via AddThis