Saturday, February 10, 2018

Puppy Love

So my goal with medical practice is to help patients define a goal.  In creating my annual DrRic's Hiking started as a goal for me to keep activity as top priority.  Modern lifestyle keeps activity and exercise on the bottom of the "totem pole" regarding multitasking.  When we keep shoveling other tasks atop the required daily move count, before you know it January first rolls around and your 5-10lb heavier, still tired, and planning a check up with doc to most likely get started another medicine since nothing changed from the previous visit.  That is why I find it easier to daisy change small tasks and have mini successes so life isn't overwhelmed with ONE BIG GOAL OF LOSING 50 POUNDS BY SPRING.  (...individual goals may vary but you get the picture about procrastinating on health) 

During the dreaded annual wellness exam (15-20 minutes max as allowed by medical insurance reimbursement)...when I hear "I know what to do I just have to do it"....I immediately retort "please don't rely on failed routines as if your technique failed to give long term success then if will fail you again" and we don' want to have the same conversation next year. 

A common benchmark for success or failure is levels of glucose, cholesterol, and vitamins.  If your deductible is too high to invest in getting blood tests or fancy imaging studies ...then we go old school. 
-new school = test blood levels and get xrays or ct scans and determine if change has occurred.
-old school  = measure waist line, weight, level of fitness, blood pressure, diet or number of meds (the more medicine prescriptions you have accumulated / the more health has "left the building")
So the inherent problem with doctors of functional medicine is they follow numbers not the person.
If you feel good now after fixing the lab values....okay but you have just accumulated more vitamins and herbs instead of medicine prescriptions!!!  If there was a way to add old school guidance to new school measuring....that would be perfect.  Using old school ways will change the basic ways of eating sleeping activity and stress should be recognized as a 360 degree change but that takes motivation (in your face accountability every day during the weakest times of the day.)   A coach for keeping eyes on your activity and making you aware of goals short and long term, a nutrition expert to remind you BEFORE the crave kicks in on what is expected by end of day and a mindful coach to design and redesign do-able routines to keep a stress neutralizing routine on your daily accomplishments.  If I act as head-coach one to twice a year during your visits....I need these coaches in your back pocket with day to day/week to week motivation. 

Either way, if you are headed to and early coffin or worse, a label of "disabled" due to stent, numerous medications, physical pain or emotional imbalance has been adopted...someone has to design a template for lifestyle change.  In taking care of lowering blood sugar, I usually like to add psyllium (fiber), timing of meals, volume of meals, ingredients of meals and level of satiety (satisfying feeling of fullness).  In Toms story of lowering sugar, the odd thing is he gained weight since his last visit which doesn't make sense as his sugar level dropped down?!...  In the Q&A that ensued, I found out his sleep was being interrupted!!!  AH HA!!! but poor sleep would cause sugar to go up?  Then he revealed the answer.  Tom got a puppy and he has been the one caring for the new family member.  The little guy wakes Tom at 3 am to pee but even with this seemingly frustrating info...Tom was smiling while talking about his new best friend.  To me this is the typical result found when people participate in laughter yoga.  Small studies have been used to check pain tolerance during duchenne type laughter and it was speculated that there may be an endorphine mediated response that changed the way damage to the body was handled.  Being in love can cause the heart and mind to be bulletproof to damage / the opposite is true too.  Maximum stress can cause a normal heart to undergo anatomic changes resulting in the heart attack.

This is where my hypothesis on love and inflammation.  Tom gains weight=sugar goes higher.  Tom loses weight=sugar goes lower.  Tom finds happiness=metabolism changes.  Tom finds puppy=sugar lowers JUST LIKE HE LOST WEIGHT!!! and the test for my theory is his weight gain should have increased sugar but actually reversed it.  Now there is alot more to test, control for variables, check the lab reliability, scale accuracy...but who cares.  Tom found a friend, puppy found a home, doctor got a reason to blog, one less medicine the insurance has to pay for. 

LOL -click here to check you how laughing changes the world

Sunday, February 4, 2018

Back to Business

The proverbial "waiting room"

When I was growing up in the 70's : (
... the waiting room was where dad's would wait while babies were being born. 
The stereotypical scene was several dad's pacing back and forth anticipating the
good news.  Now the dreaded waiting room associated with western medicine
is where you wait for hours, read outdated magazines (that sick people have leafed
through) with a sign that says no phone use.  In this culture of immediate reward,
it rubs everyone the wrong way to have to deal with waiting. 

So even before I see anyone in the exam room, an unsatisfactory review is brewing.
One wonder why a doctor would care about reading reviews when they all should be
focused on patient care ....but.... salaries are dependent on satisfaction.  The current
design structure for getting paid by a hospital has efficiency and patient satisfaction
built into the formula (RVU's).   It was started in the early millennium when large hospital
organizations had to be accountable to medical insurance payers to be efficient (and
not order too many expensive tests) but insurance companies also wanted their
clients to get the "best" health care.  One parameter of measurement was patient
satisfaction surveys.  Reviewing wasn't as hot a tool in 2000 as it is now.  Additionally around
1999...there were a still primary care doctors that owned their own medical practice paying
attention to utilities, salaries, billing, malpractice insurance...even answering their own
phones and pagers at night.  (I remember someone paging me at 2am just to say they
couldn't sleep!!!)  With medicare reimbursement decreasing back then about 3% every was only a matter of time before being a small business owner of a medical practice
would cave in to being a salaried employee.

I left medicine totally disgusted in 2005 and moved from Illinois to Florida where I was
going to start over and just be a dad.  The last thing I remember was being told by
administration that the hospital paying my salary was changing and if I didn't get
on board with the new salary structure (less pay more hours because I wasn't producing
the same as other primary care docs in rest of the country) then I should leave.  But in theory I couldn't leave even if I wanted to, there was a restrictive covenant in place that would bar me
from opening my own practice within a 15 mile radius and I would have to pay for a malpractice
insurance "tail" to cover any potential law suits filed against me for the prior 10 yrs.
-most patients don't see primary care docs > 15 minutes from their homes
-tail coverage costs about $10,000-20,000 to be paid all at once
-new malpractice insurance would have cost me $50,000 before I even opened my doors
-electronic medical records were being pushed by the government as an attempt to decrease
paper waste and have efficient doctor to doctor communication (more like doctor to insurance billing efficiency)
-offering medical insurance to future employees as a small business owner was impossible to afford (and still is)

But I had work to pay mortgage, kids education, medical insurance.....(I didn't have medical insurance
for about 2 yrs as I couldn't afford it...prayed every day to stay injury free).  So I signed up to be an immediate care doc.  See patients that I didn't have attachment to, finish work right on time and hand
off the the next doc.  No phone calls middle of the night.  "Treat em and Street em" was the motto.  That was not why I stayed in school until the "21st grade"  (I am now on my 24th grade / year of study).  I was disillusioned from medicine due to the harsh words of an administrator saying that my practice style of medicine didn't make a difference in the community as compared to the national average "I was below average"....until the phone call.

I remember being okay with life in Florida, payed hourly for immediate care coughs colds sutures injuries....then I got a call from an old patient from Illinois.  They were looking for my help as all the docs they were assigned to didn't give many options. He was dying slowly of cancer.  With the acupuncture training I finished before leaving for Florida, I remember designing a few options no one else thought of.  He died eventually but I hope my suggestions gave a small sigh of relief for at least his family.  This is the part of the movie where the hero thinks back in time and pieces together the keys to conquering the the big Boss bad guy.  I re-awakened my core thinking ..."I wasn't below average and all the weird things I invested in -acupuncture, breath, yoga, nutrition, exercise...gave options no other doc was offering.  They made a difference to my old patients who looked across north America for me, they made a difference for me during the time I had no medical insurance, I had to make major lifestyle changes to stay out of the hospital!  So I came back albeit slow, I still worked my way back into private practice (kinda) still holding onto my style of medicine.

So how does this pertain to the waiting room?  I learned from Andy Weil, Herb Benson, Deepak Chopra and Joseph Helms that the answer to the disease manifestation is in the patient.  Getting the answer out will take more than a blood pressure reading, a throat swab or blood testing.  There is a gentle teasing out of information from the human sitting in the exam room with you.  An exam is not just a physical should be a bio, psycho, social, nutritional, educational, introspective  interaction between healer and patient.  Look at the word 'patient'....connoted the need to take time for healing.  Done properly, the time spent in close proximity to a good healer will reveal the most direct path to heal-ing.  When we truncate the time spent in planning out the journey on our path to being disease free, there is more chance for error.  Making a mistake means back tracking and starting again.  This time loop of only inquiring about the biggest symptom and then treating with a temporary medicine till another symptom pops up to be repeated again...doesn't get anyone (doctor or patient closer to "healthy".  In fact this stutter stepping pushes healing farther away and brings chronic suffering into younger ages.  The answer is in the patient, to know the patient inside and out will be the best way an architect can design change, empowering change will beat disease.

This take more than the standard 20 minute visit (15 minutes actually but I have 20 years of experience!!!) so when I run behind by 45+ minutes, it is usually to accommodate for the 20 minute slot given for a "wellness check up" that turned out to be a multi-system, multi-symptom chronic presentation that needs fixing now.  I'm not blaming patients, they don't know that the majority of medical insurance payers are following the state's reimbursement of 49.95 for the most complex of visits (that usually takes about 45-60 minutes of face to face time to listen to plan out and diagnose.  Tag that onto a 6-9 month turn around on payment is a business supposed to survive? Then at the same time I have to make sure service is with a smile or I wont get my "potential" annual salary.  I am not embarrassed to say...I am getting the same salary I was paid during my first years of working for a hospital.  (in 1995)  I have the potential to make what the average primary care doc makes in the US but I would have to see more patient and practice medicine like everyone else...just contributing to the time loop, but I choose not to.

I know my body mind spirit won't tolerate practicing at this pace forever BUT for now:
-I take my salary as is (at least I have a job)
-continue to change lives (check my drricsaguil instagram posts)
-save up some money doing other things (like my youtube channel and maybe an acupuncture clinic on "days off")
-hit the lottery
-vote for change
-opt out of taking medical insurance BUT charge a reasonable fee
-continue to create a sense of calm in the "waiting room" so that patients are actually healing before I walk in to start the healing process.

My faith tells me if I provide the keys for people, the Universe will open the door for both of us.
Guess I have to take a seat in my own waiting room.