ACP Internist Blog

Thursday, January 16, 2020

Try out this simple technique for tight and sore muscles

I am very into physical fitness and working out. Playing sports and staying active is something that I've done ever since I was a young child. I am fortunate to have parents who encouraged me from a young age to get outside and participate as much as I could (which is quite rare for Indian parents, so I'm extra grateful!). In high school in England, I was captain of my cricket team, and also represented my county in the sport. I also regularly played football (soccer) and tennis. I then had a bit of a lull during medical school, and aside from the odd bit of running, didn't really become a gym addict until I had become an attending physician.

I really regret not holding myself to a regular routine during those years—and it disappointingly showed in my photos at that time—with a hint of a pot belly when I look back at them. Anyway, I've now got better habits, and currently work out almost every day doing a mix of cardio and muscle-strengthening. Free weight training is something that's relatively new to me, and I'm enjoying focusing on my strength, as well as my cardiovascular fitness.

Since I became more consistent with my overall gym routine, it's really transformed my life and the way I feel during the day. I work out first thing in the morning (when I'm working in the hospital, this often means I'm in the gym around 5:30 am). It's well worth getting up at an unearthly hour to give myself this energy, adrenaline and endorphin boost. I also consider this a crucial part of being a physician, because I want to set an example to my patients. No point talking to them about weight loss, what not to eat, and getting up and moving—if I don't do it myself.

On that note, I'd like to share a technique that I've recently incorporated into my routine, which I've found really beneficial. You can even use this if you aren't a gym-goer, in the comfort of your own home (lots of people do it in front of the TV!). Following some advice, I started using a simple foam roller (if you don't know what one is, some examples are pictured here), as part of my warm-up and cool-down routine. In more scientific terms, this is known as “self-myofascial release”. It's a relatively new trend in the world of sports medicine, increasing in popularity over the last couple of decades. The theory behind why this is so great for muscles, particularly any tender spots, is as follows: Certain muscles in your body can develop “knots” in them or become overactive (i.e. the muscle is shortened). As you roll over muscles with the foam roller—whether it be your back or extremities—you are helping to loosen them and increase blood flow.

When you feel a tender or tight spot: Hold this for at least 30 seconds. This is long enough to allow a process called autogenic inhibition to occur, when the tension-sensing Golgi tendon organs in your muscles, send inhibitory impulses to the muscle fibers, causing the muscle to relax. You should be able to feel it as the process of autogenic inhibition kicks in, and the area loosens.

This technique of self-myofascial release can be used as I use do (as a corrective static warm-up and cool-down exercise), but can also be used on its own for sore muscles, even if you don't regularly work out. I will let you research on your own how to roll correctly on different parts of your body and target certain muscle groups (for instance, the latissimus dorsi is just below your underarms). There are a ton of informational videos available online on sites such as YouTube—and it goes without saying, always speak to a trained professional first if you have a more specific problem or are at risk of injuring yourself. It's also a well-established technique that is used to correct muscle imbalances due to overactive muscles, found in certain postural abnormalities such as lower crossed syndrome and pronation distortion syndrome.

To emphasize just how beneficial foam rolling is, it's an integral part of the workout that American Football superstar Tom Brady promotes. Living in Boston, needless to say we hear a lot about Brady all the time (I'm going to be sensitive to the fact that this article may have a wide readership, but in this part of the world we call him the GOAT). For Tom Brady to remain so competitive given his age is nothing short of remarkable. His healthy lifestyle book, The TB12 Method, also highlights his mostly vegetarian/vegan diet. Brady's workout regimen is big on improving muscle flexibility, and a core part of this includes rigorous muscle loosening actually using vibrating foam rollers. You can read in more detail about his TB12 workout here in a recent Boston Globe article, and any member of the public can drop by his fitness center in Boston's Back Bay, to give it a go.

So if you have never used a foam roller before, you can try one at your next gym visit, or consider purchasing one to use at home. They come in different shapes and sizes (some are harder with rugged surfaces). Start with a simple foam one. It's done me a lot of good, and it may be just what the doctor ordered to loosen those tight muscles before and after your long day at work.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Thursday, January 9, 2020

'Doctor, what would you do?'

There's a phrase that every physician hears repeatedly from patients, that requires a nuanced response: “Doctor, what would you do if you were me?”

There are variations on this inquiry, such as ‘what would you do if I were your father’, but they all are aiming at the same target. The patient, or often the patient's family, asks the doctor what advice the physician would choose if he were in the patient's place. For example, if the physician were the patient would he opt for:
• surgery
• chemotherapy
• experimental treatment
• watchful waiting
• a second opinion
• a third opinion
• alternative medicine
• acupuncture
• hospice

Patients erroneously believe that this form of inquiry is the magic bullet of finding out what the physician's truly best advice is for a particular medical circumstance. After all, if the doctor would recommend a treatment for his own mom, then surely this must be the best option.

Except, it isn't. Here's why.

Physicians, as members of the human species, cannot be as objective with regard their own families or themselves as they are with their own patients. This is why wise physicians do not treat family members. Indeed, every physician has heard vignettes of inferior care that was rendered by a doctor to a close family member. The reasons for this are beyond what I can express here, but the core of the explanation is tainted physician judgement resulting in delayed diagnoses and incorrect treatments. When a close relative recently approached me to discuss recurrent stomach aches, I gave her good advice. Make an appointment with a doctor.

Another circumstance when physicians are known to provide inferior care secondary to judgement lapses is when the doctor is treating a celebrity or VIP.

If you ask your doctor what he would do if he were you, the doctor's response should be an explanation of why he can't give you the answer you seek.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Monday, January 6, 2020

40 years of ward attending

On Jan. 1, 1980, I walked onto the 7th floor of the old North Hospital at the Medical College of Virginia to make rounds as the attending physician. I had spent much time there as an intern and resident, but now I had a new role.

As I reflect on 40 years and probably between 12 and 15 years of total time making rounds, I first feel fortunate that I quickly discovered that my vocation was also my avocation. Now while I have retired from administrative responsibilities, I still devote 3.5 months each year to rounding with students, interns and residents. And each rotation still brings out the same excitement of going to the bedside and trying to help patients, of exposing students to the wonder of internal medicine, of helping interns through that difficult year and of helping residents in the final year of their internal medicine journey.

When I started, I thought that I really knew what I was doing. On reflection, I had some excellent instincts, adequate knowledge and yet much to learn about leading a ward team. The job has changed dramatically over these 40 years, and hopefully so have I.

In 1990, I had the wonderful opportunity to spend a month at Stanford, learning about teaching from Dr. Kelley Skeff. To this day, he remains one of my heroes and important colleagues. He taught us how to evaluate our own teaching. He provided a structure of the attributes for successful teachers:
1. Creating a Positive Learning Climate
2. Organizing Control of the Teaching Session
3. Communication of Educational Goals
4. Promoting Understanding and Retention
5. Evaluation of the Learner
6. Providing Feedback
7. Fostering Self-Directed Learning

To read more from Dr. Skeff

His insights and videos allowed us self-reflection. Under his guidance, we learned to strive for improvement and to critically evaluate our own teaching. I borrowed much from Kelley.

He transformed my teaching in many ways. The most important in reflection was that I began seeking ways to assess my own teaching through student, intern and resident feedback. I learned that experimentation was desirable for teachers as long as one could adequately evaluate the experiment. Over the years my teaching has matured thanks to the patients, students and housestaff who have given me either direct or indirect feedback.

Teaching attending responsibilities have changed dramatically over the years. When I started we never wrote notes. Then we transitioned to brief notes for billing.

It took many years to develop my unique ward rounds teaching style. I am happy to argue that there is no correct teaching style, rather each attending physician needs to develop a style that works for patients, students and housestaff.

Medicine has changed dramatically over the past 40 years. We treated heart failure with digoxin and furosemide when I started. We had no HIV, no MRSA, nascent CT scanning and MRI, many fewer drug classes, and no billing requirements. Our understanding of pathophysiology has grown. Our ability to diagnose prior to autopsy is much greater, yet we likely make as many diagnostic errors now as we did then.

The research into what makes successful ward attending rounds, “Using cognitive mapping to define key domains for successful attending rounds,” further helped me understand what to emphasize and what to de-emphasize.

At the beginning I aspired to become a great clinician-educator, although no one used that term. In the 70s and 80s (and for some today) most deans and chairs assumed that any good physician could teach clinical medicine. Today we are more clearly defining the value of great clinician-educators and hopefully insisting on quality (although this might be an aspirational hope).

So what do I know now that I did not know then. First, I have a much better personal understanding of my limitations. I know when to ask for help. Second, I have developed my best style. I allows start in the team room, discussing each patient, having the team tell me their plans. We often have a brief educational discussion of some aspect of the patient (dx, rx or something tangential). Once we all understand the general plan for the day, we go visit each patient. At the bedside I often am the “role model.” I repeat parts of the history when appropriate, repeat the high yield physical exam, answer patient questions, and make certain that the patient understands the day's plan. I deliver bad news if necessary. Afterwards, we often debrief the team about bedside manner. Whenever we have images to view, we walk to the radiologists. I started doing this several years ago, and it has become extremely popular with the housestaff and students. It also helps us more quickly get to the proper diagnosis.

My advice to junior attendings:
1. Read both linked articles
2. Try hard not to micromanage
3. When you disagree with the team, or when you are directing the plan, make your thought processes explicit; that is the number one wish of your learners
4. Respect their time. Always finish on time, even if you must see a few patients w/o the team
5. Get to know the team members
6. Ask team members what they did for fun on their off day
7. Give feedback daily, both positive and formative, and label it as feedback
8. Touch patients, sit down, learn who the patients are; your learners will emulate your bedside manner, so make it impeccable

I have left much out. Being an internal medicine ward attending is and has been my perfect vocation and avocation. I hope they let me reach 50 years.

Thanks to the many patients, students, interns and residents who have challenged me to be a better physician and a better educator. You have given me the great gift anyone could receive.

And on February 16th I go back on service for another half-month. Looking forward to it.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.
Monday, December 30, 2019

5 things patients say that should make doctors sit up and listen

Although there are many negative things that have happened in health care over the last couple of decades in terms of the medical practice environment, I am a real believer in one particular paradigm shift that's occurred in our field. That's the move towards patient-centered care and less of a high and mighty paternalistic approach from doctors. The ego-centric side of physicians might have, on some natural human levels, once enjoyed this—but when it's you or a loved one on the receiving end of a paternalistic approach, things quickly change. As a whole, we doctors underestimate the intelligence level and self-awareness of our patients. The vast majority of the time, they already know the diagnosis themselves, and I frequently like asking my patients the question after I've talked to and examined them: ”What do you think's wrong with you?” (as I wrote about in this article). On that note, I wrote this piece some time ago, that I'm resharing. Physicians take heed.

In the busy world of hospital medicine, where doctors and nurses find themselves rushed off their feet for most of the day, time to sit down and actually listen to patients is at a premium. Every doctor knows that our primary focus has to be on the most important aspects of the history and clinical examination in order to get to the correct diagnosis and treatment strategy. But at some point all of us would have also found ourselves driving home at night wishing that we had just a little more time to listen to our patients more attentively instead of cutting them off and rushing to get to that important point. When there is such a well-publicized push to improve “patient satisfaction”, one of the most common complaints from patients remains that their doctors simply do not spend enough time with them. Yet it's not just a case of blaming the doctor either.

Contrary to addressing this problem, many of the bureaucratic requirements heaped upon doctors are in direct opposition to spending more time with patients—like needing to spend huge chunks of the day navigating inefficient computer systems and having mountains of regulations to deal with. A frequently cited statistic states that on average, a doctor only allows the patient to speak for anything between 12 and 23 seconds before interrupting them. Furthermore, during the course an average interaction, lots of things can also be simply passed off—much to the annoyance of patients (and again, it's not always the doctor's fault that this happens). There are, however, some things that in my experience patients tell you which should be carefully listened to and never ignored.

Here are five of them, and would be especially good for medical students and residents to know:

1. “These are exactly the same symptoms I had before.” This applies particularly to certain conditions such as chest pain. When a patient tells you that their pain or discomfort, no matter how unlikely it sounds, “Is exactly the same as when I had my last heart attack”—take it extremely seriously.

2. “The patient just isn't quite himself.” If a loved one—be it a spouse, a parent, or a child—tells you that their relative has just “not quite been themselves,” this may sound like a very vague thing to say. It is therefore very easy to pass off in the absence of any other specific objective findings. But rarely will there be nothing wrong when a relative tells you this. Investigate it thoroughly. It could be a hidden infection, a neurological issue or an impending catastrophe. This is also the case when a nurse tells you that their patient “just doesn't look right.” I can't tell you the number of times I've heard of that being said in the presence of what appear to be stable vital signs, only to have that patient crash shortly afterwards.

3. “My medication did this to me.” There are countless potential medication side effects for every pill, affecting everyone differently due to our own unique metabolism. Sometimes patients will tell you that they know a certain medication made them feel a certain way. The symptom may sound unusual and not be a classic textbook side effect for that particular medication. Remember that nobody knows their own body better than the patient. If you hear this complaint, it's almost always true.

4. “What happens if when I go home this happens?” ”Oh, don't worry—that's very unlikely to happen Mr. Smith!” When a patient is concerned about something happening when they leave the hospital, it often finds a way to happen! Address all concerns prior to discharge.

5. Complaints about noise and rude staff. Everybody in the service industry knows that a certain percentage of people are just terrible whiners—complaining about everything under the sun. At a time when people are unwell in the hospital, we may wonder why they would have reason to complain about something else other than their illness. However, nine times out of 10 when a patient brings forward complaints about issues such as rude staff, bad food, or too much noise, they are invariably justified.

These are five things that all physicians would have heard countless times. I hear these statements on a daily basis, and it's the easiest thing to do to pass something off that sounds off the mark as being extremely unlikely or just plain nonsense. As doctors, we are trained to recognize the zebras and the 5% of unlikely happenings. When the patient is giving you the clue—listen.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.