Choosing your health care team – Part 1

Much has been written previously about the importance of choosing your doctor wisely. But honestly, much needs to be written on this topic, because smart, savvy people continue to make bad choices, despite all the advice that’s out there. 

Just like any other profession, there are some bad doctors, a lot of reasonably competent doctors, and some excellent doctors.  All are not created equally.  But most people don’t know how to discern the good from the bad.  They make their choices instead based on factors like: proximity to home or work, ease of finding a parking place nearby the clinic, the interior design of the office or the variety of magazines in the waiting room.    

Identifying excellent doctors isn't an easy task

Your choice of doctor is important in and of itself.  It also is important because it typically dictates the broader health care system and the hospital that you will be using eventually if and when needed.  You might have the best doctor in the world, but if that doctor is allied with a poor-quality hospital that has unsafe and unhygienic conditions, then you are in trouble if you ever need to be hospitalized. 

The consequences are significant.  More than a decade ago, the Institute of Medicine estimated that at least 44,000 people, and perhaps as many as 98,000 people, die in United States hospitals each year as a result of medical errors that could have been prevented.

Hence the title of this posting: choosing your health care team.  It is important to choose the right doctor, of course, and that is the focus of today’s posting.  But the broader health care system in which the doctor works is also crucially important.   Even in today’s era of managed care and preferred providers, most of us have a range of picks at our disposal.

Today, I am listing some basic factors you can look into before you meet your prospective doctor.  In future postings, I will discuss some of the things you can consider when you meet the doctor face-to-face; and factors about the broader health system that can serve as clues to the quality of services you can expect to receive.

So don your sleuthing hat and start researching.

Degrees.  In the United States, two professions are licensed to practice medicine: doctors of osteopathy (DOs), and medical doctors (MDs).  Other doctoral-level professions that can practice independently are naturopathic doctors (NDs), doctors of chiropractic (DCs), and my professional group, psychologists (PhDs).  Physician assistants (PAs) and nurse practitioners (ARNPs) are not technically doctors but can serve as primary care providers within larger health care clinics.  Certainly, excellent practitioners can be found within each of these professional groups.  I will nonetheless offer my opinion that MDs are typically the most rigorously trained and best prepared for general health care.  

In addition to the degree, I look at academic reputations of the specific schools and hospitals where the doctor has trained.  This is not a hard and fast indicator, but a clue about the doctor's rigor of training (as well as ability to be accepted into competitive schools or residency programs).  

Board certification. Beyond completing their basic training, doctors must be licensed by the US States in which they work. However, being licensed does not indicate whether a doctor has completed internship and residency, nor whether a doctor is qualified to practice in a specific medical specialty, such as internal medicine, surgery, or dermatology.  One of the best ways to know if your doctor has the qualifications to provide care in a specialty is to find out if he or she is Board Certified by the American Board of Medical Specialties.  I always look for this certification before making an appointment.

Licenses and disciplinary actions. Many US States maintain online databases where you can verify that a health care provider has an active license, and confirm that no official disciplinary actions have been taken against him or her.  An inactive license or a history of disciplinary action is a big red flag.  In some cases, disciplinary actions can be explained by mitigating circumstances but you should do your homework if you see one on a provider’s file.  

Commendations from peers.  In my city, Seattle, a local magazine conducts an annual “top doc” survey of thousands of local doctors.  Each doctor is asked: To whom would you send a loved one for medical care?  The doctors who end up on the final ‘top doc’ list have been selected by their peers as among the very best in their fields.  Most of my doctors have been, or are currently, ‘top docs’.  In locations where such a list does not exist, you can improvise by asking a trusted physician or health care provider in-the-know this same question.

On the other hand, beware of doctor review websites.  You’d think they might be a great source of information.  But in reality, most are unreliable because they are based on only a few reviews, typically from patients who have had either wonderful or awful experiences.  One study showed that only 3% of patients have ever posted an online review of their doctors.  Until these sites are used more widely, they will continue to be inherently untrustworthy.

There is no single factor or information source to lead you to the best possible choice.  But many clues are out there, if you take the time to look for them. 

  

Resources

The website DocFinder contains the licensing background and disciplinary information of physicians and other health care practitioners in addition to physician profile information from US States that have passed physician profile laws.

http://www.docboard.org/aim/

American Board of Medical Specialties maintains a database of board-certified physicians.

https://www.certificationmatters.org/is-your-doctor-board-certified/search-now.aspx

Seattle Magazine’s Top Doctors 2012.

http://www.seattlemag.com/article/top-doctors-seattle-2012-big-list

Turning towards your pain

It’s been another week on the new eating plan, and my knee pain is still absent.  I am becoming increasingly convinced that the connection is inflammation (or, more accurately, lack thereof).  We will see how things develop as rowing season begins in ernest in the Seattle area.  (Lately, the weather has been too cold and miserable for fair weather rowers like me to venture onto the water.)

Diet is not a panacea for all types of pain, to be sure.  Today, I will offer some perspectives on how to live successfully with pain that does not remit so easily.

As discussed in the previous blog post, Pain, our BFF,  pain is an inevitable part of the human condition.  And for many of us, pain becomes chronic at various points in our lives.

When pain is chronic, we often create an inner dialogue about what we are experiencing.  “I am so out of shape, it’s no wonder I threw out my back.”  “Maybe something is really wrong that the doctors have missed.”  “I don’t know how much more of this pain I can take.”

Emotions also are often overlaid onto pain.  Sadness, fear, and my specialty, anger, are common responses.

So pain becomes more than pain.  It turns into the sensory experience plus the running inner dialogue plus the negative emotions.  No wonder we find it so exhausting!

What is the solution?  In the words of Jon Kabat-Zinn, founder of the Mindfulness Based Stress Reduction program, you need to “put out the welcome mat” for your pain.  Not because you’re masochistic, but because your pain is already there.  You might not like your pain, but learning to accept its presence (because it’s already there) is the first step in disentangling your sensory experience from all the negative thoughts and emotions.

Try this.  The next time you have pain, find a quiet place to sit or lie for a few minutes.  Take a few breaths to center yourself and quiet your mind.  Next, turn your attention to the area of your body where you are experiencing the pain.  As objectively as possible, observe the pain you are experiencing.  First, try to identify its precise location.  Where exactly in your body do you feel the pain?  Zoom your attention to its center.  Next, try to identify its borders.  Where does the boundary lie between pain and no pain?  Does this boundary change with time?

After you have located your pain, turn your attention to its qualities.  Is it dull or sharp?  Steady or throbbing?  Do its qualities change over time?  Go inside your pain.  Observe it moment by moment, staying non-judgemental all the while.  Think of yourself as a scientist or an explorer of the inner world of your pain.

Stay with your pain for a few minutes more, observing its location and qualities as they unfold over time.  You will probably find that your pain is not static, but rather dynamic, transforming in character and intensity even within the few minutes of this exercise.      

According to Jon Kabat-Zinn, if you move into pure awareness in the midst of pain, even for the tiniest moment, your relationship with your pain is going to shift right in that very moment.  By seeing the pain for what it really is, stripped of the negative thoughts and feelings that usually accompany it, it becomes immediately more manageable, more livable.  The sensory experience of pain might still be present, but the suffering is diminished.  Directing conscious attention towards softening and releasing the area of pain (even by the tiniest fraction) in these moments often brings additional benefits.

Some people resist trying this exercise. The notion of paying attention to the very thing that causes them so much suffering seems overwhelming at first.  This response is understandable: humans have a natural tendency to push away from their pain.  This exercise, in contrast, calls for the exact opposite response.  It invites people to get close to your pain, indeed, to inhabit their pain and recognize it for its true nature in that moment.

What does the evidence say?  A recent study found that participants in a single session of a mindfulness-based body scan reported less pain related distress and less interference of pain on social relations, compared with matched controls who did not participate.  A different systematic review of the effects of Mindfulness Based Stress Reduction interventions on chronic low back pain revealed similar and interesting results. Pain intensity did not decrease consistently as a result of the interventions, but pain acceptance did.  My reading of this evidence is that exercises similar to that described above do not necessarily reduce pain, but they do help people suffer less.  In the words of the Dalai Lama, "Pain is inevitable, suffering is optional."

Resources

Mindfulness Based Stress Reduction program website: http://www.umassmed.edu/cfm/stress/index.aspx

Audio clip and transcript from NPR entitled Meditation a Hit for Pain Management (2007): link

A book that changed my life: Jon Kabat-Zinn. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York, Dell Publishing, 1990.  Amazon link

Research cited in this post:      

Ussher M, Spatz A, Copland C, Nicolaou A, Cargill A, Amini-Tabrizi N, McCracken LM. Immediate effects of a brief mindfulness-based body scan on patients with chronic pain. J Behav Med. 2012 Nov 6.

Cramer H, Haller H, Lauche R, Dobos G. Mindfulness-based stress reduction for low back pain. A systematic review. BMC Complement Altern Med. 2012 Sep 25;12:162.

Diet and chronic pain: fact or fiction?

“We interrupt this previously-planned blog post to bring you this breaking news. Recent anecdotal evidence supports the notion that diet might have a big impact on chronic pain.”

That’s the 1960s-style news spot that is running through my head as I begin to write this post.  I was planning a different topic altogether, but a sudden aha! moment in the shower today compelled me to change my mind.

Specifically, as I was hurrying to get ready this morning, I gazed down through the lather to take note of my pesky right knee.  Normally, it makes its presence known on an ongoing basis. In recent days, however, it hasn’t been talking to me.  At all.  Strange.  Very strange.

As I ran through a mental list of what might account for this sudden change, I struck upon a distinct possibility.  In recent weeks, I’ve changed my diet.  Specifically, I’ve stopped eating food that contains added sugars, fruit, processed grains (wheat, flour, rice, etc.), or root vegetables (potatoes, carrots, etc).  My new diet consists mainly of lean meats, dairy, vegetables, nuts and legumes.  

I made this change because I’ve added a few pounds during 2012 that I want to shed.  (Never mind that so far I’ve lost almost nothing, while my husband, who isn’t even on the diet, has lost three pounds!) Pain was the last thing on my mind when I decided to change what I eat.

So what does science have to say about the food-pain connection? Most of the evidence comes from small studies.  Large-scale randomized trials (the gold standard of clinical evidence) haven’t been conducted.  Some experts speculate that certain diets – such as the one I am following – reduce inflammation in the body, which in turn lessens chronic pain.

The strongest known connection between food and chronic pain is through obesity.  Carrying extra weight puts tremendous strain on joints, especially in the spine, hips, and knees.  New evidence also suggests that obesity might fuel pain through the impact of fat cells on inflammation throughout the body.

Obesity is not a factor in my situation.  Honestly, I don’t know what to make of my lack of knee pain.  I would be the first to acknowledge that its connection to my dietary change might be ‘spurious’ (a favorite term of scientists – basically meaning not really true).  Stay tuned.

In the meantime, I’ve listed a couple of articles (below) that discuss the potential pain-relieving properties of certain foods.

AARP magazine, May/June 2011 issue, Pain-fighting foods: http://www.aarp.org/food/diet-nutrition/info-03-2011/pain-fighting-foods

Psychology Today, April 2011, Nutrition and chronic pain by Mark Borigini, MD:

http://www.psychologytoday.com/blog/overcoming-pain/201104/nutrition-and-chronic-pain

Want to keep your resolution this year? Get a plan.

Happy 2013!  With the New Year upon us, many of us choose to make resolutions of one form or another. According to Reuters, 87% of Americans will make resolutions for 2013.  Often, resolutions focus on improving some aspect of our health, our relationships, or our finances. Some examples: "This year, I am finally going to lose weight;" "I resolve to be more patient with my children;" "I will stop spending so much."

Despite our good intentions, the vast majority of us will not meet our resolutions. According to some research, fewer than 1 in 10 of us will succeed over time. 

Why are we so bad at keeping our resolutions? After all, we really want to lose weight, be less stressed, or whatever else we have promised ourselves.  In a nutshell, it's because we don't have a real plan.  Many of us fail to define what we really want to accomplish in clear, measurable terms.  On top of this, most of us don't know how we will get there.  We haven't thought about how we will deal with challenges or barriers to meeting our goals, or on the other hand, how we can reorganize things in our lives to make it easier to keep our resolutions.

Fear not: help is available. One of the best sources for clear, concise guidance is a book written by my colleagues, Sheri Pruitt and Josh Klapow. Living SMART: Five Essential Skills to Change Your Health Habits Forever is focused on health behavior like losing weight, or stopping smoking. But its core recommendations can be applied to any type of resolution that involves changing what you do on a daily basis.  

Living SMART uses the acronym S-M-A-R-T to describe the skills needed for success. I have taken the liberty of summarizing each of the skills below.

Setting a goal involves translating a general health goal to a target behavior.  For example, “I need to relax” could be translated into “I will practice relaxation exercises for 10 minutes, three times per day, and five days per week.”  One key aspect of goal setting, according to this approach, is to start with a target that is small and achievable, and then build slowly on success.

Monitoring progress is perhaps the most overlooked component of success. Self-monitoring, using a simple chart, can be used to track virtually anything you do, including exercising, eating, spending money, etc. Research has shown that self-monitoring has an impact, in and of itself, on the target action.  Watching progress visually on a chart becomes a type of reward in itself.

Arranging the environment for success means modifying the home or work environment to encourage new habits that you want to cultivate, and/or to discourage old habits that you want to decrease or eliminate altogether. For example, if you want to stop drinking sodas, remove these drinks from the home refrigerator and storage pantries. Or alternatively, if you want to walk more frequently, place walking shoes at the front door as a reminder. The possibilities for arranging the environment are almost endless and require simply thinking about ways in which your desired actions can be prompted while undesired actions can be made more difficult.

Recruiting a support team involves seeking the positive influence of family, friends, and others to help meet your goals. Identify buddies or peers, meaning people who who want to achieve similar goals, to provide camaraderie along the way. Supporters, meaning people who are not necessarily making changes themselves but who agree to support your efforts, also can be helpful.

Treating oneself involves setting rewards for meeting your desired goals. Rewards should be decided in advance, and should occur frequently at the beginning. They don’t need to be large or expensive -  bubble baths or watching a favorite show are examples of small treats that can be used. Over time, feelings of accomplishment and satisfaction often become rewarding in themselves.

This is a quick summary only.  Sheri and Josh's book goes into much greater detail about each of these skills and how to apply them.  I encourage you to read it in order to learn more about these concepts. 

The research is clear: if you want to keep your resolution, you need a real plan. Your plan must define your target behavior in clear terms, include how you will change your surroundings to encourage your resolution, involve the support of others, allow you to self-monitor your progress, and reward your actions along the way.