Workouts for Busy Parents

And now for some fun.

Original: http://www.artofmanliness.com/2014/12/08/baby-exercise-equipment/

Art of Manliness usually has some interesting and worthwhile stuff.

Fitness Experts at the Doctor's Office

Continuing to talk about how to improve the healthcare system (like I did here) there is another clear place for primary care to improve - exercise and fitness advice at the doctor's office.

Too many times I have had friends complain, legitimately, that the doctor just tells them to get more exercise and says nothing more about the topic. They just hope that this is enough. Or maybe there is a pamphlet. 

Exercise is too big a topic for most people to just jump right in because their doctor said so. And those who do are quite likely to overdo it, injure themselves and then stop exercising because last time they got hurt. (Commonly this is thinking that you have to do 30 minutes of cardio as a minimum; which is too much as a starting point for most folks -  I talk more about this here.)

Furthermore, most doctor's don't know what's involved in a complete approach to physical activity for health. Doing a lot of running, without any kind of strength training can cause injury and does little for some of the common problems of aging like muscle loss and osteoporosis. As I've said before, I don't fault the doctor's for not knowing everything. But it is a reason for primary care to have some fitness and/or PT component attached.

What people need is someone who can guide them through getting started with an exercise program. Doctors' offices are already incorporating dietitian's to provide nutrition advice, so let's add the other half of healthy living: physical activity. 

The emphasis of such a program should be on behavior change. A topic well-covered in my undergrad program. Basic exercise advice is easy. Helping a person make long-term changes to their life is different. It requires a different skill set. It takes a lot more than just a personal trainer certification.

UMass Boston's major in Exercise & Health Sciences has a mandatory track of classes in behavior change. Graduates from this program would be the ideal kind of person to add to the staff at a doctor's office. Because this person doesn't get paid like an MD they can spend more time with each patient. They would be dedicated to just one topic when they meet with the patient, unlike an MD doing a physical which has to cover every organ system of the body.

I'm going to see what I can do about just this as part of my time at the Institute of Health Professions. Health promotion and community outreach is a part of our the program at IHP. Perhaps I'll get to run a small pilot program. I don't know. 

PT as Part of the Physical

This post is not on-topic for this blog. Well, not obviously on topic. But I want to write about this topic anyways because it's a big part of what I want from my schooling and how I think I can improve the healthcare system. Big stuff.

I have this hypothesis. The hypothesis is that if a consult with a physical therapist was a part of the regular physical then we could improve health outcomes over the long-term.

Right now, almost all PT is treatment. There is almost no component of screening or prevention. The stuff I write about strength training and physical activity for wellness are more prevention work than most PT's can do. 

Our national profession organization, the APTA, my professors and others in the field are all well aware of this limitation. And their is a desire to improve the situation. That's part of why the switch to doctorates and self-referral are important to the future of the profession.

This Canadian physical therapist elaborates nicely on the topic.

If, as a part of every physical, you had an expert who checked out your posture and your gait (the way you walk) then hopefully we can spot problems while they can still be prevented. This consult could also include talking about workplace ergonomics since that will have a huge impact on a person's body over time.

Preventing even a small percentage of low back pain cases would be huge. Low back pain is the most common cause of missed work and represents a huge drain on people's lives and the economy.

Physicals weren't called annual check-ups where I worked, when I worked for a PCP. How often you needed a full health review was based on age and specific health conditions - health 20-somethings were only expected to get a physical every five years. Part of the experiment and study needed to validate my hypothesis would be figuring out how often makes sense, both from a health standpoint and an economic standpoint.

I'm not certain that this kind of screening and prevention will pan out to work well. But it seems likely. So I want to find out.

Grad School!

A few months ago I started grad school. This is has affected my posting schedule and will continue to do so for a while. But grad school is awesome, so it's okay.

I am attending the MGH Institute of Health Professions. Technically, the MGH does not stand for anything. In reality it is there because the school was created by Massachusetts General Hospital i.e. MGH. MGH can also stand for Man's Greatest Hospital, since MGH is one of the best hospitals in the world, both from a clinical, patient standpoint and also for research.

Dr. Steven Hirsch

Well, a doctorate in physical therapy (DPT). In our profession we don't normally call ourselves 'doctor'. But it's a three year program with a residency to cap it all off. A doctorate in PT means that patients do not need a referral to be seen - they can self-refer. In turn we are required to have the knowledge to know when a person needs a different kind of care - such as a surgical consult or neurology.

My favorite part of the Institute's program is the strong clinical focus. My first patient experience will be in only the second semester of the program (a month from now). And my first full-time clinical placement is just one year in. 

Brains! and the rest of the Body

The first class this summer was Gross Anatomy, which is  a full human cadaver dissection. We spent five hours at a stretch, two days a week, for eight weeks, teasing a cadaver apart. From head to toe. From the skin all the way through the bones. Every muscle. Nerves, blood supply, organs. Just about everything. It was great!

With an undergrad degree in exercise science I already had a good handle on the musculature, but it was still incredibly informative to go through and see every part. How it connects, how it works. To look at a tendon and say, "do you think these are the finger flexors?" And then find out by grabbing them and pulling on them, to watch the fingers actually flex.

Now I also have a mind-numbingly detailed picture of the nerves and blood supply for every muscle. A useful set of information for the diagnosis of all sorts of movement related problems.

Why a Doctorate?

First, because it's required now. Everyone graduating 2014 or later has to have a DPT and every current PT has to upgrade by 2020.

More importantly is the value of self-referral. 

I worked in a primary care office for four years, as a medical assistant. When folks came in with musculoskeletal complaints we did one of three things for them:

1. Refer them to PT
2. Refer them to Ortho for a surgical consult
3. Prescribe conservative treatment because it wasn't severe enough to warrant a referral

Of those, the PT referral was the most common. Around 90% it seemed. This wasted the patient's time. This wasted the patient's money. This contributes to the overwhelming and growing cost of healthcare in this country.

And it did nothing for the patient. 

Maybe we printed out a pre-made set of exercises for them to do until they got to PT. But the doctors, PA's and NP's who worked in internal medicine didn't have the expertise to say which of those exercises any particular person should do. 

One time as a patient I was handed a sheet describing exercises that required thera-bands to do. But that office doesn't have any bands and they didn't mention where to get them. And they certainly couldn't tell me which color to use. Luckily for me I happen own a set already, but I'm not most patients.

PCP's just aren't set-up for handling musculoskeletal injuries. That's not a criticism. At Harvard Vanguard Medical Associates, where I worked, the department was actually called Internal Medicine, instead of something like general practice or primary care. And that accurately described what we were good at. The diagnosis, treatment and management of diseases of the internal organs are a big part of healthcare especially as individuals age.

If a patient may need surgery or other non-PT treatment, then a doctor of physical therapy can refer them appropriately. If a patient doesn't need a course of PT then the physical therapist can still provide a better diagnosis and basic treatment info than a PCP. Perhaps just a handful of PT visits will be much better than no follow-up but not as costly and time-consuming as the typical 2-3 times per week for 8-12 weeks that is standard for outpatient PT.

Conclusion

If you can, then skip the primary care office and go straight to a DPT for any musculoskeletal injury. This is mostly a question for your insurance company. It is still the case that many insurance plans require a referral before they'll cover PT. 
 
But you can always call and ask your regular doctor and see if you can skip the visit and just get a referral. Especially, if you've been seeing the same doc for a while and have needed PT before. And tell them you're an athlete, this will make them more likely to trust your instincts on the matter and to expect that your needs exceed their capabilities.

So, that's what I'm doing and why.