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What Can Weekend Warriors Learn From Elite Athletes?

For this week’s CBS Doc Dot Com segment, I thought I’d cover something completely non-controversial: what can weekend warriors learn from elite athletes? But I’m starting to believe that in this era of evidence-based medicine, nothing may be truly knowable. I went to the studios of the world famous Ballet Hispanico in New York City and spoke to athletic trainer Megan Richardson. She took me through the motions, emphasizing the importance of warming up and stretching in preventing injury. It sounded good and it felt good. But proving in the medical literature that it’s effective is another thing. An online search quickly produced multiple conflicting reports and advice: stretching definitely works, stretching definitely doesn’t work; stretching only works if you do it my way. Click here for a sampling:

PubMed:Warm-up And Stretching PubMed: Stretching Perspectives BioMed Central: The Effects Of Stretching

My friend and CBS colleague, Richard Schlesinger, offered his solution. ”I get around it by neither stretching nor exercising.” Had I listened to Richard, my blog post would have ended right here. But I figured I needed at least one more paragraph so I contacted a true expert on the subject, Ian Shrier MD, PhD, a specialist in sports medicine and Associate Professor at McGill University. He has a PhD in physiology and is Past-President, Canadian Academy of Sport Medicine. He’s not a huge fan of stretching right before exercise.

“First, the stretching, whether with or without warmup, does not improve performance. It makes you run slower, jump not as high, and makes you weaker.” And “stretching definitely can hurt people if you overstretch; people do it all the time if they force the stretch.”

He added, “I don’t think it hurts you in general if you do it properly but it doesn’t prevent injury.” He’s more supportive of stretching at other times, including after exercise, saying, “Regular stretching at other times is beneficial. It makes you stronger, jump higher, etc, and there are three studies suggesting it reduces injuries as well, although the results were only significant in one.” He adds that “stretching is analgesic; it allows you to put your muscle through a wider range of motion without feeling tension. And that may be why ballerinas say that stretching helps them.” Dr. Shrier spells out his take on the subject in detail in a chapter called
Does stretching help prevent injuries?

For me, Dr. Shrier’s most interesting advice, especially for weekend warriors, was about the importance of warming up. He explained that muscles need energy to function properly. Energy is mainly produced inside of cells in structures called mitochondria. When you are resting, your mitochondria power down. During exercise, it takes awhile for the cell to rev up the enzymes needed for breaking down fat and carbohydrates for fuel and for using oxygen to make energy from that fuel. If you start running at full speed without warming up, your body will produce lactic acid. Lactic acid can impair muscle function for awhile, preventing you from sprinting efficiently at the end of the race.

So Dr. Shrier suggests gradually warming up. He estimated it takes about 3 to 5 minutes to efficiently go from one level of exercise to the next – for example, going from rest to a ten minute mile or going from a ten minute mile to a seven minute mile. If you go for a jog, “you walk, then jog slowly, and then pick it up. Elite marathoners might go for a fifteen to twenty minute jog before they run a marathon. That allows them to run faster at the beginning of the race. They run the second half of the marathon faster than the first.”

In summary – and I suspect that I am the first person today to tell you this – don’t outpace your mitochondria.


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What Hospital Credentialing Looks Like

Bad news? At least 47 different signatures.

Good news? It arrived mostly prefilled. Over 100 pages.

*This blog post was originally published at GruntDoc*

Are Health Policy Experts Anti-Physician?

Health policy experts have never been shy about their antagonism towards doctors.

The focus now appears to be on physician pay, with the Washington Post’s Steven Pearlstein, for one, continuing his anti-physician columns. Derek Thompson, over at The Atlantic (via @AllergyNotes), continues the assault, with a recent blog entry wondering if doctors deserve to be paid less.

I touched upon this topic last year, in a USA Today op-ed, Doctors’ pay cuts save little in health care costs, and paraphrased prominent Princeton economist Uwe Reinhardt saying that cutting physician pay 20 percent will only result in 2 percent of health care savings. And besides, if the current system stays in place, doctors whose pay is cut will simply respond by doing more procedures.

Furthermore, many health policy experts bring out the tired statistic comparing American physician salaries with those abroad. The problem is that these are not apples-to-apples comparisons. Both the cost of medical school and malpractice insurance are exponentially higher Stateside. Fully subsidize medical school and bring malpractice premiums down to the levels of other countries first, before talking about tackling doctors’ pay.

Until then, comparing physician salaries with those in Europe is a largely meaningless exercise, and only serves to expose many health wonks’ innate contempt for the medical profession.

*This blog post was originally published at KevinMD.com*

I See You In A Different Light

squishycapWell, somebody likes their job, I must say.

Although I can’t figure out why she is smiling.

Her cap looks like conjoined coffee filters!

Conjoined coffee filters that somebody sat on!

Maybe she doesn’t realize it’s squished, and would die of embarrassment if she knew!

********************

The emergency department “regular”.

Every emergency department has them.

A patient can become a “regular” for many reasons. Maybe they are a recurrent cardiac patient. Perhaps they suffer from chronic pain. Sometimes, they become a “regular” because they utilize the ER as a clinic and bring the whole family in over the course of a month. Some regulars are drug seekers. Others are homeless and know they can find respite in the department for at least a couple of hours and maybe get something to eat.

If you work in an emergency department long enough, you will know who they are.

And you will get to know them.

*****

Recently, it dawned on me just how well you get to know them.

I work in a community hospital. It’s one of those hospitals that patients actually request to go to from all over the county. We have our shifts from hell, but it is far from the county-trauma-eight-hour-wait-time environment of the huge medical centers. There is time to talk to the patients, find out more about them than what hurts, what is swollen or what prescription they have lost.

Over time, the conversation stops being scripted and “starts getting real”, as they say.

*****

This particular shift was steady, but not crazy. And almost all the patients I cared for were “regulars”. Easily 90%. For some, it was their usual health issue. For others, something different.

I found out a lot that night over the course of that shift

Someone’s youngest would be starting kindergarten in September; someone’s oldest had just graduated from high school. Someone had gotten into a recovery program and had been clean for a month. Someone had just welcomed their first grandchild, another was mourning the loss of their mom the week before. Someone had lost their job earlier in the week. Someone had gotten married since their last visit. A baby sister was on the way for one of my patients. Another patient had enrolled in the local junior college.

We saw them, treated them and sent them on their way with a wave and a prescription.

Hopefully they left in better shape then they arrived, even if all they needed was reassurance.

All I know is that I thoroughly enjoyed that shift.

*****

I had done all the usual things.  Saline locks, blood draws. Medications and re-evaluations. IVs and education.

But I had also congratulated success, commiserated over frustrations and offered consolation over losses. We covered birth and death, struggles and successes, dropping old lifestyles and starting new beginnings.

That shift, I saw my patients in a different light.

*****

The best part of nursing has nothing to do with disease or diagnoses or procedures or prescriptions.

The best part of nursing is the patients themselves.

I thoroughly enjoyed catching up with my “regulars”.

I hope I was therapeutic for them.

They were most certainly therapeutic for me.

*This blog post was originally published at Emergiblog*

Is It Safe For Naturopaths To Prescribe Drugs?

I am a terrible Oregon chauvinist.  I think there is no better place to live on the planet. Period.  Great natural beauty, not a lot of people, best beer ever and no pro football team. Oregon is both casual and tolerant.  It is safe to say that dressing up in the Pacific NW means tucking your t shirt into your jeans.  And the citizens of the NW, especially in the Portland metro area, are tolerant of  a diverse number of alternative life styles. What more could you want?

No good deed goes unpunished. The downside of toleration is the proliferation of alternative medicine.  Portland has  a school of chiropractic, a college of oriental medicine and  the country’s oldest school of naturopathy, established in 1956.  It is a year older than me. There are about 850 ND’s in Oregon.  To judge from the number of alternative practitioner offices around my hospital,  most of the graduates stay in Portland.

There are five health care systems in Portland.   Three of the five have hired naturopaths as part of their complementary medicine programs.   My system, as of yet, does not have a scam practitioner on staff, a fact of which I am most proud.  Yet,  I suppose it will come some day. However, if you wonder if a hospital practices evidence and science based medicine, see if they have a naturopath, a chiropractor or an acupuncturist on staff.  If they do, they may be interested in issues other than providing quality health care.

Oregon has had a Board of Naturopathic physicians since 1929 to oversee naturopathic practice.  There has been a long tradition of legislative oversight of naturopathy in Oregon, but they have been able, until recently, to only prescribe medications that are naturally derived.  None of that synthetic nonsense for naturopaths. Natural products only.  Until this month.

In Oregon, naturopaths are no longer limited to natural, herbal and homeopathic concoctions, they can also prescribe substances that actually work.  Recently House Bill 327  was passed by the Oregon legislature to expand the prescriptive privileges of naturopaths.  Drugs can now be added to the naturopathic  formulary just by asking.  The bill was passed by the Senate 22-7 and the House unanimously.  Bummer. If you live in Oregon and want to pester your representative on their profound stupidity, a list is at  http://gov.oregonlive.com/bill/SB327/. Send them a link to this post.

As a “shill for big pharma and a tool of the medical-industrial complex,” I suggest this may not be such a  good idea.  Naturopaths do not have the training, experience  or understanding of medicine to safely prescribe medications. Their understanding of disease and the various therapies taught at naturopathic schools are antithetical to what is required to safely and knowledgeably  prescribe modern medications.

To give prescription medications correctly and safely, one needs to understand anatomy, physiology, pharmacology and the pathophysiology of diseases.  Real medical providers (MD’s, DO’s, NP’s and PA’s)  have to have not only years of education in school, but a residency or other training to be able to appropriately use these medications.

What is a naturopath and what is their education?

First the Philosophy of Naturopathy.  Read more »

*This blog post was originally published at Science-Based Medicine*

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