tag:blogger.com,1999:blog-79597168263355950672024-03-13T22:11:28.021-07:00eDocAmericaUnknownnoreply@blogger.comBlogger126125tag:blogger.com,1999:blog-7959716826335595067.post-63742232698193779212014-07-24T06:57:00.001-07:002014-07-24T09:16:02.893-07:00UAMS Steps Up its Support of Primary Care by Creating a Service Line (and I have a new Job)UAMS has initiated a Primary Care Service Line and I have accepted their offer to lead it. It is an exciting time for us and for me personally, after over 25 years in my current job as Executive Associate Dean for Clinical Affairs. Here is a copy of the announcement that went out yesterday:
Dear Colleagues:
We are pleased to announce that Charles W. Smith, M.D., has accepted our offer to be the Director of the Primary Care Service Line. In addition, he will also serve as the Medical Director of the Service Line. Due to the opening of our new distributed clinics, we are accelerating the startup of the Primary Care Service Line in order to adequately support these clinics. Eventually, all primary care services sponsored and supported by UAMS will be a part of the service line.
As founder of the UAMS Center for Primary Care, Dr. Smith has been focusing increasingly on this vital component of our clinical enterprise in the past few years. In his new post, he will oversee planning, development, and implementation of the service line, which includes working with the Chairs of the various primary care oriented departments, recruiting and appointing the administrator of the service line as well as the clinic directors, serving as a member of the Council of Service Line Directors, and numerous other service line duties. In his new role, he will report through the Chief Service Line Officer to Dr. Townsend, the Vice Chancellor for Clinical Programs.
Dr. Smith is ideally suited for this new role. He has worked in various roles to promote clinical programs and clinical teaching in the College of Medicine and UAMS for the past 25 years. He joined the faculty as a Professor in the Department of Family and Preventive Medicine and Associate Dean for Clinical Affairs in 1989 and was promoted to Executive Dean in 2007. For a number of years, he served in both Associate Dean role and the UAMS Medical Center Medical Director roles. While he will begin service line duties immediately, he will gradually transition out of his current role as Executive Associate Dean by the end of this calendar year.
Among many accomplishments, Dr. Smith established the Physician Relations Office to improve processes for referrals and communication with referring physicians. A key component of the office is the UAMS Associates Program, which coordinates annual visits by staff liaisons to 750 referring physicians in Arkansas to provide information and hear and relay their concerns to campus leadership. Dr. Smith also founded the Diagnostic Clinic for referrals.
Dr. Smith’s dedication to providing more effective health care for Arkansans kindled his longtime interest in electronic medical record (EMR) implementation and facilitating the use of web technology. He chaired the implementation committee for the campus’ first EMR system and has remained an active leader in EMR adoption, including the comprehensive EPIC system.
Dr. Smith has been a leader in the development of a patient portal, online physician consultation and online call schedules. In 1997 he founded an award-winning, web-based medical information company, eDocAmerica, a UAMS BioVentures-supported startup that provides patients with tools, information and input from medical professionals to help individuals make better decisions about their health and health care.
Dr. Smith is a founding Co-Editor in Chief of the Journal of Participatory Medicine, an online, peer-reviewed journal of the Society of Participatory Medicine. He has served as President of the American Board of Family Medicine, Deputy Editor of American Family Physician, and Chair of the Association of American Medical Colleges Group on Faculty Practice. He has published many articles in his field and co-authored a book, the Handbook of Family Practice.
Prior to his recruitment to UAMS, Dr. Smith was Dean of the School of Primary Medical Care at the University of Alabama School of Medicine in Huntsville. He received his medical degree from the University of North Carolina in Chapel Hill, where he completed his family practice residency.
Please join us in welcoming Charlie to his new post.
G. Richard Smith, M.D. Roxane A. Townsend, M.D.
Dean, College of Medicine Vice Chancellor for Clinical Programs
Executive Vice Chancellor, UAMS CEO, UAMS Medical Center
Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-74903350406642915872013-07-19T08:22:00.002-07:002013-07-19T08:22:51.132-07:00You Can't be Healthy if you don't ExerciseThis morning, one of my colleagues admitted: "Charlie, you know I don't work out". Even though she seems healthy, I immediately replied: "You know, you can't be healthy, if you aren't involved in a regular exercise program!" <br />
<br />
Do you agree with me that this is true? Most of my patients and friends do, but many of them claim a variety of reasons for not doing it. <br />
<br />
Perhaps the most common reason I hear for a lack of regular exercise is not having sufficient time. But my answer to you is that no one has time, they just have to make it. How can you do this? By just scheduling your exercise session and dropping everything else to do it. After all, what is more important than improving and safeguarding your health? I believe those that do not have enough time to exercise simply aren't putting this high enough on their priority list. As for me, I found that if I don't get up early and get my workout in before I leave for work, I have a lot of trouble juggling personal and family needs when I get home in the afternoon. If becoming and staying healthy is truly important to you, it is worth adjusting your daily schedule to ensure 30 min or more of aerobic exercise on at least 5 days of the week.<br />
<br />
One of the other very common reasons I hear for not exercising is people telling me that they are too tired. However, exercise is actually a good <a href="http://www.acefitness.org/article/2742/">treatment for fatigue</a>! Researchers at the University of Georgia found that persons who exercised for at least 20 minutes at least three times a week for 6 weeks were much less likely to report fatigue than those who didn't exercise.<br />
<br />
It's never too late to get started with this program. If you are currently sedentary, you should start slow and work up to 150 or more minutes per week of aerobic exercise. Increase your duration and intensity by about 10% per week until you reach your goals.<br />
<br />
So, get on board and get healthy!<br />
<br />
Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com1tag:blogger.com,1999:blog-7959716826335595067.post-28642987793775549612013-06-09T15:58:00.001-07:002013-06-15T06:05:15.834-07:00What is a Vacation Anyway?What is your idea of a vacation? <br />
<br />
Most consider it to be a week or two (or more) of kicking back in the pool or on the beach. My wife, Connie, and I returned today from a week in our house in Fayetteville, AR. Our idea of a relaxing week away from the grind of everyday life may strike you a bit differently than the traditional vacation. We enjoy our own version of a week of fitness "boot camp". Well, it may not be THAT intense, but it certainly is active. We wake up early, eat breakfast and walk for 2 1/2 hours, with our Golden Doodle "Dolly" in tow. This usually includes a cinnamon roll break at the Little Bread Company, one of the coolest little places you have ever seen and, currently, rated the # 1 eating establishment in Fayetteville. It is essentially a hippie joint where the employees all seem happy and the ambience of the place puts you in a great mood. On our way back to our house, Dolly terrorizes 3 or 4 squirrels in the center of the U of A campus. <br />
<br />
Before lunch, we load a yoga video for 20 to 30 minutes before replenishing for the afternoon. These are devoted to biking on our tandem. Fayetteville, courtesy of the Waltons, is almost finished with a dedicated walking/biking path from Fayetteville to Bella Vista, AR, a distance of about 35 miles. It is called the Razorback Greenway. Since it not yet quite finished, we spent most days doing about a 25 mile loop from Lake Fayetteville to south of town but, one of the days, we drove to Spingdale to take in the northernmost aspect of the Greenway through Bentonville and the Crystal Bridges grounds to Bella Vista, AR and back.<br />
<br />
As a side note, we were there during the annual Wal Mart associate/shareholder meetings and the scene is interesting, to say the least. There are Wal Mart workers from all over the world there, hosted in student dorms and transported around campus by golf carts and buses. While I was in Sam's buying a TV, one came up and asked me if I needed help (I did). I asked him a question he couldn't answer and then I realized he was a Wal Mart associate visiting from South Africa. The event was hosted by Hugh Jackman and featured concerts by Elton John and Jennifer Hudson. Interesting company, Wal Mart!<br />
<br />
About mid week, we decided it was time to take in Crystal Bridges in Bentonville, founded by Sam Walton's daughter, Alice, and regarded as one of the premier art collections in the world. To say it is impressive would be a gross understatement. We are not aficianados but it was very nice and well worth the afternoon we spent seeing it.<br />
<br />
Evenings were time to dine out and Fayetteville has diverse, excellent cuisine from Taste of Thai (our favorite) to Celi's Mexican and, the last night Theo's with great salads, wine and Filet Mignon. We had early dinners, so we would have time for wine and music (courtesy of Pandora) on our deck at home. A little TV, then to bed and do it again tomorrow.<br />
<br />
We came back a little tired and sore, but very relaxed, refreshed and ready to resume "normal life" tommorow. <br />
<br />
Does that sound like a vacation to you? It certainly does to us!Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-69579914998509956872013-06-02T05:55:00.000-07:002013-06-02T05:59:59.957-07:00The Scope of Participatory Medicine--Does it really include Everyone?Several of my colleagues recently joined me in writing a new chapter to add the White Paper: "<a href="http://e-patients.net/e-Patients_White_Paper.pdf">E-Patients. Can they help us heal Health Care</a>?. This chapter was recently published in the on line <a href="http://www.jopm.org/">Journal of Participatory Medicine</a>, titled "<a href="http://www.jopm.org/opinion/commentary/2013/05/16/a-model-for-the-future-of-health-care/">A Model for the Future of Health Care</a>". The paper describes a health care system where patients and providers participate as partners, with patients largely in control of their own health. The authors encourage you to open the link, read the paper and add your comments at the end of the paper. We would benefit from your feedback!<br />
<br />
I asked several friends and colleagues to read and comment on the paper and the responses I got were interesting and a little unexpected. To summarize, they said: "This is all well and good, but some patients, even educated ones, just aren't interested in the "participatory" model". Their point was that many patients trust their providers and don't have the energy or motivation to do on line research, prepare questions for the office visit, or even track their own lab results. They just want to visit their doctor periodically and hear their recommendations and follow them!<br />
<br />
The other feedback theme was that there are still many patients who don't have the health literacy or the technological wherewithal to function as participatory partners in their health. These are the disabled, poor and disenfranchised. They don't have smart phones, data plans, lap top computers, ipads or wireless internet access. Many of them hardly know how to read, much less understand the often complex health discussions found online.<br />
<br />
So, in spite of an engaged, activated, increasingly empowered cadre of e-patients out there, those of us in the Participatory Medicine movement have a big problem we need to address: What do we do about the able but unmotivated, uninterested group and how do we addressthe poor and disenfranchised?<br />
<br />
Your thoughts, comments, and expressed opinions are greatly appreciated!Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-89036781239809126222013-02-18T12:34:00.003-08:002013-02-18T12:34:38.831-08:00Sometimes, the Best Care is to do NothingThe dynamics, interactions, and expectations that are played out in the office between doctor and patient can lead to some uncomfortable moments. Most of the time, as a provider, I feel the need to obtain some test or order new medication to address the patient's issues. Often, the provider feels obliged to prescribe something, or to obtain a study, even when there is no a clear indication for doing so. This may be an attempt to provide a satisfactory encounter or to avoid professional liability risk. Often, appropriately, the provider may be simply giving the patient the benefit of the doubt. However, it may be a disservice to the patient to prescribe a test or medication if the doctor believes it isn't necessary. We should, as providers who are committed to high quality care, renew our commitment to carry out the most appropriate course of action, regardless of whether that may lead to an awkward moment with the patient. Here are a few simple illustrative examples:<br />
<ul>
<li>Patient has respiratory illness, probably viral, but requests antibiotic treatment.</li>
<li>Patient has headache, probably tension, but feels a CT scan should be ordered "for good measure".</li>
<li>Patient has chest pain and chest wall tenderness, but gets admitted to "rule out" a myocardial infarction.</li>
<li>Patient has fatigue and mild depression, with "low normal" testosterone level, and asks you to prescribe testosterone supplement.</li>
<li>Patient has had trouble losing weight with dieting and requests amphetamines for weight loss to "jump start" the process.</li>
</ul>
These are representative examples, but there are many other scenarios in which the cost or risk of side effects from the treatment likely outweigh the potential beneficial effects. It is often tempting, rather than taking the time and effort to explain the reason why "a" or "b" is not needed, to go ahead and provide the prescription or order the test, then move on to see the next patient. When we do this, we not only do the patient a disservice, but we contribute to the unsustainable cost of health care.<br />
<br />
I consult a variety of financial, legal, and other professionals expecting them to render their honest appraisal and recommendations. If this is a recommenation <strong>not</strong> to do something, I would certainly accept, and appreciate their candor; as a doctor I should do no less!<br />
<br />
Your comments and dissenting opinions are always welcome!<br />
Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-31890986615501890542013-01-25T08:55:00.002-08:002013-01-25T08:55:05.866-08:00What to Do If You Have the FluFlu season is in full swing this year, with thousands of Americans
suffering from its symptoms. The Centers for Disease Control (CDC) has
estimated that an average of 36,000 people in the U.S. die from
influenza or from its complications each year. Influenza is particularly
hard on the elderly, people with a weakened immune system, children,
and those with chronic illnesses, such as emphysema and diabetes.<br />
<br />
<a href="http://3.bp.blogspot.com/-hx8pERWVrRE/UQK4FVm4OCI/AAAAAAAAAuU/F1abh4W_iyk/s1600/20130123Pic1.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="http://3.bp.blogspot.com/-hx8pERWVrRE/UQK4FVm4OCI/AAAAAAAAAuU/F1abh4W_iyk/s1600/20130123Pic1.jpg" /></a>Several
weeks ago, a Health Tip went out encouraging everyone 6 months or older
to receive the flu immunization. As expected, most of this year's flu
cases have occurred in those who were not vaccinated. Unfortunately,
getting a flu shot does not guarantee that you will not get the flu.
While immunization remains the most effective way of preventing the flu,
recent statistics from the CDC indicates that the effectiveness of the
vaccine this year is 62%. This means that if you received the vaccine
you are about 60 percent less likely to get the flu, but not completely
immune.<br />
<br />
<b>How do you know if you have the flu?</b>
Mild cases of the flu can be similar to a common cold, but typically,
the flu is much more severe. Muscle aches, severe fatigue, cough and
headache predominate over common cold symptoms of runny nose and sore
throat. Characteristic of the flu also is fever (100-102 degrees F)
that can last for three to four days. Of particular concern in those
who contract the flu are its complications, including bronchitis and
pneumonia, which are responsible for the majority of flu-related
hospitalizations and deaths.<br />
<br />
<b>What you can do for the flu?</b>
Most people with the flu end up being miserable for a few days, but
recover on their own. A number of non-prescription medications, while
not treatments for the virus itself, can help with flu symptoms.
Over-the-counter medications and self-care measures include:
<br />
<ol>
<li>Limiting activity and getting plenty of rest.<br /></li>
<li>Staying hydrated by drinking water, sports drinks or electrolyte replacement fluids.<br /></li>
<li>Gargling salt water (1 : 1 ratio) or using throat lozenges for sore throat.<br /></li>
<li>Taking acetaminophen (e.g. Tylenol®) or ibuprofen (e.g. Advil®, Motrin®, others) for fever or muscle aches.<br /></li>
<li>Taking decongestants (Claritin-D, Sudafed, others) can ease discomfort from stuffy nose, sinuses, ears, and chest.<br /></li>
<li>Using cough medicine or cough drops for temporary relief from coughing.</li>
</ol>
It is important that aspirin be avoided in anyone under the age
of 18 with the flu because of its association with Reye syndrome, a
condition affecting the nervous system and liver. In most people,
medical attention or antiviral drugs are generally not required.<br />
<br />
<b>When should someone seek medical attention?</b>
People at increased risk of serious flu-related complications,
including young children, elderly persons, pregnant women and people
with chronic illnesses, such as diabetes, should contact their medical
provider with the first signs of an influenza infection. Emergency
warning signs in children include difficulty breathing, bluish skin
color, extreme irritability, inability to keep food or liquids down, and
high fever. Adults with shortness of breath, confusion, chest or
abdominal pain, and persistent vomiting should receive urgent medical
care. Someone in whom flu symptoms improve initially but later develop
worsening cough and fever may have a bacterial infection and should
receive medical attention.<br />
<br />
<b>What is the doctor able to do?</b> Antiviral medications are modestly effective in shortening the duration of the flu
and may help to avoid complications. For these to work effectively, however, it
is important to start treatment within 48 hours of the development of symptoms.
Below are antiviral medications approved for treating adults and children one
year and older:
<br />
<ol>
<li>oseltamivir (Tamiflu)<br /></li>
<li>zanamivir (Relenza)<br /></li>
<li>amantadine (Symmetrel)<br /></li>
<li>rimantadine (Flumadine)</li>
</ol>
In December 2012, the U.S. Food and Drug Administration expanded
the approved use of oseltamivir for treating children between the ages
of 2 weeks to one year. Antibiotics used for bacterial infections, such
as Ampicillin, Keflex, Cipro, etc., are not used to treat uncomplicated
cases of the flu. These may be required, however, with certain
flu-related complications, such as pneumonia or ear infections.<br />
<br />
<b>When can I return to work or school? </b>The
Centers for Disease Control recommends that people recovering from the
flu stay at home for at least 24 hours after their fever is gone. While
at home, flu victims should avoid contact with others in the household
to keep them from getting sick. Also, frequent hand washing will help
to keep from infecting others. <br />
<br />Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-76456740295252452352013-01-20T06:18:00.001-08:002013-01-20T06:18:58.481-08:00Is it Possible to Really Receive "Whole Person" Care?This week, along with a psychologist colleague, Chris Rule, I began a Balint Group with senior Family Medicine residents at the University of Arkansas. This approach was inspired by <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1464079/">Michael Balint</a>, a general practitioner in London who led groups of GP's along with his partner and wife Enid at the Tavistock Clinic in the late '40's and early '50's.<br />
<br />
Balint explored concepts such as the "collusion of anonymity", in which he decried the tendency of specialists to pass patients around to each other with no one caring for the whole patient. So, through the use of these groups, and the use of case presentations with discussion, he set out to deeply explore the nature of the doctor-patient relationship and to encourage his colleagues to "go deeper", to "listen to patients in a new way" and to recognize that much of the value of being a primary care doctor had nothing to do with ordering tests, writing prescriptions or assigning a physical diagnosis to every symptom.<br />
<br />
He noted that, time after time, the groups' patients "offered" up a symptom and the doctor "accepted" it, in a sense allowing that process to thwart the opportunity to explore what was truly going on with the patient. This process in no way means that the physician seeks to find a psychological cause to all symptoms but it does suggest that no one in the health care system is as well positioned to integrate psychosocial issues with biological issues to truly provide whole person care. To do this, the physician must learn to truly listen to patients, without jumping to a diagnosis or treatment approach too soon to get to the real issues. <br />
<br />
This is why I went into Family Medicine and why, after 39 years of training and practice, I am still inspired to go to work every day. I'm still learning how to get better at talking to, and understanding, patients. And, I thank mentors like Michael Balint for providing the model for integrating medicine and psychology for us.Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-21646633915367200192013-01-06T07:02:00.000-08:002013-01-06T07:02:13.505-08:00Is Your Doctor Reconciling your Medications?The Institute of Medicine’s (IOM) seminal study of preventable medical errors estimated as many as 98,000 people die every year at a cost of $29 billion. Everyone who is taking medications should be concerned about the adverse potential of medication side effects, as well as problems due to drug interactions. The Joint Commision, recognizing the risks of medication use, has begun to place major emphasis in its surveys of hospitals on a process called "medication reconciliation". <br />
<br />
Medication reconciliation involves a detailed review of current medications and doses, including assurances that the patient is taking the medications and doses as listed in the record. This process is especially important during transitions of care such as at the beginning of a hospital admission, transfer of a patient from one unit to another, from surgery to the medical floor, or upon discharge from the hospital. It is also important, during routine visits to the doctor and, whenever a new medication is listed, determination made that no adverse interactions are likely with the new combination.<br />
<br />
I strive to reconcile medications at every patient's visit with me. This may occur during annual preventive care visits or during follow up visits with patients who have chronic disease states such as diabetes or hypertension. The process also needs to include over the counter medications and supplements, in addition to any prescriptions provided by another physician. I am continually amazed that, in virtually every visit, a patient's medication list requires at least one or more modifications. I am also amazed that, whenever I see someone else's patient, the list is frequently woefully inaccurate and, in many instances, appears to have never been reconciled.<br />
<br />
What, then, is the point of this article? It is to make patients more aware of the importance of medication reconciliation and challenge you to become an active partner in the process with your primary care physician. How can you do this? Many clinics print out a medication list for review when you check in to the clinic. If this is not happening, I suggest requesting it from your team. Additionally, it will be helpful for you to bring a list of the medications and doses that you are currently taking, as this will provide a helpful and accurate tool for the nurse or physician to use to "reconcile" your medication list. <br />
<br />
A brief list of the various actions that may result from this process will illustrate the importance of medication reconciliation:<br />
<br />
1. Elimination of drugs that the medical teams think you are taking, but aren't.<br />
2. Identification of, and deletion of, medications that could be causing a dangerous drug interaction.<br />
3. Elimination of drugs to which you may be allergic.<br />
4. Drug by drug review of potential side effects you may be experiencing.<br />
5. Addition of drugs provided by another doctor that your primary physician did not know you were taking.<br />
<br />
You can become a more active participant in your own health care by assisting, or initiating, the process of medication reconciliation and making sure it happens with every visit to your doctor. <br />
<br />
Your comments or opinions are always welcome.Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-91275772089839681302012-11-18T06:21:00.000-08:002012-11-18T06:29:09.246-08:00What can patients expect after Health Reform?Big changes are on the horizon for the health care system. Physicians are going to be paid increasingly on the basis of outcomes of care, as well as effectively managing their practice population as a group; for example for all of the patients in my practice with diabetes, what is the average blood sugar of the group and, thus, how good a job am I doing "controlling" the disease state "Diabetes" in our practice? Less and less can physicians expect to be paid for doing more tests, ordering more x rays and CT scans, and seeing patients in the office more often. Instead, we will have greater incentives to be available to our patients, to work more effectively as a health care team, to communicate with patients about their test results outside of office visits, and to encourage patients to contact us via e mails, text messages, or online video tools. <br />
<br />
These changes will provide major challenges to all of us, and will pose requirements for changes not only for the health care team, but also for the patients. Below are the 5 things that I believe will be significant changes from the patient's perspective, and will gradually assume a greater presence in physicians practices over the next two to five years:<br />
<br />
1. Patients will not need to visit the doctor's office as often.<br />
As primary care practices begin to function as Patient Centered Medical Homes, they will be paid through outcome incentives and on a "per patient per month" basis rather than fee-for-service, making it more desirable to do things in ways other than using the relatively inefficient doctor visit approach. Followups will occur via e visits and online portals (see below) will allow transmittal and review of data such as glucose and blood pressure monitoring in order to make decisions about the management of chronic disease.<br />
<br />
2. Prescriptions will be routinely refilled, and many new prescriptions provided, using e mail or text messaging.<br />
For established patients, there will rarely be a need to come to the office for a prescription refill; rather, using e mail and electronic prescribing, this relatively mundane, administrative aspect of practice will become much more efficient for both doctor and patient.<br />
<br />
3. Patients will be challenged to put increased emphasis on preventive practices.<br />
Rewards will be provided to providers for practices that obtain high levels of immunizations, recommended exams, mammograms, cholesterol checks, etc. This will result in much more focus on preventive practice by your physicians.<br />
<br />
4. Interaction with physicians offices will increasingly be through online electronic portals that are connected to the electronic medical record.<br />
One of the primary reasons this method has not taken hold sooner is the lack of payment for it, forcing providers to funnel their patients into office visits in order to make a living themselves. With the reform methods in the works, these perverse incentives will begin to disappear and the doctor patient relationship will be freed up to be what it should be, with free flowing communication independent of financial constraints.<br />
<br />
5. Patients will be increasingly recognized as the drivers of their own health care.<br />
The Participatory Medicine movement challenges patients to recognize that they, not providers, are the drivers of their own health, and to take control of this through acquisition and monitoring of their own health data and by obtaining the information they need to become, and stay healthy.<br />
<br />
These are major changes that will not come overnight, but in order for the health care system to avoid bankrupting the country, and to begin to eliminate the billions of dollars spent on medically unnecessary care, they are sorely needed. <br />
<br />
Your comments, questions and dissenting opinions are always welcome.<br />
<br />Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-63004212961559731762012-11-04T05:02:00.000-08:002012-11-04T05:02:00.840-08:00Working Together to Create an Affordable Health SystemAs we approach the presidential election next week, health reform is front and center as a key issue for the US. Entitlement programs, liability concerns by professionals, broad insurance coverage plans, and patient requests for expensive care have put the country on an unsustainable course that threatens us financially. <br />
<br />
Many of the ideas for health reform, including encouraging more comprehensive primary care through patient centered medical homes, bundling payments to providers, and reclaiming money paid to hospitals for unsatisfactory outcomes are nibbling at the edges of what needs to be done.<br />
<br />
But I can envision a radically different system from the one we currently have, one that centers on effective partnerships between professionals and patients in which the focus is on the issues that are truly necessary and really make a difference.<br />
<br />
Here listed is a few of these:<br />
<br />
<ul>
<li>A commitment to nutritional balance and appropriate calorie consumption</li>
<li>Regular exercise</li>
<li>Avoidance of smoking</li>
<li>Moderation of alcohol consumption</li>
<li>Regular preventive visits to the doctor, using published guidelines for testing</li>
<li>Commitment to careful control of blood glucose for diabetics</li>
<li>Patient commitment to blood pressure measurement and adjustments necessary to achieve control.</li>
</ul>
<div>
Finding a physician who will lower the barriers to care, communicate easily and effectively with you to help you answer your questions, and provide guidance as needed is another crucial step in the effective, efficient health care system of the future. </div>
<div>
<br /></div>
<div>
There is currently a growing shortage of primary care physicians, especially those who are open, innovative, and willing to maintain these types of patient relationships. An essential part of the effective health reform of the future will require addressing the need to train these additional primary care physicians. </div>
<div>
<br /></div>
<div>
Far too much effort, attention, and money is currently being spent on unproven or ineffective strategies and far too little is directed towards the outcomes in the bulleted list noted above. Hopefully, this discrepancy will begin to be increasingly noticed and will start to be addressed. </div>
<div>
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The answers to our un-affordable health care lies not in personalized medicine and ever more expensive procedures but in focusing on the basics of health and building a system around keeping Americans adherent to those principles.</div>
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Your comments or dissenting opinions are always welcome.</div>
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<br />Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-62939070071577006972011-08-07T03:18:00.000-07:002011-08-07T03:26:49.200-07:00Phone service expands eDoc's ReachOne of the limitations to eDoc's information services is that one has to have a computer linked to the internet. This, of course, is not always possible. So, if you're away from your computer, don't have a link to the internet, or may simply not have internet access at all or may not even own a computer, you can communicate with us by telephone. <br /><br />Since our service is "asynchronous", meaning provider and client are not connected in real time, we do this by using a unique telephone interface that records your message and transmits it to the eDoc providers in a voice file that we can open and listen to at our computers. We then can type an answer to your question and our system calls you back and "reads" our answer over the phone. It has a little bit of a "robot" sound, since the text to voice technology is not actually a human talking.<br /><br />I encourage you to put the phone number in your directory and, the next time you need to ask us a question, but aren't close to your computer, give this new technology and try. Then, let us know how you like it or how well it worked for you.<br /><br />By using technology the folks at eDoc are trying to improve your health, and the health care system, by making it easy and convenient to get the answers you need, from reliable professionals, at the time you them them.<br /><br />Thanks for using eDocAmerica.Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-68383986758490303842011-01-26T04:07:00.000-08:002011-01-26T04:12:11.400-08:00eDoc Launches New Site for IndividualsIf you are an individual, not associated with a corporation or group that already has eDoc benefits, log on to our new site <a href="http://www.edocamerica.com/individual">http://www.edocamerica.com/individual</a> and check us out. This new plan allows you to access to eDoc services free for the first month, then for the low price of $11.99 a month after that. <br /><br />Give us a try. I believe you will find our services to be second to none in the category of reliable, on line health information.Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com1tag:blogger.com,1999:blog-7959716826335595067.post-28999590334489312522010-12-28T12:48:00.000-08:002010-12-28T13:24:24.783-08:00On Patient AutonomyRecently, I was involved in a discussion on an e mail list serve and decided to takes some of my comments on patient autonomy and blog about them. This arose following a debate about whether the term "patient" engendered a sense of passivity and, therefore, whether the term should be dropped in favor of something else, like "client" or something similar.<br /><br />Having participated in the preparation and dissemination of the <a href="http://e-patients.net/e-Patients_White_Paper.pdf">white paper on e patients</a>, I don't see the need for 'factions' or disagreements in the service of advancing Participatory Medicine. As <a href="http://www.drgreene.com/meet-dr-greene">Alan Greene </a>aptly stated, "This is a big tent, with room for all". I want all of my patients to be as autonomous as possible. In my view, their autonomy is independent of the doctor/patient relationship that I have with them. They make the choice to enter into, or to activate or deactivate the relationship with me. They may ignore my input, seek a second opinion, or fire me and seek the care of another physician at any time. They truly are in control, in that sense. The only thing I have control over and am responsible for is trying to provide the best advice or consultation that I can.<br /><br />They use the internet for education about their health issues and, increasingly, to join patient communities for problem solving, support, information and research. Some even seek the input or advice of professionals they have never met through online services like <a href="http://www.edocamerica.com/">eDocAmerica</a>. Sometimes, they may find that information they get on the internet or from other patients demonstrates that what they received from me was in error. So much the better, if they can use networking to improve the quality of the information at their disposal, we will have a healthier, more efficient health system.<br /><br />The less they "need me" the better I like it but I continue to hope, in their best interest, that they are exerting their autonomy by making good choices and achieving optimum outcomes. Just like I don't expect to achieve an optimum outcome with a complicated home repair without a consultant such as an electrician, or to be able to fix my car without a mechanic, or achieve a legal victory without a lawyer, most patients won't achieve optimum medical or health outcomes without a medical consultant. And, has also been pointed out, some outcomes absolutely require a physician (e.g. surgery, intensive care, chemotherapy, radiation, etc).<br /><br />And, do these consultants ever make errors, be they of commission or omission, you bet! That is why the partnership is important. As good or as meticulous as a doctor might be, he is inevitably going to miss things that the patient and their caregivers are in the best position to recognize and correct. They may also be, by virtue of networking and patient communities such as <a href="http://www.acor.org/">ACOR</a> and others, privy to information that is more current or more relevant than what they may receive by their own physicians. We, as physicians should not worry about, or be threatened by this, but should embrace it as the best chance for the patient to achieve optimum outcomes.Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com1tag:blogger.com,1999:blog-7959716826335595067.post-63385041002634453672010-10-15T12:47:00.001-07:002010-10-15T12:48:10.317-07:00Fitness, Part 2This is another "eDoc Academy" video on <a href="http://www.youtube.com/watch?v=U2CPGwaLqCo">non aerobic fitness</a>. I hope you enjoy it.Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-44790536089793925472010-10-14T14:57:00.000-07:002011-03-03T13:00:32.313-08:00More on FibromyalgiaI'm calling these Youtube videos "edoc Academy". This is the third in an ongoing series of topics from my practice. This one on <a href="http://www.youtube.com/watch?v=IqhY18ok1i0">Fibromyalgia</a>.Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-14888877404098659032010-10-14T13:48:00.001-07:002010-10-15T18:58:28.952-07:00FitnessTake a look at this cam recording video that I did on getting started with a <a href="http://www.youtube.com/user/chasws49#p/a/u/o--ydPjHwmro">fitness program</a>:Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-29063173233297425162010-09-02T14:15:00.000-07:002010-09-03T06:36:20.841-07:00Introduction to Participatory MedicineThis is a video called<a href="http://www.youtube.com/watch?v=h6V5DS8DxeY"> "Introduction to Participatory Medicine"</a> which I recorded today on You Tube. Take a look if you get a chance and feel free to share your ideas and reactions.<br /><br />Thanks.Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-84060463856812431142010-07-04T08:41:00.000-07:002010-07-04T09:08:08.611-07:00Sugar May Be Raising Your Blood PressureMost of us know that salt raises blood pressure in many people. When I learned that in medical school almost 40 years ago, I have not touched a salt shaker since. I enjoy having a low normal blood pressure. A new study published in the Journal of the American Society of Nephrology (July, 2010) suggests that sugar, especially the fructose that comes from corn syrup, may also raise blood pressure.<br /><br />A study team from the University of Colorado in Denver looked at sugar intake among thousands of Americans in a major national nutrition survey between 2003 and 2006. Those who consumed more added sugars such as the fructose in soft drinks had significantly higher blood pressures than those who did not and ate more natural foods such as fresh fruit.<br /><br />Fructose from corn syrup is a major cause of the obesity epidemic and may also be contributing to the most common chronic disease of adults, high blood pressure.<br /><br />I have a bold suggestion to make that if followed will improve your health and that of our nation:<br /><br />Eliminate all soft drinks and fruit drinks from your diet and the rest of your family. Whether with sugar or "sugar free", they adversely affect your health. Drink water instead. If you want caffeine or some other flavor, drink tea (not sweet tea) or a modest amount of coffee, both natural substances. Use a slice of lemon in your water or tea if you prefer to alter the flavor. Get your fruit natually from an orange, apple, bannana or berries, not from juice.<br /><br />The elimination of soft drinks and fruit drinks would transform the American diet and help us be healthy again. And don't worry about the soda companies. A growing part of their business is bottled water today. We need to move them in the right direction too.jschergerhttp://www.blogger.com/profile/07786244502043698680noreply@blogger.com3tag:blogger.com,1999:blog-7959716826335595067.post-45028431386630163812010-05-22T19:56:00.000-07:002010-05-22T20:20:00.077-07:00Food Rules to Live ByMichael Pollan has become one our most important writers about human nutrition. His book, The Omnivore's Dilemma (2006), spelled out why the almost 8 billion humans on this planet had better balance what we eat, for our own health and the health of the planet.<br /><br />He published a small book in 2009 (Penguin Books) called Food Rules: An Eater's Manual. His rules are around 7 words in 3 brief statements: Eat Food, Not Too Much, Mostly Plants. How simple and wise is that!<br /><br />These three statements make up the three parts of this small book, with lots of practical "rules". Here are some of the best:<br /><br />Don't eat anything your great-grandmother would not recognize as food<br />Avoid food products containing ingredients that no ordinary human would keep in the pantry<br />Avoid foods that are pretending to be something they are not (like imitation butter)<br />Shop the peripheries of the supermarket and stay out of the middle<br />Treat meat as a flavoring or special occasion food<br />Eat animals that have themselves eaten well<br />Don't overlook the oily little fishes<br />The whiter the bread, the sooner you'll be dead<br />Be the kind of person who takes supplements - then skip the supplements<br />Eat more like the French, or the Japanese, or the Italians, or the Greeks<br />Have a glass of wine with dinner<br />Stop eating before you are full<br />Eat when you are hungry, not when you are bored<br />Eat slowly<br />Spend as much time enjoying the meal as it took to prepare it<br />Buy smaller plates and glasses<br />Serve a proper portion and don't go back for seconds<br />Breakfast like a king, lunch like a prince, dinner like a pauper<br /><br />and the last one:<br />Break the rules once in awhile<br /><br />So, enjoy a healthy diet and eat right!jschergerhttp://www.blogger.com/profile/07786244502043698680noreply@blogger.com1tag:blogger.com,1999:blog-7959716826335595067.post-13852810263473037412010-05-19T14:26:00.000-07:002010-05-19T14:40:43.978-07:00Getting and Staying Healthy: Getting Enough SleepOur busy lifestyles often aren't conducive to getting the recommended amount of sleep at night. According to the <a href="http://www.sleepfoundation.org/article/how-sleep-works/how-much-sleep-do-we-really-need">National Sleep Foundation</a>, adults need between seven and nine hours of sleep every night. <a href="http://www.mayoclinic.com/health/how-many-hours-of-sleep-are-enough/an01487">Dr. Kenneth Berg from the Mayo clinic </a>states that persons who get less than seven hours of sleep per night have a higher mortality than those who have adequate sleeping habits. Inadequate sleep has been linked to increased risk of motor vehicle accidents; an increase in body mass index – a greater likelihood of obesity due to an increased appetite caused by sleep deprivation; increased risk of diabetes and heart problems; increased risk for psychiatric conditions including depression and substance abuse; and decreased ability to pay attention, react to signals or remember new information.<br /><br />So, if you are currently getting less than 7 good hours of sleep at night, consider making a change to try to increase that to a minimum of 7 or 8 hours. Here are some other suggestions for you to consider to improve your quality or quantity of sleep: <br /><br />1. Establish regular sleep and wake schedules.<br />2. Have regular, relaxing bedtime routines such as taking a hot bath or playing quiet music.<br />3. Create a dark, quiet, comfortable and cool environment.<br />4. Make sure you have a comfortable mattress and pillow.<br />5. Avoid watching TV, using a computer or reading in bed.<br />6. Avoid eating 2-3 hours before your regular bedtime.<br />7. Exercise regularly during the day, but avoid exercise at least a few hours before bedtime.<br />8. Avoid caffeine and alcohol products close to bedtime.<br /><br />Let me know if you have comments or additional suggestions...Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-4061022083568557582010-05-19T14:20:00.000-07:002014-07-23T06:33:13.095-07:00Getting and Staying Healthy: Getting Enough Sleep<div>Continuing this series on getting and staying healthy, another one of the basics, other than obtaining and maintaining normal weight and getting enough exercise is getting adequate sleep at night. Our busy life styles often don't lend themselves to the 7 or 8 hours of sleep usually recommended to maintain health. </div>Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-26621236043034427942010-05-09T07:20:00.000-07:002010-05-09T07:44:27.674-07:00Exercise Part V: Exercise and Weight LossI am often consulted about diets and weight loss. I witness a blinding array of dietary approaches to weight loss and, alas, have discovered that most simply don't work! Yes, that's right, diets if they work at all, tend to be short term solutions at best. People can usually rally their will to restrict their intake and lose for awhile but, inevitably, without a more basice lifestyle change, the pounds slowly creep back over weeks or months.<br /><br />So, if you are overweight (over <a href="http://www.webmd.com/diet/news/20100210/percentage-of-overweight-obese-americans-swells">63% of American's are obese or overweight</a>), and want to shed pounds what is the answer? It's actually very simple. The basic concept is "calories in-- calories out". One merely needs to <em>slightly</em> reduce the number of calories consumed per day and burn additional calories over what has been your past pattern, such that a "deficit" is created between the number of calories consumed and the number of calories burned.<br /><br />If this idea seems rediculously simple, it is but, apart from bariatric surgery, or the rare case of a life-changing epiphany, a simple commitment to combining exercise with moderate caloric restriction is the secret to losing and maintaining weight.<br /><br />Let me provide an example of how this might work in practice: Let's say, you are 10 to 15 pounds heavier than you want to be and have been having trouble losing it. How should you approach it? First, decide a couple of items typically consumed in a day that you can manage to leave aside that would amount to between 250 and 500 calories. Let's say you decide to give up one soft drink, or one Starbucks flavored coffee or Latte plus the bag of chips that you usually have for lunch; <em>or</em> that you give up the piece of pie or cake that you have with dinner. That's it. It's just that simple. Otherwise, just continue with the diet that you are accustomed to. <br /><br />Then, with your exercise program that you have committed to (30 to 45 minutes five days a week in the "aerobic zone"), you are burning an extra 300 to 500 calories. At the high end of this scheme, you would have a "1000 calorie deficit" (the 500 fewer calories you take in and the 500 extra calories that you are burning). This would take you towards a faster weight loss and at the low end (250 fewer in and 300 burned) to a 550 calorie deficit. The latter plan would likely result in a one or two pound per week loss and the former a 2 to 4 pound loss.<br /><br />This is not an exact science and, since everyone is different, daily flexibility and adjustment is required. Therefore a daily or every other day weigh in is essential. If the weight is not trending in the right direction, an adjustment is made, either in cutting out a few more calories from somewhere or increasing the duration or effort level of your exercise. This is the fine tuning that is the ultimate secret to the success of this approach. And this regular adjustment process should continue indefinitely. This daily/every other day weigh in serves to reinforce your program and remind you of your commitment to maintaining fitness and weight control.<br /><br />So, there you have it. The exotic Smith plan for exercise and weight loss, otherwise known as the "Anti Diet Plan".<br /><br />Your comments and dissenting opinions are always welcome...Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-28907851649957859722010-05-02T17:59:00.001-07:002010-05-03T13:07:51.112-07:00Exercise, Part IV: Injury Prevention, Stretching, Warm Up and Cool DownPreventing injury is an often-neglected component of an exercise program but, when the basics are incorporated into your daily routine, you will be much less likely to spend time on the sidelines because of pulled muscles and other overuse injuries.<br /><br />Warming up can be confusing to many who are starting out with an exercise program. But, there is nothing complicated about it. The basic tenets are simply to start slow and stay slow until your body is ready for the stress of the workout. This will allow your cardiovascular system to infuse all of your key muscles, and will get your heart and lungs functioning on "high alert" to endure the stress of the workout. For most people, this process involves exercising at appoximately half speed for about the first five minutes; then, if all seems well, you can move to full speed and complete your exercise session. Failure to properly warm up may result in a high degree of muscular stress on muscles and tendons that are still tight and not adequately vascularized, and render them much more susceptible to injury.<br /><br />Cooling down is a good idea and is almost as important as warming up. What cool down accomplishes is allowing the body to reduce the heart rate and blood flow while, at the same time, reducing the amount of stress and work that the muscles are doing. During this time, the blood courses through the muscles and begins the work of cleansing toxic breakdown products such as lactic acid that can cause soreness and stiffness. It also provides a few relatively stress free minutes to concentrate on form and technique, which are also important, over the long haul, to staying in balance and avoiding injury.<br /><br />What about stretching? How often should you do it? How should you do it? And, should you stretch before or after a workout? Stretching is important in maintaining optimum flexibility and preventing injury. Failure to stretch results in progressive shortening of the muscles and tendons to the point that, after years of exercising and not stretching, some people literally cannot completely straighten their legs. For walking, running and biking, the most important stretches are the legs. For tennis, weight lifting, handball and other upper body skills, arms and shoulders are most important. It's not that you shouldn't stretch all of these areas regardless, it's just that, if push comes to shove, it is much more critical for a biker to stretch his hamstrings and quads that it is for him to stretch his shoulders and arms.<br /><br />Stretching should be done a minimum of 5 or 10 minutes three to four times a week. The preferred technique is "<a href="http://www.thestretchinghandbook.com/archives/pnf-stretching.php">proprioceptive neuromuscular facilitation</a>", which involves alternating contraction and stretching of the muscle in question. I prefer to stretch hamstrings for 30 seconds, then the other side, returning the first one for a total of two stretches on each side. I do this by placing my heel about waist high and leaning over til I feel the stretch, alternating contraction and stretching to increase the amount of muscle lenthening that can be accomplished. I stretch the quads by holding on to my foot behind me, same way, 30 seconds on each side, repeat times one. Most people tend not to like to stretch and, so, they often avoid doing it, resulting in a very tight body that cannot perform optimally and is more prone to injury.<br /><p><br /><br />Next time, we'll talk about exercise and weight loss...</p><p>Your comments are always welcome.<br /></p>Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-20687762418785852472010-04-30T12:32:00.000-07:002010-04-30T12:51:58.086-07:00Exercise, Part III: Motivation and RecommitmentEveryone who has exericised regularly has experienced problems and challenges of remaining motivated and committed to keeping up with your exercise schedule and level of intensity in order to stay at the peak of fitness. Some days, if you exercise in the morning, you just feel too tired to get out the door to do your workout. Other days, you feel emotionally lethargic because you have something on your mind that you just can't get over long enough to get started on your daily workout. Other days, you have a cold, headache or other illness that makes it all but impossible for you to workout.<br /><br /><br /><br />Sometimes, when two or three of these days pile one on top of another, you find yourself falling off the wagon and, suddenly, you realize you've missed a week or 10 days and panic starts to set in. What if I lose everything I've worked so hard to gain? Why does it seem like getting back in shape is so much harder and takes so much longer than it takes to lose it?<br /><br /><br /><br />Here are my "10 commandments" for dealing with this problem:<br /><br />1. Realize that every fitness enthusiast has this problem and it doesn't mean that you are lazy or that there is something wrong with you.<br /><br />2. Don't entertain the illusion that daily workouts are "fun" or a "piece of cake" and, therefore, it should never seem easy to just bounce out of bed and do your daily workout. Regard daily workouts as part of your work, not part of your play. That is why it is called WORKING out!<br /><br />3. Remember that becoming fit requires weeks of work, not days and don't allow yourself to become discouraged when you don't feel fitter or slimmer after a few days, or even a few weeks, of working out.<br /><br />4. Give yourself permission to take two days "off" per week and position those days strategically (such as days you have early meetings or days when you stay up late the night before, etc).<br /><br />5. Remember to advance your efforts no more than 10% per week, so that you don't overtrain. Overtraining is one of the best ways to injure yourself or just plain burn yourself out.<br /><br />6. If possible, band together with one or two others who will help motivate you and hold you accountable to your fitness program.<br /><br />7. If you're having a bad day or feel rushed, give yourself permission to shorten your exercise session for that day. It is better to work out for 20 minutes than to miss the day altogether.<br /><br />8. In a similar vein, if you don't feel great or are just having a low energy day, give yourself permission to lower your target heart rate by 10 or even 20%. It is better to get in a light day of exercise than to miss the day entirely.<br /><br />9. If you start to feel burned out with your exercise because you are doing the same thing every day, change your course or use a different modality. For example, if you are a biker, get on the elliptical or treadmill on occasion for a change of pace. If you are a runner, get on your bike. Cross training is a great antidote to boredom and burnout.<br /><br />10. If you have trouble getting up and jumping into your exercise clothes, get up early enough to enjoy a cup of coffee and read the paper before you venture out.<br /><br /><br /><br />Everyone struggles with motivation to do their daily workout. The fitter you are and the longer you've been in the habit of doing it, the lower your risk of becoming discouraged and quitting, but motivation issues never go away completely. Just accept their inevitability and apply one or more of the 10 commandments noted here to help you get back in the game.<br /><br /><br /><br />Next, we'll talk about injury prevention, including warm up and stretching. Your comments are always welcome.Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0tag:blogger.com,1999:blog-7959716826335595067.post-8768554720746381612010-04-25T06:30:00.000-07:002010-04-25T06:59:02.666-07:00Exercise, Part II: Getting StartedPerhaps you, like many patients I talk to, would like to begin an exercise program, but the idea seems overwhelming. It can be if you decide to start a program without a sound plan, because it will almost certainly not be something you can sustain for the long run. Patients often have no idea how long to exercise, how much to stress or strain their system, or how long it takes to "get in shape". All of this tends to lead to early errors, injury, or discouragement and giving up on the idea of becoming fit. It is important, and possible, to avoid this trap with the proper approach.<br /><br />If you haven't been exercising regularly, it is important that you first consult with your doctor about whether it is safe. If you are 45 years of age or older, it is probably a good idea for you to obtain a treadmill exercise stress test. It is also important to have a good idea of your risk factors for cardiac disease, including your cholesterol and blood pressure level. You should also get a reading of your body mass index and set a target for your weight (more on weight loss later).<br /><br />Assuming you get the green light, I recommend starting with about 15 or 20 minute sessions, three days a week. You should choose an aerobic activity, such as walking, jogging, biking, swimming, or an exercise machine like a treadmill or an elliptical machine. Aerobic activities are important to form the basis of your program because they are sustainable and lead to better cardiovascular fitness. We'll talk about the value of anaerobic activities, especially weight workouts, later.<br /><br />If possible, either work out on a machine that has a heart rate monitor or else purchase a wireless continuous heart rate monitor. It is very difficult to exercise for fitness efficiently without one and they have become very affordable in recent years. As I noted earlier, it is important to exercise in the "aerobic" zone, which is about 60 to 80% of your maximum heart rate. You can obtain an estimate of your maximum heart rate by subracting your age from 220. For example, if you are 30, your estimated maximum heart rate is 220-30=190. So your exercise target is between 114 and 152. I usually recommend a midrange target of 70% or about 130 for this example. <br /><br />It is important to be patient and persistent, remembering that each day builds on the last and that rest and exercise work together to stregthen the muscles and the cardiovascular system. By starting at 20 to 30 minutes three days a week, you minimize the risk of becoming too sore or fatigued to continue your program. A good rule of thumb is to increase your workouts by about 10% per week. So, if you start with 30 minutes, three times a week the first week, then you should increase one of your workouts by 10 minutes the second week. Then, the next week, increase one of your other workouts by 10 minutes. The next week, increase one of your workouts to 45 minutes and repeat the cycle. When you are up to 45 minutes three times a week, then add a 15 or 20 minute session on another day a week; then increase that session to 45 minutes, until you get to 5 days a week, 45 minutes a session. By the time you have reached this schedule, you will have completed at least 12 or 14 weeks and should have achieved a pretty good level of cardiovascular fitness. Congratulations!<br /><br />Then, when you have achieved this schedule, which is reasonable to maintain, you can continue to pursue your fitness by maintaining your heart rate targets as you become more fit. As you do this, you will actually work harder and the the "10% rule" will continue more or less automatically by allowing you to "do more work" at the same heart rate as you become more fit. This is called the "training effect".<br /><br />Next time, we'll talk about issues with motivation and what to do when you "fall off the wagon".Charles Smith, MDhttp://www.blogger.com/profile/15454455752861414055noreply@blogger.com0