Insurance reform?

I have been frustrated by the whole health care reform debate. Now that health care reform is "over" perhaps it is time to reflect a little. It seems to me that the debate was not so much about reform as about insurance. To reform the system would be to change the basic structure of how care is provided and what is paid for. Clearly we are not ready for that! When talk of looking at end of life issues conjures up discussion of "death panels" and adjustments of insurance coverage are defined as massive reform, I don't think either side gets it. As long as we do more and more complex procedures for more and more people who (by virtue of what we are doing) live longer and longer, costs cannot go DOWN. Now if we actually focus on prevention, keeping those same people from getting sick initially, THEN maybe costs can go down.

I believe insurance is the wrong model for health care. I have fire insurance on my house, collision insurance on my car, but I really do not want to use either of them. I don't know the statistics, but I'm sure almost everyone who has health insurance uses it every year. This is not insurance but pre-payment. To be sure, few of use could afford a serious medical evaluation without insurance, but why do we want it to cover everything? All we are doing is offering to pay someone else for for giving our own money back to us (less a substantial fee!). Can you imagine loaning money to the bank and they paying them to keep it for you? With the exception of catastrophic coverage, that is essentially what we are doing.

As a physician, I recognize that fewer people would see me if they had to pay out of pocket, and that is indeed one of the struggles of a primarily wellness business. the ones who do, however, are motivated to transform their lives. This is true health reform.

Tortoise and the Hare

You know the old story of the tortoise and the hare. The hare starts out fast, gets over confident and loses the race to the slow but steady tortoise. For many this seems to be the case in weight loss. It has always been alleged that fast weight loss is unhealthy. Although I have lost the reference, there as a recent study showing that actually rapid weight loss may be more beneficial in achieving both greater and more lasting results. This is only one study and hardly enough to draw conclusions. Nevertheless, rapid weight loss is not unhealthy per se. Unmonitored rapid weight loss and unhealthy eating is risky for sure. There have been many documented deaths from starvation diets, unwise use of over the counter appetite suppressants and the like. It should be noted there are far more deaths attributable to obesity and inactivity, but we all know that.

As a bariatric physician, it is my experience that rapid weight loss under supervision is quite beneficial. We observe our clients who get off to a good start are more likely to keep up their losses and less likely to drop out. getting up a full head of steam right out of the gate does help in my opinion.

Overall, my bet is on the hare, as long as we can keep him directed and not overconfident!

Too fat to fight!

A recent article on our bariatric society web site quoted top military officials as complaining about obesity in the 17-24 age range. Currently about 27% are too overweight to join the military. As an "old guy" from the Vietnam War era, I never even knew this could be a reason for rejection! I took my chances with the lottery and fortunatly did not get drafted due to a favorable number. How times have changed. The pedicatric obesity problem has gotten a lot of press as has the general population problem, but I'm not sure this particular age group ha gotten much press. This is the age where folks should be in their prime. This is the time to look back on when our health begins to fail: "If I were only 21 again!"

How can we help people see the course they have set for themselves? Children are dependent on parents, adolescents heavily influenced by peers, but this group is in the process of maturing fully. As a society we need to find ways to help with positive body image, mature patterns of eating and activity, and a sense that life is to be lived fully, not just observed on a screen. Yes, the business of life gets in the way, but all the more reason focus on staying healthy.

April Foolish Advice

With tongue fully planted in cheek I offer the following weight loss advice:

1. Use that newly released secret recipe that the medical community is hiding so they all don't go broke. It results in excellent weight loss and improved health (as long as you take it at least three times per day after 60 minutes of vigorous exercise)

2. Eat less and exercise more. That's all it takes! (Actually this is somewhat true but often results in weight gain on a practical basis. People find it hard and give up because it is not as simple as it seems!)

3. Want to lose weight, go to bed earlier.(Also some truth in this! Getting less sleep is associated with weight gain, but an earlier bedtime is usually not sufficient to result in weight loss on it's own.)

4. When your doctor stops recommending rest and starts recommending diet and exercise, change doctors! (You may not lose weight but you will gain a co-dependant!)

5. You are a strong independent American and can do it on your own! Don't bother trying to get any help. (Actually 25% of people can lose 20 pounds on their own but most cannot keep it off.)

6. Join NASA, in outer space we are all nearly weightless!

7. Don't investigate any claims of pills or providers who promise miracles. After all, they wouldn't be allowed to say it if it wasn't true, right? (BTW, I have this bridge in Brooklyn you may be interested in....)

8. Wait for the weight to come off. It's bound to happen as soon as _____ (fill in in the blank) starts or stops. (BTW, about that bridge....)

9. Keep your tongue in your cheek. This will make chewing and swallowing impossible with resultant impressive weight loss.

10. Laugh it off. Actually some truth to this also. Stress is reduced by laughing, and you can at least lose that heavy mood!

Save your brain with the Mediterranean diet?

According to Gad A. Marshall, MD (Instructor in Neurology, Harvard Medical School, and Associate Neurologist, Center for Alzheimer Research and Treatment, Brigham and Women's Hospital, Boston) two recent studies demonstrate a reduction in the risk of mental decline in people who follow a Mediterranean diet. In a study in New York City, risk this showed up as a decline in the risk of Alzheimer's dementia in those who followed a Mediterranean diet, exercised regularly, or both. The hazard ratios were 0.6, 0.67, and 0.64 respectively. The study was large, well controlled of confounding factors and followed people for over 5 years. It would appear that in this population the diet reduced the risk of dementia by about 30-40%! A similar study in France, which was smaller, showed reduced cognitive decline (better maintained brain function) but not reduced risk of dementia. This study may not have been powerful enough to show benefit in preventing Alzheimer's, but results are still encouraging.

It seems to me the more we learn about diet and exercise, the more benefits we find. Perhaps Hippocrates was on to something when he recommended healthy (presumably Mediterranean given his location) diet, fresh air and exercise!

An example of good parenting!

I was sitting on our front porch this evening because it was warm and beautiful. Lots of people were walking by, walking dogs, riding bikes etc. A mother with a boy about 4-5 years old passed. He was riding a bike which hit a bump and he went sprawling hands first onto the sidewalk. It almost looked like he leaped forward. He rolled over onto his butt and was clearly unhurt. He looked up at "Mom" for a reaction. I would expect to see her concern, maybe some sympathy, even offering a cookie or treat. Many times I've seen the "Oh, oh are you OK" response which usually just make the child cry. This Mom remained smiling. Her response was "So, did you catch the rabbit?" How inspired! He did look a lot like my beagle when she tries to jump something, only difference is no howl from the kid! I couldn't tell the mother what a good job she did, and I doubt she will ever read this, but at least I can tell someone. Hope it helps you keep your stumbles in perspective. May you "catch the rabbit!"

Wholistic, holistic or integrative?

There are a lot of terms around to describe the attempt to integrate body mind and spirit into health. Some of the more common terms are integrative, functional, mind-body, holistic and wholistic. None of these terms yet conveys anything very specific about the practitioner or style of practice. I'd say this is in development, but if so it has been for a long time! When I first became interested in "wholistic" medicine it was spelled with a "W" and done mostly in church basements. The "holistic" moniker has often been used by chiropractors and often includes nutrition, supplements and the like as well as manipulation. Integrative and functional are more recent terms used by a variety of practioner types, including a few of us bolder MD's. It implies bringing together multiple disciplines to improve health and/or treating function rather than disease.

As I reflect on my preferences, I find myself gravitating toward the older "Wholistic" for a few reasons. The concept of "whole" including multiple aspects of body, mind and spirit. I know the actual root of "holistic" is "hol," the same root as Holy. It seems to imply more focus on the spiritual. Although this emphasis is not a bad idea given the subordinate position the spirit is usually given, a more even emphasis is more to my liking. I think as a wholistic practitioner I should be willing to address body mind and spirit in any combination and not value one above another.

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What is a doctor?

The mind body expo this weekend in Minneapolis gave me a different perspective on my title. If I said I was a "doctor" or a "physician" I got constant requests for clarification! The only unambiguous title was "MD" but this was not always a welcome one. Considering insurance companies now insist on calling me a "provider" (which I always thought was something I helped do for my family, being one of only two) I'm beginning to wonder if society has a role for people like me. Surely the education, study and practice of the past 30 years are of value. I know my skills are helpful to people and believe in my own worth independent of titles, but they do help people understand roles. I am not really ready to given them up either to generalization from "physicians" who have had much less training, or to be downgraded by insurance to a generic cog in the wheel- the role is only to see patients and generate revenue.

This brings me to what I should call the people who come to me for care. For decades I have used the term "patient" (and many of them have been VERY PATIENT with me, especially in the early years!) but I am coming to prefer the more modern term of client. This puts us on more of an equal footing which I do like. We are really collaborators in health.

Once the relationship is established, I don't think it matters as much what we call each other, but names do have implications.

Where am I today?

My decision to act this time resulted in a shorter delay than initially! I started our program Jan 1st, 2010 and have lost 20 pounds already! Although fully aware of the importance of proper balance in my diet and the need for regular exercise, I still struggle. Schedule changes have made my old positive patterns more difficult regarding exercise, and the cycle of splurging on carbs is hard to break! Focusing on developing new patterns seems to be working better than "getting back" to my old ones, since it is now clear that my old patterns are not possible.

Spirituality and centernedness are the cornerstones of the patterns I am now trying to develop. I can do daily Yoga before I even leave the house and focus on being centered when I eat. Lent is a good time to focus on spirituality and face one's darker side. Repentance is turning away in a Wholistic sense, body mind and spirit. Perhaps this will be a useful and inspiring concept for me over the next several weeks.

What is Wholistic Health?

As a starting place, for a practitioner to be "wholistic" there must be a genuine acknowledgement of Body, Mind and Spirit as related. My belief is that they are inseparable aspects of the same reality. To use the theological concept, a trinity. This is a multi-directional webwork of relationships. What affects the body affects the spirit and affects the mind. This is true of any permutation you can imagine. At Sage, each of our staff from reception to physician buys into this concept.

There needs to be a willingness to address each of these major areas in more than a superficial way. A complex web does not lend itself to a single program or a uni-directional approach. There needs to be an understanding that relationships are multi-directional and what affects one aspect will affect others in often unforeseen ways. Each strand has intrinsic value and a contribution to make. At Sage we have collected providers of as many different modalities to address as many different aspects as possible. (See our website: www.sageweightandwellness.com) We are open to others as availability and need present themselves.

Wholistic medicine is also integrative. It in not just a collection of different practitioners under one roof. To be wholistic, the model itself must be integrated. At Sage, we talk with each other, have a common record, share information and ideas and act as collaborators with our clients in their transformation to health. At a very real level we have a common mind, common body and common spirit.

These concepts need, themselves, to be more than mental constructs! They need to be integrated into the hearts and souls of those who would serve others. At Sage Weight and Wellness we have recruited an entire staff who not only acknowledge this but put it into practice in their own lives as well as their relationship with our clients.

I do not mean to imply that the "medical model" has no value. It is very valuable but is only one strand. As a strand, its values must be respected, including: the scientific method, "evidence based medicine," technology, and pharmacology among others. Wholistic Medicine is not simply discarding Western Medicine for other "alternatives" which may or may not be superior in a given situation. At Sage, we get this. You will not hear us badmouthing doctors or discounting science. We ARE aware, however, that Western Medicine is only ONE perspective.

Although as an entity, Sage Weight and Wellness has only existed for four years, our staff has been involved for decades. As a physician, my initial choice of Family Practice was heavily influenced by the fact that it recognizes relationships and family systems as important to health. It was the closest thing to wholistic or integrative medicine that existed 30 years ago! I have not abandoned this approach, but only expanded and deepened it. My recent Bush Fellowship, in Traditional and Alternative Treatments for Obesity, my experience and explorations into meditation, yoga, exercise and many other disciplines are evidence not just of an interest but a commitment.

My work with the Episcopal Church Pension Fund through CREDO has further broadened my understanding to include financial, and vocational aspects of health as well as physical and spiritual. Our other staff also have long journeys in wellness which need to be respected, but which I will not detail here.

I welcome questions or comments. Come and see for yourself! I'd love to show you around!

Physician Heal Thyself!

As I continued to adjust to running a business and all that involved my stress levels grew and my waist line with them! Excuses were too easy: I don't have time, I'm too tired, if I can just get ahead a little then... or I'll start tomorrow. Listening to myself talk to clients about their weight was educational. What I knew in my head had not yet made it down past my neck! Tomorrow was becoming a long way off. I had regained half of my former loss and it was time to do something. "Physician heal thyself!" But what I learned was even with all my knowledge and experience I could NOT do it myself! Fortunately I have the best staff in the world! (Come meet them and you'll see!) When I looked in the mirror and got on the scale, the change was evident. I was also starting to have the return of fatigue, less exercise capacity, more back pains and generally not feeling as well. I had regained almost half of the 60 pounds I initially lost. Time to act.

A New Venture

Our next major development was moving out of New Prague Clinic. This move could be more about the history of Sage than my personal history, but it did change the dynamics for me personally. I learned (or rather was reminded, since I have been in solo practice before) how stressful having a business can be. I had lost most of my excess weight and managed to follow my own advice as well as what I had learned from The National Weight Loss Register about keys to long term success. Soon after the move, I was accepted as a Bush Fellow to study traditional and alternative treatments for obesity in children, adolescents and adults.

There was some stress related re-gain of weight but only a few pounds and my program was on course. Having the Bush fellowship was exciting and in spite of the stress of having a business, things were going well. Focusing on helping others was beneficial for my own health. For me, key in staying healthy was exercise daily in the moderate to vigorous range, monitoring diet, eating breakfast and limiting my carbohydrate intake. I had learned my lessons, or so I thought....

So what is OPTIFAST?

OPTIFAST is a trademark of Nestle nutrition. It is a formula based diet (shakes and bars) which allows a physician to utilize a very low calorie diet with patients. It is specially balanced and formulated to allow for an intake as low as 800 kcal and still maintain full nutrition, vitmain and minteral intake, and avoid starvation response. Because of it's restricted nature it is only safe when used under a physician's care. It is only one tool which can be used for weight loss and is only effective if combinted with nutrition education, behavior change, and exercise. It is mostly for people hoping to lose more than 50 pounds or those with medical problems related to weight.

The principles involved include proper balance of protein, fat and carbohydrate. This balance helps reduce hunger. Another is called "stimulus narrowing". I call this the "reverse buffet" effect. When we go to a buffet we overeat in part because of all the stimulation of seeing and smelling the food. It seems we are taking small amounts but we take and eat more than we think. By limiting choices, we eat less. having a choice of only shakes, soup, and bars in a few flavors, just makes people lose interest.

There is a lot more information on the OPTIFAST website. Most of the questions I get have to do with safety (only under MD supervision) and weight regain (no more than any other program and dependent on PEOPLE STAYING ACTIVE in their treatment.)

Although we utilize this tool a lot, we never force people to choose it. It can be very effective, however.

Better and Better

I had been running my weight loss practice through my family practice office. I was trying to do it all, managing behavior change, exercise and diet with my clients. i was getting good, if average results and it was taking a lot of time. It was becoming more difficult to do within the context of a 15 minute office visit and I started running way behind if people brought up weight issues. I also had not learned yet how to determine readiness to change and therefore wasted a lot of time. Also the weight loss was often not fast enough for clients who fell away after a month or so, which is pretty typical.

I read about the OPTIFAST program and talked to them about their methods. There was ANOTHER traning program to go to but this was only three days since I was already Boarded by the ABBM. With this program I made some changes and began working with a team. The basic concept is a formula diet for rapid weight loss (more on that at a later post, or check our website for more info: www.sageweightandwellness.com ) and extensive education for retraining of eating and exercicse as well as behavior. I concluded that this would work best with a team and after hours. The first major revision was complete and our results were much improved.

Study, study, study

I decided I really needed to pursue Diplomate status with the American Baord of Bariatric Medicine. If I was going to do this, I was going to do it right. I did not want to be just another "fat doctor!"

I started my bariatric (weight loss medicine) education by getting some tapes from former academy meetings. These were very helpful and I followed up by attending meetings. There was a total of 50 credit hours required, but I exceeded this greatly to learn all I needed to know. There was a written exam as the first official step toward certification, and I knew I had to pass with an absolute percentage. There was no "grading on the curve." I was pleased to do pass on my first try.

Now I was authorized to take the ORAL exams. More studying and case reviews! Standing in front of 3 experts in bariatrics and answering questions about cases was daunting, but in a strange way fun as well. I passed and went on the the next stage.

To be a Diplomate of the Board I was required to have a program running for a year and meet specific quality criteria. I had about a year and a half under my belt (no pun intended!) and the program was going well. I was struggling with the realization that many of the people who were initially interested were not yet ready, so my numbers were small, but the results were good. This was to be an on-site evaluation by another member of the board. Our program passed without difficulty (although it has improved a lot since then!)




To my great joy, I received diplomate status in 2004.

Excitement!

I received a lot of attention for my weight loss and that felt great. People kept asking me how I did it, and that made me think they were interested. Some in fact were, many were not. In any event, it generated a lot of enthusiasm in me and I decided I could offer something similar to what I did in New Prague. After all, it is not rocket science!

I looked to see if anyone was doing training in weight loss and found the American Society of Bariatric Medicine. This group or physicians does training in obesity and related diseases, and tests for competency. This seemed like a good idea, so I started the process. I was sure I would be having people break down the doors, given the excitement generated.

Out of the mouths of children

The year is now about 1999, a mere eight years from my initial revelation! It is before Christmas, I am up to about 220 pounds again and have my "winter growth" of beard. Upon walking into the exam room I am greeted with great delight by a 5 year old girl: "Doctor Santa!!"


Mom was mortified, I was entertained, but also saw a little more clearly. My research began again and this time I knew I could do it with help. I signed up for a comprehensive weight loss program and the real success began. My program included diet, exercise, behavior modification, and initially medication.



My success was transforming! I lost about 60 pounds over 6 months and felt great. My exericise program benefitted greatly as well. As my weight came down I was actually able to do more and felt so much better. People started asking me how I did it, and like a fool I thought they really wanted to know!

Clearing the decks

Although my weight was my primary concern, the elephant in the livingroom was my work schedule. I realized that I would never have the energy needed to make the changes needed if I didn't stop working 80+ hours per week. I managed to find my way out of solo practice and into a small group. This turned out to be more turmoil that I expected, but my hours were less. I started exercising and felt the weight would just melt away like winter snow in April. Many of you who have lived in Minnesota know snow does not always melt in April, indeed some big storms can happen then. Alas so it was with my weight loss efforts. On the plus side, I was exercising and feeling better. Change, however was feeling as remote as a Minnesota spring seems on this snowy early February day. There is always hope, perhaps soon action as well.

Taking immediate action!

So being a man of action after this revelation I stayed in the "contemplation" stage of change for about 2 years. At that time I applied for a life insurance policy and had begun a few changes in terms of exercise. When I met with the agent I told him I was in the process of trying to lose some weight, and asked if I should delay my application until this had occurred. His response was "like that's ever going to happen!" The primary outcome from this interchange was an immediate change in insurance agents! I decided at that point to investigate and see if anyone really did manage to lose weight and keep it off. What I found was the National Weight Loss registry, a database of people who had lost over 50 pounds and kept it off long term. This was the beginning of my realizing that I COULD do it but would need some help. Commitment was now tied to hope, and progress could begin.

In the beginning

Every story has to start somewhere, so I will start at the time I first realized I was out of my "maintenance free decades." On the eve of my 40th birthday I was in solo family practice in the small town of Montgomery, MN working 80-100 hours per week ( about 100% more than anyone ought to work), eating about 100% more calories than anyone ought to eat, and exercising well.... not at all! I had never been much on sports, was always glad gym was pass-fail, and really had not given exercise much thought since high school. Consequently my weight was 220 pounds which gave me BMI of about 33.7 if I counted myself as 5'8", literally a stretch!

In this condition, the day before my birthday I decided it would be a good time to clean up the garden to get it ready for winter. I felt tired but OK after spending about 4 hours in the garden. OK that is until the next morning. When I woke my first thought was: "If this is 40, I'll never make 50!" Every muscle in my body hurt, and I could barely make it down the stairs. HAPPY BIRTHDAY TO ME!

The full extend of my decline was evident later when I was consulted by an 85 year old women who's chief complaint was "every time I spend 5 hours or more in the garden my back hurts a little."

And so the story begins.....

I am Dr Milan Schmidt, founder of Sage Weight and Wellness in New Prague. Sage is a team of exceptionally qualified professionals dedicated to helping you achieve your health related goals. We are starting an exciting new program of Membership which is specificaly designed to meet your health care needs.
Whether you are trying to get and stay healthy, minimize your use of medication for chronic illness (such as hypertension, diabetes, depression or others), or are trying to get your whole family's lifestyle moving in a healthy direction, membership may be for you.
To give you a background on who I am and how Sage developed, posts over the next weeks will focus on my personal wellness journey, followed by information on our staff. You can check us out any time at our web site: http://www.sageweightandwellness.com/