I recently read this book, which is an overview of the Affordable Care Act (a.k.a. Obamacare), written by one of its principal architects.  Dr. Ezekiel Emanuel is the brother of Pres. Obama’s former chief of staff Rahm Emanuel.  He was an important advisor to the President during the process of writing and passing the health reform law.  He is currently the Vice Provost at the University of Pennsylvania School of Medicine.

Here is a (fairly) brief overview of this book.  There are 3 sections.  The first section discusses the history of the US health care system prior to Obamacare, the details of how people get care and how hospitals and doctors get paid, and the main problems with the system.

The second section discusses the history of health reform efforts since the founding of the country, the process of writing and passing the ACA, the Supreme Court case upholding the law, a detailed description of what’s in the law, and finally a description of how the law will affect patients, doctors, and insurance companies.

The third section discusses the problems with the launch of healthcare.gov, gives benchmarks on how to measure whether the law is successful or not in the future, possible improvements to the law, and predictions for the future.

I think there are a lot of strengths to this book.  First, Dr. Emanuel is a good writer with a clear style.  He does a great job of summarizing and simplifying what are extremely complicated subjects (the American health care system and the ACA).  This could easily be a very dry book but it is not.

This leads me into another strength: the book is an excellent resource for anyone who wants to understand how our health system functions.  Even as a doctor (and a doctor who is interested in these topics), I learned a lot of details from this book that I did not know before.  Dr. Emanuel talks about how the health insurance system works, how doctors bill for services and get paid, and the effects of government regulation on the system.

The third big strength of this book is a comprehensive summary of what exactly is in the Affordable Care Act (hint: there’s a lot more than you think!).  The law is certainly controversial, and I believe that reasonable people can disagree about it.  However, there is a LOT of misinformation out there coming from the media, talk radio, politicians, and other sources.  I think it is important for people to understand what is actually in the law before they decide to support or oppose it, and I think this book does a good job of describing what is in the ACA.

Shortly after Obamacare was passed in 2010, I gave a lecture to my department in residency about the law.  It was difficult to find reliable information that gave a full overview of the law at that time.  This book is a much better source than anything I found 4 years ago.

Now, on to the weaknesses of the book.  First and most obviously, the book is skewed toward a positive impression of the ACA. The book is written by a strong supporter and drafter of the Affordable Care Act.  So, the author is clearly biased to take a very positive view of the law and its potential future effects.  There is very little discussion of possible ways the law could have negative effects or cause unintended problems.  I would like to see a similar book written by a (reasonable) opponent of the law or at least an objective writer who gives both sides of the argument.

Dr. Emanuel makes a series of predictions about the future effects of the law toward the end of the book, but he wisely gives the disclaimer that he is only making educated guesses.

Dr. Emanuel also (in my opinion) makes light of how easy it will be to implement the vast structural changes in health care technology, how doctors and hospitals get paid, and many other features of the health care law.

He suffers quite a lot from “Ivory tower syndrome,” meaning that he has spent his entire career in academia and public policy and thus does not fully understand the situation of most doctors in private practice.  Sweeping pronouncements like “A private practice will probably need 10 or more physicians to have sufficient scale- financial resources, physician time and attention, and staff- to support the experimentation that will be part of the necessary transformation in care” are frequent throughout the book.  Right or wrong, there is going to be a lot of resistance by doctors to these kinds of mandates if they are not made with understanding to our situation.

In summary, Reinventing American Health Care is an interesting, informative read, but take its predictions and rosy outlook with a grain of salt.  I would encourage my readers to check it out.  Link to Amazon for anyone who is interested in reading it.

Well, today’s post is a bit off the usual ENT related topics, but it’s good to mix things up from time to time, right? I’d like to talk about Bikram yoga, which is something that I’ve been doing regularly for about the past year.

Bikram yoga is a standardized 90 minute long series of 26 postures and 2 breathing exercises that is done in a hot room (105 degrees, 40% humidity) with an instructor leading the class. The first half of the Bikram series is done standing up, and the second half lying or sitting on the floor. Throughout the class, the instructor is talking the large majority of the time giving you a somewhat standardized monologue of instructions on the postures. (Each instructor adds their own twist, but you’ll hear a lot of the same lines every class).

A guide to the postures is HERE.

The workout is intense, and you’ll sweat a ton and burn a lot of calories. Although it’s claimed to be a “full body workout,” I find that the main strength benefit is to my legs, back, and abdominal muscles. Physically, my flexibility and balance have also improved substantially since starting Bikram.

Perhaps an even greater benefit is mental health. The most important part of Bikram yoga is keeping your mind clear and focused on your body and the instructor’s words. In class, my mind does wander sometimes, but most of the time it is relaxed and focused on the present moment. Afterwards, I feel a tremendous calm and clarity of mind, and I can easily say that Bikram yoga is the only exercise I’ve ever done where I feel more energized afterward.

Proponents of Bikram yoga make a lot of claims about it being able to reverse injuries and other health benefits. I cannot make any claims other than what I’ve noticed in myself. Fortunately, I have avoided any major injuries in my life and I’ve generally been in very good health. I do feel that my health is better since starting Bikram yoga, though. I have more energy and core strength, and I just feel good!

The studio where I practice, Pure Bikram Austin has created a nonprofit organization (Pure Action) that funds medical and scientific research of the benefits of Bikram yoga so we may find out more proven benefits in the future.

So, what should you do to start? First, before starting any exercise program, it is safest to consult with your primary care doctor. The staff at your local Bikram studio can also be helpful- if you have it, they’ve probably seen it before.  I’ve seen people of all ages (age about 10 to at least 70), shapes, and sizes in Bikram class.  No one is going to judge you- the instructors and other students are some of the nicest and most supportive people I’ve met anywhere.

Before class, it is important to optimize your hydration and avoid eating for at least 3 hours before entering the hot room. Optimizing hydration means more than just drinking a lot of water, it also means getting enough electrolytes in your system. So, drink a Gatorade, coconut water, or another high-electrolyte drink in addition to water before class. I personally drink 1 liter of water mixed with a packet of Electromix 2-3 hours before class and I’ve never had any problems with cramping or other signs of depleted electrolytes. I drink water with all my meals as well. Also, try to eat healthy the day of Bikram class. I’ve gone a couple times after eating a greasy lunch and it was not pleasant…

During class, you’ll need a yoga mat, a towel to put over it, and a bottle of water. My studio offers mat and towel rentals, and I would guess most others do as well. For your first few classes, your only goal should be to stay in the room for the whole 90 minutes. If you find yourself getting out of breath or lightheaded, stop and rest for as long as you need to. It is fine to sit and watch! After a couple of classes, you’ll get used to the heat and things will come a lot easier.

After class, congratulate yourself on coming out and doing your best. I would suggest taking a quick rinse-off shower and changing clothes before getting in your car. Otherwise your car will start smelling very bad very quickly. You can take a longer shower once you get home.  Make sure to drink more water and electrolytes after class to minimize muscle cramping.

Give it a month of going regularly to decide if Bikram is for you. I’ve found that 2-3 classes a week is the best schedule for me. Some hardcore folks go every day, but that is too much of a time commitment for me and I also would get bored of the class if I went that much.

For more information:

Pure Bikram Yoga (4 Metro Austin locations)

Hill Country Hot Yoga (Wimberley and San Marcos locations)

Pure Action (researching the medical benefits of hot yoga)

I read this blog post (“Why doctors and hospitals shouldn’t advertise“) on KevinMD.com a few days ago and decided to write a response.

The writer of the piece, “Skeptical Scalpel” is a surgeon who has been in practice since the 1970s and is opposed to advertising by doctors or hospitals.

To argue against advertising by doctors, Dr. “Scalpel” makes two points:  First, his (unsuccessful) experience with advertising in the Yellow Pages in the 1970s and 80s.  And second, an advertisement he found in an airline magazine for another surgeon which claims a very high cure rate for prostate cancer surgery with a very low rate of complications and side effects.

His conclusion: “The public is flooded with advertisements promising miracles that often cannot be delivered. Disappointment surely follows.”

I agree with Dr. Scalpel on a number of points.  I believe strongly that doctors and other health care providers have an additional burden to advertise ethically and truthfully above and beyond an average business.  If you buy a crappy new TV based on an inaccurate advertisement, you’ll be out of some money and might be annoyed at the poor quality picture.  But if you choose a crappy doctor based on overhyped advertising, you are potentially risking your life and health!

I don’t know a lot of details about prostate surgery, but I agree the advertisement quoted by Dr. Scalpel sounds a little fishy.  If I were going to see that doctor, I’d ask some very pointed questions about what exactly is meant by “cure rate” and how that doctor got those numbers.

However, I think the conclusion that all advertising by doctors is bad is the wrong one.

My foremost goal in my career is to be a healer and do the right thing for all my  patients.  But after that, I am also a business owner and I want to run a successful and profitable business.  Advertising is a potential way to help my practice succeed.

But advertising is by no means guaranteed to work.  Huge corporations with multimillion dollar budgets have had epic failures in advertising (anyone remember New Coke from the 80s?).  So, the fact that Dr. Scalpel’s advertisement in the Yellow Pages didn’t work out is hardly a condemnation of all advertising.

Health care advertising that claims overhyped or dubious benefits is indeed a problem, but I don’t believe that just because some ads are inaccurate, all ads should be banned.

I personally think that advertising CAN be helpful in both generating business for my practice and educating potential patients about treatments that could help them.  I think it is important that doctors get involved with the ad writing though.

If I hire a marketing firm to create ads for my practice, they could easily overhype what I have to offer.  It’s up to me to ensure that the advertisement provides a realistic picture.  A marketing firm only cares about generating business and revenue. As a doctor, I also care about who does NOT need treatment and making sure that those people are educated and counseled appropriately (even if I don’t make as much money from treating them).

Like it or not, health care is a business in America, and I have to run a successful business to be able to help patients.  If I can use honest and ethical advertising to help bring in more patients that can benefit from my care, I most certainly will.

America is also a free country, and doctors, hospitals, and drug companies will continue to advertise within the limits of free speech and legal requirements.  As a doctor, part of my job is to tell patients that just because they see some new procedure or drug in an advertisement doesn’t mean it’s right for them.