Strength Training in Primary Care

[Lithotomist]

It might be unfortunate. Maybe it would be good to have that kind of coverage.


So, as an S&C professional, I'm pretty sure I don't want to be involved with third-party payors--government or corporate (the former over-regulate and over-prosecute; the latter are just fucking crooks and cheats and monsters).

Look, exercise medicine is just that, but as I've pointed out many times, it has several properties that make it a unique medicine--inverted dosing, active self-administration rather than passive receipt, reducing the need for other medicines, and so on. Another unique property is its cost. Compared to most allopathic medical interventions, exercise medicine is really cheap, even if you go platinum with in-person training with an SSC. It's even cheaper when you consider the long-term impacts on health....personally and globally.

And then there are the intangible effects--beneficial on balance, I think--of putting up some of your own $ for this particularly powerful and cost-effective medicine. That's a big topic in itself, touching on issues of motivation, compliance, responsibility, etc.

None of which obviates the outrage that most primary care physicians are not actually prescribing exercise medicine, or prescribing it improperly. Our discharge instruction system in the ER has no option to produce written instructions to the effect that "you should really get up off your fat, lazy ass and go for a walk every day...it'll make you feel better than these toxic pills we just prescribed." In 25 years of medical practice, I've seen exactly one exercise prescription....the one a new client brought to me a couple of months ago ("strength training twice a week for 6 months").

So yeah...it's all fucked up. But I'm not convinced that coverage is the answer.

Yes, essentially all of that. The more integrated one gets into 3rd party payers the more one is subjugated to regulations, paperwork, the nightmare essentially. As for why a urologist is recommending strength training I see a lot of men for concerns of low testosterone, libido and whatnot. Unless there are clear reasons for their condition such as a pituitary tumor etc I've incorporated strength training as first line therapy prior to starting TRT in most cases. I know the data regarding T response to strength training is all over the map but there is more to it than just the number. As you all know the global benefits from this work far exceeds what you would get from T alone.

[OITW]

Yes, essentially all of that. The more integrated one gets into 3rd party payers the more one is subjugated to regulations, paperwork, the nightmare essentially. As for why a urologist is recommending strength training I see a lot of men for concerns of low testosterone, libido and whatnot. Unless there are clear reasons for their condition such as a pituitary tumor etc I've incorporated strength training as first line therapy prior to starting TRT in most cases. I know the data regarding T response to strength training is all over the map but there is more to it than just the number. As you all know the global benefits from this work far exceeds what you would get from T alone.

Just a word of support. I was sent to a British endocrinologist "specialist" in hormones because I complained of low T (200s as a 40ish male, way low but the GP called that "in range" and said that raising my T with my "high cholesterol" would kill me). Endo quizzed me whether my breasts ached. Took me a while to figure that because I lifted he figured I was doping. Once we got that squared away he asked if I could still get erections. Yes. Well, then, there's no shortage of T at all, is there, thank you, good day.

Got sent to an American urologist at the base for something else, holy cow, first guy that ever had a clue about T and the processes of making it and the myriad potential disruptors, and the first to understand that a total T number in the 200s was damn near dead. First guy that actually ordered the right tests for me (after many, many indequate tests). Even better, between the above "specialist" visit and the urologist, got rid of the (now) ex-wife. New T count in the 500s.

I wouldn't have expected the urologist to know more than the endocrinologist, but I know better now. And he encouraged my lifting as well. So here's my vote of support to you for being the doc who knows what men need.

[Culican]

And FYI, Medicare is the largest payer and most insurances follow their lead, so it affects everything.

Thank you, that explains a lot.

At 5'9.5" and 179lb my doctor put a notation in my medical record that my BMI was too high. I saw it when I was looking at my lab results on the online patient portal. The weird thing was that he never even said a word about it to me. I was angry at first but then thought, "Well, maybe he has to do this because of some Obamacare requirement", so I calmed down.

I am up to 185 now, I can hardly wait to see what happens at my next visit. BTW, I am 61 and it is private (employer provided) insurance.

[Kiril]

At 5'9.5" and 179lb my doctor put a notation in my medical record that my BMI was too high. I saw it when I was looking at my lab results on the online patient portal. The weird thing was that he never even said a word about it to me. I was angry at first but then thought, "Well, maybe he has to do this because of some Obamacare requirement", so I calmed down.

I am up to 185 now, I can hardly wait to see what happens at my next visit. BTW, I am 61 and it is private (employer provided) insurance.

In my language it means 80 kg for 1.8m. Which weight did he expect from you? 70 kg? 65?
Even if you are very thin person, but have a big belly, like many people at their 60's, what has it to do with the BMI? It's the body composition problem, not the weight. I just hope your doctor has some algebraic issues, not a scientific ones.

[I_iz_a_fatass]

This kind of shit is coming to America. Medicare is starting to enforce their "MIPS" measures. If docs don't badger their patients about BMI at every visit, pay will be docked 9%. This is what happens when you put your government in charge of your health care.

Given (at least in the USA) that no state is below a rate of 20% obesity and half the states are at at least 30%, I don't see BMI being brought up for the overfat being a bad thing. Pity they can't get decent advice about how to conquer it from the same doctor though.

[Elephant]

My hospital group is currently pushing a MIPS drive, and no, I don't get to choose which measures I follow. They have chosen about 5 that they want to see in a note somewhere during the admission, and if the patient gets handed off, the new provider needs to do it again. Many of these measures are best left to the outpatient setting, for instance, I'm supposed to document their blood pressure and document that I've talked to them about lowering it. Blood pressure is pretty unreliable in the inpatient setting, and often the blood pressure is high because patients are sick and in pain and stressed out. Often not a great time to diagnose essential hypertension or start new meds.

And yes, I'm supposed to badger them about their BMI on each visit and each change of provider in that visit. The whole MIPS documentation is longer than the actual note and takes a long time to complete while adding no useful information except as a way to dock pay if it isn't there and in the proper way.

And FYI, Medicare is the largest payer and most insurances follow their lead, so it affects everything.

Your hospital group has chosen to include BMI on its list. They could have chosen other measures. That is not quite Medicare forcing all doctors to badger patients about BMI.

Insurers have the choice in this regard to follow Medicare or not. The government is not forcing them.

I've heard many doctors complain about their hospitals' electronic records systems and documentation requirements, quite apart from Medicare. Electronic records systems are generally a mess.

Doctors advice patients keep BMI in a range even in countries without Medicare or its equivalent. From what I can tell, it's a reasonable, simple to compute, proxy for bodyfat in most people. A lot of people would do well to decrease bodyfat. The problem is not realizing that BMI doesn't work for all, such as those with lots of muscle.

[Pluripotent]

Your hospital group has chosen to include BMI on its list. They could have chosen other measures. That is not quite Medicare forcing all doctors to badger patients about BMI.

It wouldn't matter which measured they chose, it would be equally burdensome and make about as much sense, and have no impact on patient care except to shorten face time because of increasing documentation requirements. I suspect they chose the measures they did because they are the least burdensome to document, and it's still a pain.

Insurers have the choice in this regard to follow Medicare or not. The government is not forcing them.

I'm not sure what part of a 9% dock in pay is "not forcing" compliance.

[QUOTE]
I've heard many doctors complain about their hospitals' electronic records systems and documentation requirements, quite apart from Medicare. Electronic records systems are generally a mess.
[QUOTE]

Virtually everything that was supposed to be the reason to enforce EMRs is yet to come to pass. They were implemented far before their time. Quite apart from bringing medical records "into the future," they have instead locked it in the past circa 1990s. They all must be opened in a sandboxed window that launches the corresponding anachronistic operating system that can launch the browser from that era.

Doctors advice patients keep BMI in a range even in countries without Medicare or its equivalent. From what I can tell, it's a reasonable, simple to compute, proxy for bodyfat in most people. A lot of people would do well to decrease bodyfat. The problem is not realizing that BMI doesn't work for all, such as those with lots of muscle.

So having your doctor be required to constantly tell you to reduce a number that would be irrelevant if you were healthier helps who?

[Culican]

In my language it means 80 kg for 1.8m. Which weight did he expect from you? 70 kg? 65?
Even if you are very thin person, but have a big belly, like many people at their 60's, what has it to do with the BMI? It's the body composition problem, not the weight. I just hope your doctor has some algebraic issues, not a scientific ones.

It calculates to 26 which is just slightly overweight. I guess that's why he put it in the record.

[David Kirkham]

I just had a nerve conduction study done for nerve pain in my left shoulder. Damn that hurt.

When the doc finished sticking needles in and shocking confessions out of me he said, "Everything seems normal, though your ulnar nerve does conduct slightly less in your left arm than your right. Have you lost any grip strength?"

(Keep in mind this guy looked like he was allergic to barbells. I'm pretty sure I could have snatched him overhead...I'm not kidding.)

I replied, "Yes."

"How do you know?"

"Well, I used to dead lift 390 double over hand. I can only do 350 now without the bar rolling out so I have to supinate everything above that."

His eyes got really big.

"How much do you dead lift?"

"425."

I swear this is what he said next--word for word, "Well, THAT'S your problem. Your neck and trapezius muscles aren't strong enough. You need to go to PT. They have "special exercises" to strengthen your neck muscles. Also, the dead lifts are irritating your nerve. Stop lifting."

I said, "Doc, It's been hurting for 25 years. I've only lifted for 5 and lifting makes it feel better, especially overhead presses."

"Well your neck isn't strong enough. You need special PT exercises...and stop dead lifting."

All I could do was stare at him...

"Thanks for the study doc."

[Chad Mynhier]

I swear this is what he said next--word for word, "Well, THAT'S your problem. Your neck and trapezius muscles aren't strong enough."

So, your neck and trapezius muscles aren't strong enough to be doing what they're obviously strong enough to be doing.

"It doesn't matter how beautiful your theory is, it doesn't matter how smart you are. If it doesn't agree with experiment, it's wrong." -- Richard Feynman