Full disclosure: This topic has been discussed many times and the best article I have read on this question by far is by our fellow direct primary care doctors at CovenantMD. Please feel free to read their full article by clicking the link. 

The most common question of all questions I get is "Why would I pay a monthly membership when I already pay for health insurance premiums?" The first thing I do is remind people that most people with insurance already pay twice for health care. Once for your premiums and then the second time for prescriptions medications, labs, imaging, and anything else outside of the premiums. So, direct primary care aims to decrease the amount you pay the second time you pay for health care, while adding significant value to your investment. 

Scoliosis, as many of you know, means lateral curvature of the spine. It is a structural alteration that can progress as the person grows, leading to significant deformity. Adolescent idiopathic scoliosis (AIS) is typically defined as curvature greater than 10 degrees. Curvatures that are less than 10 degrees have no long term clinical significance. 

The 3 subcategories include:
- Infantile (0-3 years)
- Juvenile (4-9 years)
- Adolescent (>10 years)

So how common is AIS?
The prevalence of AIS is approximately 3% and only 10% of those adolescents require treatment. Males and females are affected equally. However, the risk for curve progression is 10 times higher in females than males. The degree of curvature is measured by Cobb angle. When considering prevalence, think about this:

• Cobb Angle > 10 = 2-3% 
• Cobb Angle >20 = 0.3-0.5%
• Cobb Angle >30 = 0.1-0.3%
• Cobb Angle > 40 = <0.1%

So if a family member or friend has scoliosis, first appreciate their strength and uniqueness, and then ask about their angle if they wish to share. Knowing that piece, one can greatly appreciate the prevalence of their condition. 

It may surprise you, but your primary care doctor can screen for scoliosis, diagnose, order the X-ray, and even start brace treatment if needed. If surgery is indicated, your primary care doctor can coordinate efficiently with an orthopedist. Point is, don't run to an orthopedist the minute you hear about scoliosis. This diagnosis, like any other diagnosis, requires a conversation.

What does having scoliosis mean? Do I have to have surgery? What are the post surgical challenges I may encounter as I am recovering? Even after treatment, what should I worry about? What about pregnancy? What about sports or even contact sports? Is this genetically linked that I need to have my kids screened? What about working out - any precautions I should take?  

So, what does all this mean in adulthood?
Regardless of getting treatment or not, there definitely are clinically significant concerns one may face as they enter adulthood. Even when the spine is corrected to midline with surgery, individuals must be cautious when weight training, aerobic activity, and may have chronic back pain. The muscles that support the spine have to adjust and may be prone to strain. Rotation is largely limited in the surgically treated spine, so one may not be able to participate in some activities. 

Mental health studies have yielded conflicting results based on surveys. My opinion is that this only reminds us that diagnoses are perceived differently by each one of us. I argue that your perception of your diagnosis, whatever it may be, is facilitated by your team of doctors. As physicians, we have a duty to treat illness, but also to be a coach, a friend, and most importantly a partner in any journey that requires chronic management. Positive thinking and supportive behavior has shown study after study to improve outcomes - that is the job of the physician. Be a true advocate and partner. 

After surgical correction, pulmonary function improves, but skeletal alignment may still have long lasting joint pains. 

In those patients where surgical correction is not done, the curvature can progress and cause more pain with pulmonary issues. As our bones get weaker with age, the spine may slump even more leading to alteration of your gait. 

Surgical correction at times requires repeat operations, scar healing, and hospitalizations can be prolonged. Thus, the sooner we can screen and treat, the better outcomes we get. Self-image might be an issue in adolescents. Wearing a brace or having visible scars after surgery may leave keloids that challenge an adolescents self image. 

Scoliosis is a condition that must be identified early, have a management plan, and must be included in long term management. This is not, like any other diagnosis, something that is "repaired" and forgotten. 

Build a relationship with your primary care physician to be at your side as you enjoy the many blessings life has given you. Nothing is impossible. We just have to make some adjustments with the challenges that are thrown our way. 

Please help me raise awareness about scoliosis and I hope I taught you something new about this condition that you may not have known before. 

To your health and our community, 
Dr Ahmed 

Memorial Day was originally established to celebrate Civil War heroes in a single unified day, instead of separate days celebrated by the Union and Confederate states. Around the 19th century, Memorial Day expanded to celebrate all veterans who fought as American forces. 

As physicians, we learn from one another and are united in our thirst for knowledge to better serve humanity . War, in all its ugliness and chaos, demands innovation in science and technology. Thus, it is not surprising that modern medicine seems to have strong roots during times of war. The ancient philosophers and scientists created a foundation for physicians during the Civil War to innovate to meet the demands of its wounded soldiers, but also to create standards of care that we practice even today. Here are 5 innovations that were developed during the Civil War:

1. LIFE SAVING AMPUTATION 
- The old practice of saving limbs with wound cleaning using rats and maggots was replaced with cutting off infected limbs to prevent the spread of infection. In fact, Union soldiers were known for amputations, had less mortality from their procedures, and took no more than 6 minutes to perform. The technique not to cut through joints and to cut far away from the heart as possible became the standard of care. 

2. THE ANESTHESIA INHALER 
- Stonewall Jackson's surgeon recommended the removal of his left arm after it was injured during friendly fire. When a chloroform-soaked cloth was placed over his nose, General Jackson muttered, "What an infinite blessing," before going limp.  The cloth was inefficient as the liquid evaporated quickly, so Dr. Julian John Chisolm invented a 2.5 inch inhaler. Chloroform was dripped through a perforated circle on the side onto a sponge in the interior - the patient inhaled through tubes and the vapors mixed with air. This new method required less liquid; thus, allowing the physicians to treat more soldiers and using less supplies. 

3. CLOSING CHEST WOUNDS
- Benjamin Howard, an assistant surgeon, was told to do busy work while his superiors performed the surgeries. He started to experiment and realized that if he closed the chest with staples and linen, the lungs did not collapse as they did when the chest cavity is opened from negative pressure; thus, there was no suffocation. Survival rates quadrupled with this new technique. This technique became the standard treatment. 

4. FASCIAL RECONSTRUCTION 

Dr. Gurdon Buck, father of modern plastic surgery, looked onto a young 20 year old private named Carleton Burgan of Maryland. This private had battled pneumonia and now the mercury pills had led to gangrene that was moving from his mouth to his eyes. His right cheekbone had to be removed and the young man was willing to try anything  to stop the infection. Dr. Buck was the first to photograph his progress of his repairs and use tiny sutures to minimize scarring. 

5. THE AMBULANCE-TO-ER SYSTEM
- The Union went into the First Battle of Bull Run on July 21, 1861 not expecting a true battle. As approximately 1,011 Union soldiers lay wounded, the ambulances remained empty, leading to high numbers of mortality. The civilian drivers at the time were, according to some, described as "cowards" or "drunkards." 

Jonathon Letterman, the medical director of the Army of the Potomac, created a model of triage that we all know today. He established caravans of 50 ambulances, each with a driver and 2 stretcher bearers. He hired private wagons to carry medical supplies. The ambulances had spring suspensions and a lock box to prevent soldiers from stealing protein, bedsacks, and morphine that was reserved for the injured. 

Every war brings innovation and the medical community must not forget the sacrifices made by soldiers, scientists, physicians, and several other professionals who made modern day medicine what it is today. 

In this reflection, we must ask the question, have we been effective in preserving that fundamental drive that our predecessors had to innovate to help a large number of people without regard to creating any complex systems that may interfere in allowing the injured to access the innovation?

Memorial Day should make all of us pause and reflect on the many lessons learned across  all professions during our times of war.  What is even more fascinating is that those lessons continue to teach us today; regardless of how advanced we think we are as a society.

In loving memory of all fallen soldiers, 
Dr. Ahmed   

Many of you might have read the book Toyota Kata, or heard of lean management. Furthermore, many may have heard about lean health care. As the principles of lean management take over organizations across many industries, we find that the most successful organizations are those who achieve integration and implementation of these principles. But, it is not these principles alone that make an organization successful. It is the organizational culture of commitment, leadership development, empowerment, and employee investment that makes the difference. 

Health care has become an industry that is one giant green monster that is zapped from many stakeholders, like the government, private corporations, pharmaceutical companies, and insurance companies, all trying to get this monster under their control. But who is really out there protecting the people? 

As I mature as a physician in this circus, also known as United States health care system, I am starting to realize a few things. When I was a medical director at a large health system, I saw how decisions in health care are largely led by thinking of margins before patient care. My department was not a revenue generator compared to others, but a cost savings one. But, as I continued to grow my team and expand our services, I realized that no matter how hard I tried the decisions I would make were always under the scrutiny of corporate leadership. How is this different than the practice of medicine?

The decisions that physicians make "out in the field" - in clinics, hospitals, etc - are largely guided by insurance companies, government insurance, hospital policies, and pharmaceutical companies. We often hear, "that costs too much" or "my insurance does not cover that" or "they are not in my network" or when a hospital finds out a patient is not in network, the move to a different hospital happens at lightening speed! 

Kata, in Japanese, means a way of doing something, a pattern, or a standard form of movement. So as leaders, the challenge is to get team members implementing a routine without requiring constant input from administration. The idea is to have a routine that nurtures continuous improvement and adaptation. More importantly, decisions are pushed to those who are closest to the issue. So, when Toyota stops the line when a part is not put in correctly, the lights go off, the line stops, managers come over to help repair the part, others assist as needed, and the line resumes once corrections are made. This process is more efficient, has a team approach, allows everyone to adapt and improve the process immediately by correcting a routine to make it more efficient. 

Health care today, uses cost benefit analysis (CBA) to the max! The problem is that the budget is a dependent variable, not independent. 

Instead of CBA, health care providers and leaders must think in terms of target conditions to move towards their vision. More importantly, not only do organizational leaders must think this way, but physicians must practice this with their patients; thus, developing their patients as leaders of their health care! 

Here is an example of how this works, especially in primary care. If I have a overweight type 2 diabetic, my first visit might be discussing the importance of blood sugar control, diet, and how their current medications will help them prevent further organ damage. 

1st step: Understand the current situation. What is their current blood sugar control and where do they want to be in terms of their diabetes control? What does the future look like? What is their overall prognosis today if their current situation does not change? 

This visit is truly about goal setting. As Charles Duhigg says in Smarter, Faster, Better, goals should be SMART (Specific, Measurable, Achievable, Realistic, Timeline). 

2nd Step: Set SMART goals or target conditions to achieve the vision of - coming off insulin, achieving BMI less than 25, having an A1c< 6.5%, etc. Put a timeline together. Discuss potential barriers with possible solutions the patient can use when they might come across these barriers. 

3rd Step: Meet frequently. I recommend every 1-2 weeks the first month. Reflect on barriers, solutions, and give feedback of how to improve to stay on tract to achieve the goal set for that month. This is the  value of direct primary care, instead of the insurance model. 

4th Step: Provide ongoing support and always keep focus of the patients vision. When the vision is realized, celebrate! Get feedback from the patient and provide them with your feedback so that they can lead others. 

In my young career, I have held a few leadership positions and have been mentored by great leaders. My Master's program was fantastic and had created a good foundation to build my experiences. All my experiences and positions in health care form my current vision for my fellow Americans: Patient leaders who then lead others in achieving their quality of life. 

Imagine a United States health care system that truly implemented Kata principles and SMART goals. Naturally, in this type of system, primary care becomes the most crucial aspect. It is the place where patient empowerment begins and grows. Patients as leaders of their health care must be the mindset of future health care entrepreneurs.

In my company, this is how we achieve success - develop everyone around us as leaders. Whether it be patients, partners, or staff, our focus is to develop leaders. Empowered health care consumers should not be just a term we throw around. It is time we implement this belief  and it is the missing ingredient our health care needs. Otherwise, we remain broken. 

To better health for all, 

​Dr. Ahmed

Climate change, according to the EPA, means that the Earth is warming. In fact, the average temperature has risen 1.5 degrees Fahrenheit over the past century. It is expected to rise another 0.5 to 8.6 degrees Fahrenheit over the next hundred years. Why should we care and as a physician, what does this mean to our health?

This is an important topic. So important, in fact, that the American College of Physicians (ACP) has written a position paper on this matter. The rising temperatures have led to changes in weather and climate. This means more floods, droughts, intense rain, and more frequent and severe heat waves. 

Oceans are heating up and becoming more acidic and with glaciers melting, sea levels are rising. Many bacteria, insects, and other disease causing organisms thrive in these environments. You see, insects are effective carriers and vehicles for spreading disease to large populations. The Zika virus, Lyme disease, West Nile Virus, Ehrlichiosis, and the list goes on. 

In addition, water is at risk of becoming contaminated and the air is becoming more polluted and full of allergens, which lead to significant health hazards from infectious disease to cardiovascular and respiratory illnesses. 

The health effects are already being felt by all of us, especially physicians. The number of emphysema exacerbations, sinusitis, allergies, asthma flares, and respiratory failure from these pathologies is increasing in frequency and severity. The number of strokes and heart attacks in young and healthy individuals are increasing - in fact, I tweeted a NY Times article a few months ago that raised this concern. 

I was in the doctors lounge last weekend and talking with a critical care friend of mine. As we sat there talking about our day, I asked him "how has the flu season been?" To this he responded, "we had worse years, but still lost a few." To us, the stories of healthy 18 year olds going on ECMO - life saving bypass machines- are not extraordinary. Unfortunately, it is all too common. In our experience, we have seen and heard of many young healthy folks pass away from things like the flu or an asthma flare triggered by allergies. Cases of infectious disease from contaminated water or food poisoning are also common. Ultimately, cases that come from contaminated food and water that should have been "ancient" are present and claim many lives today. 

It is hard to convince the general public about the importance of climate change and it's effect on all of us. Thus, we write position papers, use TV, radio, and journals to get the word out. But like any other health issue, as much as physicians long for conversations like this to take place before any crisis happens, it almost always ends up being at the bedside surrounded by concerned family members. 

The issue of climate change transcends countries, race, nationalities, or gender. This is a human issue. It's a international issue that must be taken seriously by each of us. Like many health challenges and pathologies, there are solutions and steps we can take today to prevent the development of global disease and fatalities.  Please read the ACP position paper published yesterday and also visit www.epa.gov to learn more about how you can help.