A Recent Case Summary
A recent case might help clarify some of the theoretical ideas about how RiverRock works.
A patient found RiverRock looking for help to deal with a swollen knee. He had already been to an urgent care physician, and received basically an x-ray and a referral to an orthopedic surgeon. He didn’t get a chance to discuss whether surgery was really necessary, and was looking for at least a thoughtful 2nd opinion, if not other options.
RiverRock’s Basic Medical Care
In the office, even our standard medical care went far beyond the usual. We pulled the fluid by needle out of the joint right there in the office (which provided some relief), and sent it for additional testing, to rule out infection, crystal disease, inflammation. We suspected that it was a meniscal tear, but wanted to make sure it wasn’t a blood clot, so we ordered an ultrasound, and confirmed the diagnosis with an MRI.
With the diagnosis confirmed, we were aware of a paper that had changed the recommendations for treating meniscal tears, indicating that surgery was no better than placebo. Knowing that, we used our partnership with Rubicon MD to obtain online consultations with an academic orthopedic surgeon, as well as an academic rheumatologist, to get the latest thoughts on treating these tears from two different specialties.
Since neither one recommended immediate surgery (the other doctor’s recommendation was out of date), we were able to avoid referring the patient to a surgeon, and instead referred the patient to a physical therapist to strengthen the knee, and protect the meniscus from further injury. We also offered to inject the joint with a steroid for pain relief (which the specialists had recommended), but the patient wanted to avoid that if possible.
The RiverRock Difference in Action
We then started discussing the RiverRock-based analysis. One of the major reasons for meniscal tears weakness in the muscles surrounding the knee, leading to poor body mechanics, and unnecessary stress on the cartilage. Physical therapy would help strengthen the knee, and improve the mechanics, but the patient was overweight, and the additional stress from that weight would inevitably increase the risk of further injury.
We started using motivational interviewing techniques to discuss possible dietary changes (RiverRock is a strong advocate of low-carb diets), but the patient quickly objected that making significant changes would be difficult due to the amount of stress he was experiencing at work.
We realized that only by helping him deal with his stress would he be actually successful in implementing any lifestyle changes. So, we switched gears, and began discussing different mechanisms of reducing stress, including utilizing the HeartMath mindfulness biofeedback device, and increasing his social interaction with his close friends.
Although we didn’t really discuss diet any further, we noticed that the patient was quickly able to make changes in his diet on his own, after he reduced his stress levels. He has now lost almost 20 pounds, and has done very well with physical therapy.
While he still has a ways to go, he is actually addressing the root causes that ultimately led to his knee injury, and will ultimately protect his knee from further injury. Most medical practices would not have made the connection between mindfulness and stress management and the patient’s knee injury.
We also did a number of other things for this patient, including calculating his 10-year cardiac risk to decide if he needed cholesterol medication or aspirin (he didn’t, but had incorrectly been recommended to take both by other doctors), checking his vaccines to make sure he was up to date on his adult vaccines, and making sure he got his colon cancer screening (he didn’t want a colonoscopy, so we were able to set him up with the new cologuard test instead – no one else had told him there was another new option). He was concerned about his family history of Parkinson’s, so we dicussed starting a NAC supplement (unproven benefit, but very very safe).
We coordinated all of his testing using project-management software (tribe.do) so that both the patient and his doctor did not lose track of what needed to be done next.
While some of these things might have been done by DPC doctor as well, almost none of them would’ve been done by any insurance-based physician, and even most DPC physicians would not have done all of these things.
Using the 5 aspects of RiverRock’s root-cause analysis:
- Cognition/emotion – stress, social integration
- Behavior – diet, exercise
- Standard medicine – knee joint fluid testing, ultrasound, MRI, specialist consultation, prevention
- Genetics – family history
By analyzing the case in terms of root causes, we were able to elevate the patient’s health in a much deeper way than simply sending him to a surgeon.