05/21/2026
"My story". This will be the first time this has been written down but has been explained to many throughout my medical career. Why I do what I do as a physician and surgeon.
Preface, when you see me as a patient, only those who come from other medical offices for second opinions realize how differently I do things. Comments include: no one ever examined me before, the doctor just looked at a report in the doorway and said I needed surgery, I never saw the doctor...only his assistant. I've never seen the surgeon. No one told me anything or explained anything.
As a freshman swimmer, I had an injury which greatly affected my life. Constant pain, lack of sleep, regular ice packs on both my shoulders day and night particularly at 300 am all while trying to get grades and compete collegiately.
My mentor at home referred me to "THE" Sports medicine guru of the US and world who was a founding member of our national society in Orthopaedic Sports Medicine.
I was first seen by the Orthopaedic Fellow (I was one of those at one point learning subspecialty training in Sports Medicine after my Orthopaedic Surgery residency). The doctor asked me two questions (he clearly didn't know anything about swimmers). He did only two exam maneuvers on me - a Neer and Hawkins test. (mind you I was 17 and I even knew then that the guy didn't put much thought or effort into finding out what was going on with my shoulders). He left the room.
A while later, he walked back into the room with "THE" guy!. He was giving the verbal presentation summary we all did in training. "THE" guy never looked at me, never introduced himself, didn't examine my shoulders, buried his head in the chart (old fashioned days with paper charts) and said, "Just quit swimming." He then walked out.
That was it. Nothing else.
Later, my mentor at home sent me to a local SoCal doc who was not nationally/internationally famous but was an ex-Yale swimmer. We had a nice Ivy League and Swimming chat for 5 minutes and he gave me a much more comprehensive exam and admitted he didn't know what was wrong with me, but we reviewed my technical stroke and made some suggestions to modify.
That was it.
It took me until I finished college, medical school, residency and sports medicine fellowship and a few years in practice before I finally took the time to self-diagnose my injury.
So, how do I do it as the doctor?
1. I'm going to ask a lot of detail on how your problem started. Injury? Position of your body? What the motion or injury was? Details of the initial symptoms? later symptoms? changes in symptoms? Current issues? What's been done to diagnose? What's been done to treat the symptoms. Where, if you have, did you go for PT (different PTs have different strengths and weaknesses just like us doctors). Injections? Where was it injected, how much pain relief? how long was it helpful? Surgery? What was done. How did you do? What the problem resolved? If not, what stayed the same or what changed? What is the current issue? Are you in competition now? When's the next event? If in school, what year? Years of eligibility? Position? Sport? etc.
2. Examination. I do on initial presentation and frequently the following appointments after, a full comprehensive examination. This is so much so that I actually have taught this examination to medical/osteopath students, family medicine, internal medicine and orthopaedic surgery residents, sports fellows, and physician assistants students for years. I published the exam technique years ago as a resource for others who are interested on Youtube (Doctor Miao). With this examination I can make an educated guess at the problem 95% of the time and with that make a reasonable guess at associated issues that most physicians won't look for.
3. X-rays, MRI's CT scans. I always review the images myself. I do not rely on written reports and have about a running 20% disagreement rate with them (both when I was in Kaiser and subsequently here in Las Vegas). My reasoning is that I see the pictures and body and can compare and contrast the reports, pictures and actual damage (or lack thereof) when doing surgeries. That gives me an advantage over the radiologist who has never seen the actual body or tissue damage. I always insist on reviewing these images in person with my patients rather than giving results over a phone call so that the patient has every opportunity to learn about their problem and ask direct questions about findings.
4. Injections. I will always explain what I'm injecting, to what part of the body and why. I always ask about allergies, if someone has diabetes (steroid medications can raise blood sugar levels and the patient can decline an injection or consult with their family doctor if not sure if it's safe for them), and if they are on blood thinning medications that lead to excessive bleeding or bruising to avoid a bleeding complication from the injection. In the last 15 years, I was the first physician in Las Vegas to introduce the use of ultrasound guided injections for both diagnostic accuracy, accuracy of the injections and identification of issues that may affect care. Some injections are clearly better suited for its use than others, but I have done extra training to make sure I have a good base of experience for its use and benefit.
5. Reviewing information. My habit is to list out the main issue and accompanying issues to my patients. Here's where it gets interesting. There are many situations where a patient thinks he/she knows what they have wrong. I would say that patients are at best 50% of the time on the right tract. The reason? Their information is usually from friends/family or the internet. Certainly, well-meaning sources but not likely knowledgeable to the individual's case. I will always explain what I'm finding and what I would suggest as options for care. It is important to me that the patient has a definite role in the decision making process rather than a passive one since it engages the patient to understand more and be actively a part of getting better. That works the best.
I'm well aware of the reviews that say, "he didn't explain anything to me" and can respond that what these folks are really saying is " he didn't tell me what I wanted or expected to hear" and so they didn't want to hear my (or at least acknowledge what I said) explanations. The very least I will do is try to educate and offer advice but can't expect to satisfy everyone's "expectations" if they are rigid to their own beliefs and not open to different ideas and pathways to health.
So, in summary, I do the opposite of my experience as an injured athlete. I will do much more to explore, think and determine what I think is a good path to health for your benefit as a patient because I deserved as much when I was a patient myself.
