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Dr. Darrell White's Personal Blog

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Archive for May, 2009

The Death of the Three-Sport Athlete, Part I

My younger son Lil’ Bingo, more universally known as Randy, is not going to play football this coming Fall. He suffered a concussion a couple of years ago as a freshman, and had another one this Spring playing lacrosse. His parents have decided that it’s too much of a health risk for him to take to play football this Fall. Unfortunately, but for a very good reason, Randy will therefore join the ranks of kids who are NOT  Three-Sport high school athletes. I thought of this as I was reading my email and came across the following:

Lacrosse Coach, in a wrap-up email to players and parents: “Make sure you take advantage of the July Lax camp list I sent last week.”

Universal response from players and their parents: “OK! As long as they don’t conflict with football.”

What? Wait! It’s July! The state rules say that football in Ohio can’t start until August 1st. Never mind lacrosse camp, what about summer jobs? Family vacations? Trips to visit potential colleges choices? Heck, what about marathon cloud Rorschach Test contests?

I hate to go all “old school” and everything, but remember back in the day when it seemed like everyone played everything? You know, Lance Armstrong (the original) All-American Boy kind of thing? The boys played some combination of football, basketball, baseball, hockey, or track and the girls played field hockey, basketball and softball. There was always someone who snuck in a season of some individual sport, some tennis or golf or swimming. Soccer and lacrosse were niche sports that were only played in tiny regional or economic pockets, but even the soccer players and the lacrosse players played a couple of other sports, too.

You remember those Three-Sport athletes, too, don’t you? It seems as if they weren’t just athletes. I remember being in class with kids who would graduate in the top 20 in high school who also seemed to be on every team in school. If you look around today they turned out to be some of the most successful adults you know.  Heck, I think my Williams friend Paul Bossidy was All-State in Connecticut  in football, basketball, AND baseball; my med school roommate Pat Spafford likewise in Upstate NY.

What happened? Where did they go? Where are the Three-Sport athletes of today and why aren’t they playing three sports?

The answer lies in the responses to the lacrosse coach’s email. In my (not so humble at all) opinion the problem lies not with the young athletes but with the coaches and parents of those athletes. I haven’t seen any evidence that the kids themselves are any different today than they were “back in the day”. Given their druthers I think today’s kids would choose to play a bunch of sports just like Paul and Pat and my sisters Tracey and Kerstin (both multiple sport All-Staters).  No, the problem lies with coaches who insist that “their” athletes devote all of their efforts to that one and only sport, and it lies with the parents who lack the gumption to stand up to the coaches and say “NO!”.

Let me offer an example of how this works at the highest level of high school athletics. There is a Catholic boys’ school here in Cleveland that is noted for both its academic excellence and rigor ,as well as for its sterling athletic record. This school, let’s call it St. Someone, is particularly famous for its longstanding football successes under a coach who has been there for 2+ decades; let’s call him Coach Win. Coach Win has been subtly and not so subtly telling his football players that they must play and train for football, and only football, all year round. Young men are discouraged from playing basketball because it interferes with “voluntary” off-season weight training (at which attendance is taken and recorded). They are discouraged from playing baseball or lacrosse because everyone knows that most of Coach Win’s  football starters run track (which he also happens to coach) in the Spring, even if most of them never go to any meets.

Not a lot of Three-Sport athletes at St. Someone ,as you might expect. This despite the fact that a huge percentage of the best jr. high athletes on one side of Cleveland forsake their public high schools specifically to play sports at St. Someone. Well, “so what?”, you might say. He keeps winning; he must be doing something right. Who cares if the boys don’t play other sports?  And how about all of those boys going on to play football in college on scholarships? Didn’t his way make that possible?

Here’s the rub…he should be winning MORE. With all of the athletes who are drawn to St. Someone he actually hasn’t won enough. His “way” of subtle and not so subtle pressure on the boys to play and train for only football has actually DECREASED the pool of football players and has contributed to several sub-par seasons in which a mediocre regular season was followed by an early post-season exit. Four years ago the Cleveland Plain Dealer’s columnist (the major local paper has columnists for high school football!) lamented the premature demise of the St. Someone football season after the starting QB and running back went down with injuries. In a school where 150 boys went out for freshman football a lack of depth was given as the cause! Where were the back-ups? Despite a stated desire to continue playing multiple sports many of them  felt forced to choose. When told that basketball practice or a baseball hitting drills were not adequate reasons for missing “voluntary” winter football workouts they chose to drop football. The following season injuries to a “thin” line resulted in another early playoff loss. Where were the backups? You guessed it. Playing their other sports despite a professed love and nostalgia for playing football.

It’s not just happening at St. Someone, either. The lacrosse coach quoted above coaches Randy at  Suburban High School which is most notable for its low student participation in sports, and it’s rather extraordinary mediocrity in all but the “tail that wags the dog” sport of soccer. Here, too, rather than reveling in the opportunity to have Three-Sport athletes on the football team ,the coaches behave in exactly the same manner as Coach Win at St. Someone. What about soccer at Suburban then, where Coach Kick has an equally long run of championship teams? Ah, that’s where the other half of the problem comes in– the athletes’ parents and all of those college athletic scholarships that supposedly are only going to go to the athletes who do it Coach Win’s or Coach Kick’s way.

How many times have you talked to someone and asked them why Little Johnny or Little Janey is no longer playing whatever and heard something like this: “Well, we just think the only way Johnny is going to play at the next level is to concentrate on just this one sport now.”? No matter how old Little Johnny might be. As soon as there are tryouts for a sport, as soon as there is a travel team or developmental team, as soon as there is a coach who will say that “the chances are better” if the athlete only plays that sport the parents start to see college dollar signs. Heavens, some of them start to talk about pro sports! A good little lacrosse player at Suburban High School did NOT come out for the lacrosse team this year after Coach Kick suggested a local spring Premier soccer program. Funny thing, though…he failed to make the team and lost out on playing lacrosse, too.

You see, that’s the dirty little secret that Coach Kick and Coach Win never let on to. Most of these kids are not going to play their sport in college, at any level, with or without a scholarship. The odds against them are just too great. The kids who ARE going to play in college would have played even if they were on one or two or even three other teams. In fact, they may have been BETTER in their primary sport if they had continued to play other sports, acquiring additional athletic skills and avoiding over-use injuries and such. Let’s not even bother to talk about the (un-) likelihood of a pro career; the numbers are so small and the roadblocks so numerous that it is the height of folly to even mention making a living at a sport when discussing high school athletes.

So, is it hopeless? Is the multi-sport high school athlete as extinct and little-lamented as the Dodo bird? Nah, of course not. It doesn’t have to be like this. The responsibility and the power rests in exactly the same place that harbors the problem: in the hands of the coaches and the parents. My brother Randall is raising a son who is a legitimate Div. I prospect in two sports, lacrosse and hockey. The longer he plays lacrosse the smaller the chance he has to play at “the next level” because of the prevailing coaching attitudes there, and yet he plays on. Why? Because he’s having a ball! Because his Dad (the best natural athlete I know, who is an ultra-competitive nut, by the way) thinks that’s just fine. Because both his lacrosse coach and his hockey coach find that multi-sport athletes tend to be great kids to coach. They seem to have learned a bunch of different ways to WIN! For whatever it’s worth my nephew is presently going over his Div. I lacrosse offers.

I think my nephew’s coaches are somewhat rare,though. Too rare to depend on as the solution to this problem. The self-interest of having kids playing only one sport is simply too irresistible for them.  No, in the end if we are going to save the Three-Sport high school athlete from extinction the effort is going to have to come from the parents.  The parents of our young athletes are going to have to wake up the the fact that their true self-interest does NOT lie in creating a  one-sport scholarship athlete because there is simply too much that is beyond the  ability of any parent to do so.

Parents need to wake up to the reality that it is their job to create this next generation’s Paul Bossidys and Pat Spaffords, the next Tracey Godins and Kerstin Winklers. Those 3-sport athletes tend to do pretty well on the playing fields of life.

They tend to be winners.

The Ultimate Consumer Service Business

I’ve been thinking a lot about health care recently. Real health care, not Health Care as in “Health Care Crisis” or “Health Care Reform”, but the kind of health care that is provided by doctors and nurses and all kinds of other health care providers. You know, like making sick people better, and keeping healthy people healthy. The kind of health care that old guys like me (I’m 49, in case you were wondering) got from pediatricians like Dr. Roy in Southbridge, MA in the 60’s, or like my sons get from Dr. Gerace in Westlake, OH today.

I did a lot of thinking about this some 5 or so years ago, too, when I developed the concepts that eventually resulted in Skyvision Centers. My mini-epiphany at that time is that medicine is the ultimate consumer service business. At its core medicine is about one group of people providing a service to another group of people who either want or need that service. It’s the most intimate type of service, too. One to one. Face to face. You and me.

There is a remarkable lack of difference between doctors (and hospitals, for that matter) when you look at the outcomes that arise from that service– how many people get better after receiving medical care for their illnesses. The difference between the top 1 or 2% of doctors and the 50th percentile in terms of real medical outcomes is remarkably small, and much smaller today than it was in the days of my Dr. Roy.

Sure, there are differences in how people arrive at getting better. Some very instructive studies from Dartmouth have shown dramatic regional differences in the U.S. in how much money is spent on treating heart attacks, for instance. By and large, though, the same number of people get the same amount of better no matter where they are treated or from whom they received that treatment, and the quality of those treatments is several orders of magnitude greater and better than it was in my youth.

So what was it about Dr. Roy that people in my generation seem to have so much trouble finding in medical care today? If the treatment of diseases is so much better now why do so many people complain about medical care today? Why is it that Dr. Gerace has people lined up waiting to see him while other doctors don’t? Why do people rave about their experience at Skyvision Centers and complain so bitterly when they need to have a consultation at some of the most famous medical institutions in Cleveland?

I think it’s because Dr. Roy, Dr. Gerace, and I were all, once upon a time, caddies.

Seriously. We spent the earliest part of our working lives on the lowest rung of the service ladder, providing one-on-one service for a single customer. Because of that I think each of us realized that what really sets doctors (and hospitals) apart is what a patient experiences when they visit. The most successful doctors and the most successful medical practices are those who have realized that the central character in the play is the patient. The most successful caddies never forget that the most important person on the course is the golfer. The job of the caddy is to help the golfer perform a well as possible (maximize the health of her game) while at the same time making sure that she has a wonderful experience on the golf course.

Ben Stein wrote a recent column in the NY Times about his first real job; he was a shoe salesman. Imagine, at 17 years of age, selling shoes. Days filled with all manner of customers and handling the foot of each and every one of them. Customer service and sales is “learning the product you are selling, learning it so well that you can describe it while doing a pirouette of smiles for the customer and talking about the latest football scores” no matter who that customer might be. Tinker, tailor, soldier or spy, junior partner or janitor. Be they humble or haughty, gracious or grating. Totally focused on that one customer in front of you in order to provide them that service. The same can be said for any front line service job. Waitress in a diner, car mechanic, you name it.

My first summer job was caddying, and I caddied for parts of each summer through medical school. As I think about it now after reading Stein’s article it’s amazing how many parallels there are between my first job as a caddy and my career as an eye surgeon. I toted the bags for one or two golfers at a time; I usually have a patient, patient and spouse, or parent and child in the office. I was a better golfer than almost all of the men and women for whom I caddied; I know more about the eye than every patient who visits, google notwithstanding. In both circumstances my success was/is determined by my customer’s (golfer/patient) outcome, their “score”, as well as their view of the experience. Even a career-best round doesn’t feel quite as enjoyable if it took place over 6 hours in the company of a surly caddy!

I’ll tell the story of how this turned into Skyvision Centers another time; it’s a neat story and I love telling it. For the moment, though, I have a little experiment for anyone who might be listening, and a modest suggestion for the powers that be in medical education (who most assuredly AREN’T listening). The next time you visit a doctor ask him or her what their first couple of jobs were. See if you can predict which of your doctors or dentists or nurses had what kind of jobs before their medical career based on the kind of experience you’ve had in their offices or institutions.

Let’s add a little time to the education of the folks who take care of our medical problems, especially our doctors. How about 6 months selling shoes at Norstrom’s. Or a year of Sunday mornings slinging hash at a local diner. Better yet, let’s get all of those pasty white interns out on the golf course with a bag on their shoulder and a yardage book on their hip, golf hat slightly askew and Oakleys on tight (for the record, even people of color end up “washed-out” after a year of internship). Let ’em learn how to take care of a customer without the huge advantage of all that medical knowledge. We’ll take the best of them and turn them loose in offices all across the land. Those who can’t hack it, the ones who can memorize the history of Florsheim but can’t bring themselves to touch a foot, who are scratch golfers but can’t bring themselves to congratulate the hacker who sinks a 30 foot double-breaker, those we’ll hide in the lab, or put them in huge, anonymous medical centers, one more anonymous member of an anonymous team hiding under the brand umbrella of some “World Class Clinic”  where one-on-one customer service never really happens.Because the ultimate consumer service business is medicine.

Just ask a caddy.

Of Google, Heroes, and Crossfit

HERO: A person noted for feats of courage or nobility of purpose, especially one who has risked or sacrificed his/her life.

I wrote an essay in college titled “There Are No More Heroes.” I actually wrote it in French–I was a pretentious fop in college. Raised on the stories of athletic exploits from the 50’s, 60’s and 70’s, with the memory of my Dad’s words about JFK and RFK front and center, I viewed the question of present-day heroes through the prism of a post-Watergate world in which sportswriters were no longer covering up the mis-adventures of the athletes they covered.  No one talked about heroism at home or at war, since the war at hand was Viet Nam. With such a narrow focus it’s no wonder that I reached that conclusion.

It turns out that other people have been looking at this same question of late. Maureen Dowd, columnist for the New York Times, was recently interviewing Eric Schmidt the CEO of Google. Ms. Dowd was taking Mr. Schmidt to task for Google’s perceived role in the demise of the newspaper as a viable business (and confusing “newspaper” with “journalism”, but that’s another post). Google, and Craigslist, have slowly usurped the newspaper as the “go-to” advertising location for enormous swathes of commerce. His defense is that Google has simply offered a better product: “The whole secret here is the ads are worth more if they’re  more targeted, more personal, more precise.”Schmidt calls this “[understanding] your history,” whereupon Dowd laments that Google is a “leader in stripping away privacy.”

” ‘It’s fair to say that there will be no heroes,’ Schmidt says. ‘Heroism requires understanding the person in the absolute best light. I’m not sure this is good. What was Barack Obama like in elementary school? Oh yeah, here’s a picture of him picking his nose. God, he’s no longer a hero.’ ” Here is where Eric Schmidt and I fall into the same trap. We are confusing heroes and celebrities; we are equating heroism with notoriety and fame. Another common (though inaccurate) definition of Hero is: a person noted for special achievement in a particular field; synonym = celebrity.

What Mr. Schmidt fails to do now, and what I failed to understand way back in 1978, is understand that heroes demonstrate the attribute “heroism”, the qualities characteristic of a hero such as courage, bravery, fortitude and unselfishness. Most acts of heroism, and indeed most heroes, are anonymous even in these days of Google. Even with our “gotcha” journalism obsession (you know, to sell newspapers, Ms. Dowd) the overwhelming majority of heroes pass among us in total anonymity, disguised by yet another heroic characteristic, humility.

Contrast Schmidt’s take on heroes with Crossfit, a fitness program that has spawned a rather curious community known for its fierce devotion to its fitness principles as well as to its founders.  The Crossfit community is also known for its open “hero worship”, naming benchmark workouts after Crossfitting Special Forces servicemen and other first responders who have died in the line of duty. This very special devotion has in turn dramatically raised the awareness of living heroes who walk in our midst, especially among those of us who are not in the first responder business. You know, like the off-duty Cleveland cop who was ambushed  along with a dozen other motorists and prevailed in a shootout with the thugs without any civilian injuries. Still unnamed, he was at work the next day. Would he be any less of a hero if I saw him doing bad karaoke on Youtube?

Nah. I think I had it wrong back then and I think Eric Schmidt has it wrong now.  The Crossfit mentality of seeking out heroes both living (Tosh) and dead (Murph, JT, Michael, Badger, et al) will prevail because heroism will prevail. Google is quite likely to continue to be successful, and to continue to be more powerful as time goes on, but Mr. Schmidt misses the point when he conflates heroism and fame; Google has no power over a hero for heroism has no need for fame, and heroes remain so whether it was a “pick or a push.” There will ALWAYS be heroes.

Tomorrow in the United States of America it is Memorial Day. Many in Crossfit Nation will do “Murph” in honor of Lt. Michael Murphy, a hero who gave his life as a Navy SEAL in the service of his country. You can read about him in the book “Lone Survivor” written by Marcus Luttrel,  another SEAL who’s life was saved by Murph.

Better yet, why don’t you Google him.

Memorial Day and Coach Cat

Adapted from bingo’s Sunday Musings 5/24/09 www.crossfit.com.

When I was a high school senior my football coach became my friend after the season had ended. Only 10 or 12 years my senior, Cat was still single and for the next 4 or 5 years we spent quite a bit of my at home time together. There are quite a few articles in the Memorial Day papers this morning, some of them about the difficulties encountered by our servicemen and women when they return from deployment; that’s gotten me to thinking about Coach Cat.

My friend Chris, Coach Cat, and I were having a couple (dozen) beers one summer night when out of nowhere Cat had a rather scary “flashback” to the jungles of Viet Nam. Turns out as a young 2Lt his squad got cut off from support and he was on his own, leading his men out of the jungle. I remember him sobbing that night, choking out “I can’t believe what I had to do, what I did to get us out.” Stunned, Chris and I gently steered him to bed at a buddy’s house and then we drove home in silence.

For after all, what can you say? What can someone like me, never a minute “in country”, say to someone at a time like that? Indeed, even in a non-crisis moment, how does one respond, how does one express understanding and gratitude to one who has done what needed to be done “there”? Papers this morning are awash with stories and commentaries on a nation’s citizens not at war. Of empty, meaningless gestures and expressions of “thanks” and “appreciation” and “support”. Is this true? Are we who are here, so safe and so far behind the line, are we that shallow and insincere?

I confess that I just do not know the answer to that question. Perhaps neither I nor anyone else ever will. Here’s what I think is different now, though, from those days of my youth spent drinking with a friend who’d done his duty and returned to face both his countrymen and his demons–now I think about this generation’s Coach Cats every day, and I think about how to express my understanding, my empathy, and my gratitude every day. I hope that I am not unique. I hope that the columnists are wrong.

In the end tomorrow is just a Monday off work if you think about it. When we are a country with men and women ON the line, Memorial Day is every day of the year.

I gotta find Cat’s phone number.

I’ll see you next week…

Comment #56 – Posted by: bingo at May 24, 2009 6:43 AM

Tort Reform Equals Healthcare Reform

I’m a big Game Theory guy. I think you can explain the actions of the participants in any structured activity or enterprise by looking at the rules of the game. When you look backwards in time you discover that the “players” almost always made choices that represented rational self-interest. This is especially true in games played using Zero Sum rules: someone wins only if someone else loses. How the game is set up, what the rules are in the beginning, determines who “plays to win” and who plays “not to lose”. Unfortunately, it is impossible to forecast all of the outcomes of a Zero Sum game before play starts because it is impossible to forecast who and why each player plays the way they do.

The Medical Malpractice Tort system in the United States is a Zero Sum game.

There is a significant amount of medical care provided in the U.S. that does not have any significant positive effect on medical outcomes. This care has been broadly termed “Unnecessary Care” and it is rightly cited as a major contributor to the systemic healthcare economic crisis now facing the U.S. Unnecessary Care is also a part of the systemic issue of poor health in the U.S. Every time a patient receives care that does not contribute to better health she is exposed to potential complications of that care, and every dollar spent on Unnecessary Care is a dollar that won’t be spent on care that delivers better health.

“Defensive Medicine” is a form of Unnecessary Care. The best working definition that I know for Defensive Medicine is medical care of any sort that is ordered or performed solely to prevent either the filing or the loss of a medical malpractice lawsuit. Defensive Medicine is typically extra care layered onto reasonable, effective ,necessary medical care to provide cover in the event that a bad or unexpected outcome occurs. Various extimates exist regarding the extent of Defensive Medicine. Anywhere from 15-25% of all medical expenses are said to be some form of Defensive Medicine. That’s 15-25% of a $2 Trillion part of the U.S. economy. $300-500 Billion. As I will show below, most of this money does NOT show up as revenue for the doctor who is playing defense.

How can this be? Why would doctors do this? Well, let’s return to Game Theory for a moment. The Medical Malpractice Tort system in the United States is a Zero-Sum Game. Someone has to lose in order for someone to win. It is a punitive system, one meant to punish the doctor or hospital that committed malpractice. The financial and psychological costs of being sued are so severe for a doctor that nothing is too much to do to prevent being named in a lawsuit (simply receiving a letter stating that a suit is being considered typically results in an increase in malpractice insurance premiums). Doctors therefore play this particular game “not to lose.”

Patients, on the other hand, seemingly have very little to lose under the rules of the American medical tort and medical insurance systems. They are largely insulated from the cost of all of their care by what we call “medical insurance” (which is actually a pre-paid service contract), and a contingency fee system that allows them to bring suit without any personal financial cost, win or lose.

So how does this work? Let’s use an example of a very common medical complaint, and an all too common story of the medical care associated with that complaint. Let’s look at a patient with a really common type of headache, the migraine headache. Every doctor takes care of patients who complain of headaches. Some, like me, more than others, at least in terms of actually working to diagnose and treat the headache (not a lot of orthopedic surgeons working too hard on headaches, to pick on my “bony Brethren” again).

A patient, well known to her primary care doctor, comes into the office with a history that is bang-on, straight out out of the textbook for a Classic Migraine Headache (there really is just such a diagnosis). It’s a really severe headache and she’s really suffering. she’s scared, because it hurts so much. Her doctor, a “middle of the Bell Curve” American PCP, which is to say in the top 5% of PCP’s world-wide, makes the diagnosis. Classic Migraine. Given the history the likelihood that this is the correct diagnosis is in excess of 99%. Less than one our to every 100 patients who present with this history will have anything other than a Classic Migraine. Fee for the visit: $75.

But it’s a really bad headache, and headache is one of those things that can turn out really badly if the diagnosis is missed. She had some visual symptoms before the headache, some wavy lines in her vision–Classic Migraines have a prodrome or a warning sign. It still feels like it’s a Classic Migraine, but just in case better send her to an ophthalmologist (this is how eye doctors get to be headache doctors). She really has a bad headache so a CT scan can’t hurt, and you never know, so let’s have her see a neurologist, too; they’re REALLY the headache experts.

The CT scan is normal (fee: $500; chances of correct diagnosis now 99.9%). The ophthalmologist finds a normal exam and agrees with the diagnosis (fee $125; 99.91%). The neurologist agrees with the diagnosis, too (fee $250; 99.991%) but she spends her entire professional life treating nothing but the rarest and most complex types of headaches. She can name the next 29 diagnoses on the list of the top 30, as well as numbers 71-100, off the top of her head. She suggests an MRI, “just to be on the safe side; just to be sure.” The MRI will cost $750 and a negative test will increase the accuracy of the diagnosis by another factor of 10 to 99.9991% (anyone else notice how little the ophthalmologist added?!).

But…but…but…this is MADNESS! Why would they DO this? Why do the doctors keep ordering tests? And for Heaven’s sake, why does the patient keep going for these consultations and these tests? Well, let’s return to the rules of this Zero-Sum Game, shall we? The patient is insulated from the cost of all of this medical care by the nature of our “health insurance” system in the U.S. and therefore has no reason to question the suggestions of ANY of her doctors. The doctors, fearing a lawsuit if they miss even the rarest of problems, have no reason NOT to order more care. There simply is no amount of care that is enough when you are trying “not to lose” if a little more care might prevent a lawsuit. One should note that the additional care, the Defensive Medicine, the Unnecessary Care that is ordered by each physician, does not result in income to that physician; contrary to common belief, Defensive Medicine does not produce income to the doctor practicing defensively.

How do we begin to change the way we pay for healthcare in the United States? I say we start by changing at least some of the rules. Start by changing the Medical Malpractice Tort “Game” from a Zero Sum game to a NON-Zero Sum Game and gradually remove the perceived need for doctors to practice Defensive Medicine. This will also allow for more complete reporting of medical errors and misadventures, which will in turn allow for a more complete “root cause analysis” of these problems leading to better medical care and better health.

Let doctors stop playing “not to lose”. Medical Malpractice Tort Reform EQUALS healthcare reform.

Crossfit: The Athlete I Am Today

Crossfit. Constantly varied functional movements performed at high intensity. At 49 years of age I am nearly the athlete I was in my twenties. How can that be, you might ask? Well, while I am not truly as athletic as I once was, I believe that I am more FIT than I ever have been. This is allowing me to participate in athletic and other physical endeavors that I really have no business thinking about at my age. What kind of athlete might I have been if I trained in my teens and twenties the way I train in my forties?

All sports came easily to me in my youth. Blessed with the genetic gifts of eye-hand coordination, speed, and quickness there was literally no sport that I tried in which I didn’t excel. Couple this with the fact that I was a very early grower (I was the center on my Jr. High JV hoops team) and I was the classic local sports prodigy for that era. In addition to pulling me out of the deep end of the athletic gene pool my parents also provided a home environment that was bathed in competition. Heck, blood might be drawn when my siblings and I tried to make the first mark in a new jar of peanut butter! I was far from special in my family; all four White kids were All-State in something, and my brother might still be the best natural athlete I’ve ever met.

The first time I “peaked” as an athlete was freshman year in High School. I didn’t know it at the time, of course, but I would never be a better High School athlete than I was that year. I had stopped growing (I was now the point guard on the High School JV hoops team), and I continued to depend solely on my natural ability. I was still skilled, fast, and quick, but I was not terribly FIT. Under-strong. Not a ton of stamina. Typical teen diet. Add in a couple of injuries and a family move and I really didn’t return to that freshman year peak until my senior year.

My next peak as an athlete came in my sophomore year in college. As a freshman Division III tailback I did well enough, but the head coach was rather underwhelmed by my size and suggested a switch to defense. Stung, I set about proving him wrong (credit that family competitive gene) and got stronger, bigger, and tried to get faster (oops…better not get THAT much bigger). For the only time in my athletic career I trained to be a better athlete, a better football player. It helped immensely that my position coach, Dick Farley, turned out to be the best coach I ever had, and that he cared more about results than size. I started a bunch of games as a sophomore and really played rather well.

I then reverted to my tried and true, relying on whatever remained of those original genetic gifts from my parents. I never got better. Not one little bit. Given the opportunity to play tons of football over the next two years, to receive the benefit of magnificent coaching and possibly become a player to remember, I coasted. In the end I was nothing but a middle of the Bell Curve DIII cornerback, an average  Division III athlete. I wasn’t fit enough to do the work necessary to continue to get better and along the way I let both myself (and my teammates) and Coach Farley down.

If only I knew then what I know now. If only I had then what I have now. Bored and lonely in the gym, watching the ever outward creep of my waistline and the ever upward creep of my cholesterol, I stumbled upon Crossfit in the periodical Men’s Journal in December 2005. As a doctor who made it through Williams College, med school, and a residency I had long since learned that I wasn’t really THAT gifted. Hard work was now an intellectual and life habit, but until I  discovered Crossfit I had yet to do the same thing as an athlete. Whoa! This stuff turns out to be pretty powerful medicine!

“Practice and train the major lifts: deadlift, clean, squat, presses. Master the basics of gymnastics: pull-ups, dips, push-ups, sit-ups. Bike, run, swim, and row hard and fast. Mix these elements in as many combinations as creativety will allow. Routine is the enemy. Keep workouts SHORT AND INTENSE. Keep food intake to levels that will support exercise but not body fat.”–Greg Glassman.

On January 1st, 2006 I began the Zone diet and I did my first Crossfit workout, “Angie”. Crossfitters name their benchmark workouts after women. You know…like hurricanes. 100 pull-ups, 100 sit-ups, 100 push-ups, and 100 air squats. For time. For, like, as fast as you can. Seriously. It took me 45 minutes to complete and it took me 45 minutes to get up off the floor. All 100 of the pull-ups were assisted and 80 of the push-ups were from my knees (word of warning: don’t call ’em girlie push-ups. Most Crossfit women are scary fit and NEVER do push-ups from their knees).

I was hooked! My fitness went through the roof. My waist size shrank. My cholesterol plummeted. Three days on and one day off for 3 1/2 years and I am as fit as the day I graduated from med school at age 26. World class fitness based on workouts that typically last 20 minutes or less utilizing functional movements performed at high intensity. Competition? Yup. Me vs. me. Every day is a competition in which the opponent is yesterday’s version of Darrell, and victory is achieved if tomorrow’s version is just a little bit better than today’s.

So why now? Why at age 46? I confess that I just don’t know. I was certainly ready for Crossfit at 46, but I would probably have been ready for it at 36, too. I’m just very happy to have found it at all, frankly. Very happy to be more physically fit today than I was yesterday, with the hope that I will be able to continue to say that for years to come. Coach Glassman thinks most athletes can hope for 10 full years of improvement no matter when they start. Man, wouldn’t it be great if he was right!

Yet I do wonder, every now and again. I can’t help but wonder, what kind of athlete might I have been if I had Crossfit as a young man? If I could have been ready for Crossfit as a young athlete. When I had Dick Farley as a coach.

How many more peaks might I have reached?

Sunday Musings “Longevity”

Adapted from bingo’s Sunday Musings 090503 http://www.crossfit.com

Sunday musings (thinking about color)…

1) Lil’ Bingo and I met a color-blind Minister yesterday. Solved the wardrobe issue of being color-blind with his career choice, don’t you think?

2) If you choke a smurf, what color does he turn? (I just love that one)

3) Bill Cosby. America’s warm and fuzzy comic has been receiving some less than warm and fuzzy feedback about his quest to encourage the African-American community to take responsibility for many of its problems. He has specifically taken to task young Black men on the issues of crime, drug use, and the abandonment of what then become single-parent families. He has emphatically stated that the solution lies within the African-American community.

His harshest critics say that all of these problems are really the result of on-going systemic racism in America. These critics say emphatically that no effort from within the African-American community is worthwhile or necessary until this systemic problem is eradicated.

From 30,000 feet the question begs to be asked: Why can’t both sides be mostly right? Why must it be one or the other? Why can’t the fight against systemic racism, overt or covert racism, continue while at the same time members of the African-American community work to change the powerful negative forces that work within?

Why is this black or white?

4) Longevity. My Dad (Grampbingo) lost his high school mentor and champion this week. Margaret Nolan passed away at the age of 92 in her home town of Waltham, Mass. I shared a couple of tidbits of this story  some time ago on Crossfit.com.  My Dad is the only family member of his generation to have gone to college, pretty much solely due to the efforts of a young high school teacher who saw the intellectual spark in a child of the working-class depression, a cardboard-in-the-shoes kind of kid. She plucked him out of the trades track and placed him in college prep; she even bought him a pair of shoes to wear at graduation.

How do you live to be 92 years old? I think it’s about being loved. Miss Nolan lived her entire life with her also unmarried sister, deeply devoted to one another and to their shared passion for teaching. For decades they reached out to students with love and caring, and for that they received the same in return.  A Nolan Sisters sighting at any gathering in recent years was a significant event because of this.

My Dad planned long ago to fund a college scholarship for poor kids like himself, to be named in honor of Miss Nolan after she passed away. A very wise man, counsel to my Father, convinced him to fund that scholarship right then so that Miss Nolan would know how my Dad felt, so that she could see all of the students who would benefit from the help she gave to one poor kid back in the Depression. My Father sent in the 27th scholarship check the week Miss Nolan passed away.

So for 27 years Miss Nolan was able to know and experience my Dad’s love, and the love of all of those kids now unexpectedly off to college. There’s another lesson here, too, if you are interested. My Dad didn’t wait to honor Miss Nolan. He didn’t wait until she was gone to proclaim his thanks. He listened to that wise friend and showed his love right then, and every year since. Rest assured that Richard White’s four children will show him OUR love and gratitude by doing whatever it takes to fund that scholarship long after Miss Nolan’s student has left us, too.

How do you live to be 92? I sure don’t know, but I have to think that part of the secret lies in being loved.

I’ll see you next week…

Politics, PAT, and Outcome-Based Medicine

As the cost of providing health care in the U.S. has risen we have been bombarded with new terms and new ideas as “experts” attempt to solve our “Health Care Crisis”. In truth doctors, nurses, and other health care providers in the United States are dramatically better at treating and curing diseases than their counterparts anywhere else in the world. We really don’t have a “Health Care Crisis” in the U.S. What we have is a “Health Crisis” (our people are not as healthy as they could or should be) and a “Health Care Cost Crisis” (treating all of this poor  health is very expensive).

Major challenges exist when we begin to tackle this “Health Care Cost Crisis” (I think I’ll just call it the Cost Crisis hereafter). How do we reign in the cost of providing this international “best in class” medical care? How do we do so without creating either rationing of disease care, or the appearance of rationing? Regardless of the direction that our health care system may take, how do we prevent the politicization of a process that should be driven by those who are in the trenches providing that health care?

There is another term that is now ubiquitous in my world as a physician, one that is cropping up more and more in the non-medical media: Outcome Based Medicine (OBM). OBM is a rather loosely defined term which essentially boils down to medical care that has been proven to work. Pretty simple, huh? Unfortunately, OBM is getting rather fuzzy around the edges as it is used (or ignored as we will see) to achieve economic or political goals in addition to achieving the best possible medical outcomes. You know, stuff like a longer, better, healthier life.

The very first prospective (forward, not backward, looking), randomized (some folks were treated and some were in a control, or un-treated group), double-blind (neither the doctors treating nor the patients being treated knew which group was which) was actually an ophthalmology study. The Diabetic Retinopathy Study or DRS was published in the late 1970’s. It showed that using laser treatment to the retina of those patients with severe diabetic retinopathy saved more vision than doing nothing. Outcome-Based Medicine proven in a clinical trial.

Subsequent medical trials have proven the beneficial effect of innumerable medicines, surgeries, and treatments.  Other trials have been launched to provide a head-to-head comparison of competing treatments. Right now there is a trial in ophthalmology evaluating the effectiveness of two medicines, made by the same company, in the treatment of the most devastating type of macular degeneration. Macular degeneration (AMD) is a potentially blinding disease of the elderly which will become more and more common as our population ages. One very expensive medicine has been approved for the treatment of AMD and the other, inexpensive medicine has been approved for other uses and adapted by retinal specialists because it works. The hope underlying this study is that the doctors treating AMD will be allowed to generate a conclusion about which medicine works on which people in what circumstances in order to provide guidance on the most cost-effective EFFECTIVE treatment of AMD without the interference of politicians, bureaucrats, or accountants for the company that makes the medicines.

Which brings us to Pre-Admission Testing (PAT) and OBM, and an example of why I am fearful of the abuses that may befall this process. PAT is a process that some patients are asked to undergo prior to having anesthesia for surgery. The one and only reason to undergo PAT is to determine if there is any medical or health condition that will make the anesthesia more dangerous, to help prepare the anesthesiologist in the quest to prevent anesthesia complications. There is NO OTHER REASON to do PAT.

I am an ophthalmologist, an eye surgeon. I operate on people to save, restore, or enhance their vision. Many of these people receive anesthesia as part of their OR experience. After more than 10 years in which my OR patients were simply screened with a phone call by anesthesia I was recently informed that all of my patients receiving any anesthesia in the OR would now require PAT. Why? Essentially because the hospital said so. “That’s how the in-patient division does it so that’s how the out-patient has to.” The Joint Commission said that Medicare wants it.” ” Why do you care? It’s no more work for you.” And other such non-answers.

Well…I DO care. PAT is expensive, even though no one ends up paying for the physical exam part. EKG’s and lab work cost money. Patients and their families must take off work, go to a hospital or clinic, endure needles and disrobing. All for something that doesn’t matter. All for something that doesn’t contribute to better medical or health outcomes. Because you see, there WAS a study that looked at that EXACT question. Does routine PAT have any effect on the outcome of cataract surgery done on an out-patient basis? (Schein, et al. NEJM January 2000, Vol. 342, No. 3, 168-175).Turns out the answer is “NO”.

18,000 patients undergoing cataract surgery were split into two groups, one undergoing PAT and the other receiving no PAT. There was no difference between the two groups in intra-operative or post-operative events. There were no differences between the groups in complications. The firmly stated conclusion: Routine medical testing before cataract surgery does not measurably increase the safety of the surgery. PAT, in 2000 costing roughly $200-250 Million /year, before cataract surgery is a WASTE OF MONEY.

OBM at its very best. Ignored. Ignored by the hospitals who get paid to do the tests (although free-standing surgery centers typically do not do PAT). Ignored by Medicare, because we all know there’s lots of free cash floating around in the Medicare till just looking for a place to be spent. Ignored by the bureaucratic minions who skitter and twitter about the OR with their checklists and their rules and their regs. Who pays? Well, every patient  or family member who has to miss work or make a co-pay, and of course you and me through our taxes.

In the end Outcome-Based Medicine is only as good as the people who are reading and reacting to the results of the studies. When good research (my goodness…18,000 patients! The New England Journal of Medicine!) is ignored in a situation where there is little political capital on the line, what hope is there for us when someone sees votes (nationalized health care?) or real money (cholesterol and heart disease?) on the line?

What do you think THAT outcome will be?

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