Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

Archive for December, 2010

Sunday Musings, 12/19/10

Posted on Crossfit.com:

Sunday musings…

1) Caterwauling. Oh, I like that word very much, thank you.

2) Vacation mode. The present state of my brain. Apparently this is an “auto-start” thing for my particular brain as I will not be on vacation until sometime in mid-February.

3) Homework. “The Heir’s” dog, Abbie, ate my surgical charts the other night. We came home from dinner to find my charts strewn over the kitchen floor in various states of chewed.

That’s right…my dog ate my homework.

4) True science is to technical proficiency as music is to playing an instrument.

5) Compliance. There is a long-standing conversation in medicine about the challenges faced by patient non-compliance. Recently a newer word, indeed a newer concept has been added to the conversation: adherence. I think this is actually a better word for the problem in the world of my day job, and I think these two words apply to our Crossfit world, too.

Adherence implies the simple following of a program, following instructions. It’s a measure in part of how simple or easy it might be to go along with what has been prescribed. People who ADHERE to the prescription do so without much understanding of what is asked, and certainly do so without much in the way of buy-in. This probably represents the majority of the interactions between prescriber and prescribee. Understanding this is to accept as the prescriber the necessity of consciously looking for and then removing as many barriers that might reduce adherence (for instance, a one time/day medicine chosen over a four time/day one).

COMPLIANCE, on the other hand, strongly implies a significant measure of buy-in on the part of the prescribed to. This is actually one of the reasons I am pleased that “compliance” is being replaced with “adherence” in my day job, because it’s just really difficult to effect this buy-in. But here, in Crossfit, it’s all about compliance. You simply MUST understand the prescription in order to receive the benefit. You simply MUST buy-in to the prescription in order to receive the benefit. In the Crossfit gym there is a shared responsibility to achieve compliance, shared by both coach and athlete.

Here, in the cyber-gym, or in your garage gym, it is left to YOU, and you alone, to determine if you are adherent or truly compliant.

6) NNN. Well, I suppose I can’t avoid this one. So let me channel the great Ronald Reagan and offer this to the Nattering Nabobs of Negativity above: you are suffering from premature speculation.

The owners and decision makers of Crossfit, Inc. have accepted an offer from Reebok to provide support for Crossfit, the movement and Crossfit, the business. Did you listen to Coach’s remarks? There is no investment involved; Crossfit is still 100% privately owned. There was pretty much nothing promised FROM Crossfit in return for giving Reebok the ability to market to and on behalf of Crossfitters. Indeed, it has been said that when Coach was asked in a Q&A at Reebok HQ what he and Crossfit were now going to do to support Reebok he said: “I’m wearing a Reebok shirt today.” Period. Pretty ominous, huh? Not.

Think of some of the other previously underground things many of us like around here, like UFC for instance. Or triathalons after the mega-growth of the Ironman brand. Are they worse now that they are bigger, now that there is commercialization and a bunch of money? Not really. I see more visibility in more places which should result in more clients for CF affiliates. Should result in more access for CF trainers to places like schools and youth athletic teams.

If you look under the hood just a bit you will see that the engine is really the same one that was there before Reebok. The rules for affiliate ownership are no different (thanks to Ken C. for bringing up this important concern), one trainer-one gym. A free website jam-packed with not only the alpha version of CF but everything you might need to do Crossfit solo, for free.

Why so negative? Why impugn mal-intent to every growth step? Every change? Every business decision? It’s been a great ride. Why shouldn’t we assume that what’s around the next (Reebok) corner won’t be just as much fun as the ride we’ve already taken?

In the end some of the folks above are correct in that Reebok is about selling a physical product, and maybe we’ll get some of what we need or want from them. Might turn out to be a pretty good business decision for them. But Crossfit is about DOING some version of Crossfit, and about BEING a part of the Crossfit community. No change there as far as I can see.

So Reebok, welcome aboard. Fasten your seatbelt.

I’ll see you next week…

Posted by bingo at December 19, 2010 11:34 AM

Thoughts on Crossfit Hero WOD’s

A new Crossfit “Hero” workout or WOD was posted today. Here are my thoughts on what these workouts mean.

“Whitten”, and heroes before and to come…

We are all part of a rather unique and special community, whether here in the cyber-gym or members of a Crossfit Affiliate gym. There are many reasons for this to be sure, but one in particular stands out today as it does each time we are introduced to a new “Hero”. We acknowledge those who have made the ultimate sacrifice on our Nations’s behalf, not as a political statement or with an underlying agenda as is the case with many of those newspaper lists, but with a true thankfulness bordering on reverence.

This, after all, is how it SHOULD be. It is how it was in the wars and conflicts of our forefathers. Neighborhoods, towns, entire states would reach out in solidarity and support for the families of the fallen. As a nation we seem to have forgotten how to do this, lost as it were in the debates about the propriety and righteousness of whatever conflict might be at hand, as the historically quiet discomfort with such things has been replaced by the braying of the disenchanted here in the present.

You may think the quiet discomfort felt in the privacy of the homes left behind by those serving is the ideal. You may be convinced that the “means justifies the ends” approach of more contemporary protesters represents a high watermark in a maturing nation. Frankly, I don’t care, and how I feel is irrelevant in this discussion.

But what you mayn’t do is forget. It is not permissible to forget that there are people who serve, some in far-enough away places that it might be EASY to forget. While we as a nation of people have not really been asked to share in any hardship through open sacrifices like rationing or the like, we must STILL openly and consciously acknowledge these men (and women) who make the ultimate sacrifice on our collective behalf.

How? How might we do this? Well, I’ve talked a little about this in the past, but there are a lot of new “faces” here chez Crossfit, so it probably bears another telling. The introduction of a new “Hero”, indeed the posting of any “Hero” WOD, is not only an invitation to remember that this particular Hero gave his life in the line of duty, but because we choose to willing accept the suffering induced by the WOD it is an invitation to remember that there are LIVING heroes and heroines on the line right now. They leave behind families who live each day a little more fearful of what might come than, say, the family of an ophthalmologist.

How do we express our support for those on the line, outside the wire? Easy. We circle the wagons a little bit around those families they left behind when they boarded the transport, or stepped into the cruiser, or hopped on the back of Engine 44. Grand gestures are not really necessary; small kindnesses are enough. It’s now winter above the Mason-Dixon line. Maybe you go a little further with the snowblower and “forget” to stop until you’ve done the walk in front of that Marine’s house. It’s the Holiday season in much of the world–it’s just too easy to bake and deliver an extra dozen cookies to the cop on the corner. You travel a bit for business, and the bill for that burger is magically paid for that private in the airport who looks like he’s 14, hungry as he starts or finishes his journey.

It’s little stuff, I know, but not trivial stuff. These are gracious people; they will understand. They chose their paths and they do not NEED these gestures to validate their choice, but the subtle “thank you” still feels good. The knowledge that the sidewalk is clear of snow brings a small but real comfort.

So today, or whenever you get to it, as you suffer through “Whitten”, think not only of this young Captain but also about all of his brethren still on the line. Think just a bit about some small, concrete way to express your support for them and their families. For this, I am sure, is also what Coach has in mind when he offers up these epic challenges and names them after those we have lost.

This, I am sure, is what makes our community just a little bit different.


The Folly of Trendy Physician/Industry Regulation

I want Dick Lindsrom’s old job. Hell, DICK LINDSTROM  wants Dick Lindstrom’s old job! I mean, seriously, who WOULDN’T  want Dick Lindstrom’s old job? The  guy was the highest paid consultant for not one, not two, not even three, but something like FIVE ophthalmic manufacturing companies AT THE SAME TIME. Oh yeah…he was also the most famous ophthalmologist on the planet, and just happened to be a fantastic surgeon, too. He’s still got those last two things going on as far as I can tell.

Eventually someone is going to have to take up the mantle. Dick has been 59 years old for 10 or 11 years now, and he’s sure to turn the big 6-O at some point and decide to “retire early”. When he  does choose to do that, or if he is driven out of the consulting business by all of the petty new restrictions on physician relationships with industry (and vice versa) it will be a sad day, indeed. Not only for  the entrie ophthalmic community mind you, but also for the legions of patients-to-be who will NOT benefit from his influence and guidance.

Allow me to explain. Several years ago some folks in government and some consumer goody-twoshoey types all of a sudden “discovered” that doctors were consulting for companies that made medicines and things like implants and the like. They also “discovered” to their collective horror that these same companies not only paid these consulting doctors, but they also sometimes did “gifty” stuff for doctors and their staff members. Terrible stuff like, I dunno, buy lunch for the office or leave a bunch of logo pens or sticky notes around the nursing stations. Even more recently the startling discovery was made that these same pharmaceutical and medical device companies have been supporting post-graduate medical education.

The horror…the horror… (apologies to Conrad).

Dick Lindstrom has been one of the most influential clinical investigators in all of medicine for more than 25 years. By this I mean that he has suggested, launched, led, participated in, and reported on to his colleagues so many studies that led to ground-breaking clinical breakthroughs that his legacy must be considered not only in eyecare but in ALL of medicine. If you had a better medicine, or if you made a better cataract machine, chances are Dick not only had a hand in its development, but he also jumped to your better widget even if your competitors were paying him to consult on theirs. Patient first.

The guy just couldn’t be bought, in my opinion. Not only did he always choose whatever medicine or instrument was best at any given time, but his widespread, almost omnipresent involvement across the industry gave him a platform to push each competing company to outdo its competition. A continuous daisy-chain of technological advancement with Dick Lindstrom as ringleader. And now this small-minded, short-sighted movement would have Dick give up either his consulting or his clinical practice. Did I mention that he’s been among the most talented practicing eye surgeons for 25 years, too?

The food and goodies part of this stuff is inconvenient (I bought pens for the first time in my adult life this year), but really not much more. It does make the jobs of the industry reps more difficult, and frankly just seems to be mean-spirited and  petty. I mean…come on…if Dick Lindstrom hasn’t been swayed by the massive sums he’s been paid by companies for whom he has consulted, how insulting is it that the prevailing opinion in Washington and elsewhere is that MY choices can be bought for a Subway foot-long?! Seriously?

The development of new technologies and new medicines is expensive. So, too, is the post-graduate continuing education of our nation’s physicians. They can’t occur in the vacuum of the laboratory, nor can they occur in the vacuum of the boardroom. The people who do this work need the assistance of doctors who not only take care of patients but who also understand both research and business. To prevent pharmaceutical and medical device companies from supporting programs for continuing education, while at the same time allowing these same companies to market directlty to patients, is simultaneously the most cynical and naive hypocracy imaginable.

To erect arbitrary and artificial barriers that prevent people like Dick Lindstrom from making the kinds of contributions for which he is justly famous (and for which he has been appropriately compensated) is pure folly. Folly which approaches madness.

Here’s the rub…I don’t think any doctors are going to quit what they’re doing because we have to buy our own pens, and I doubt that any of us will hang up our spurs just because we now have to make our own sandwiches for lunch. I AM concerned that participation in major medical meetings will decrease if it becomes more expensive because industry support is legislated away. I AM concerned that doctors of all types will do only the minimum continuing education necessary to mantain their licensure. I AM concerned that these foolish proposals that seek to prohibit clinical educators from also receiving compensation for consulting will dramatically reduce the quality of whatever education we might be receiving.

To do ANYTHING that might prevent Dick Lindstrom from being Dick Lindstrom is pure folly, and I AM concerned about that.

Wait…wait a minute. Could that be it? Could the whole problem simply be Dick? That it’s really just a Dick Lindstrom problem? Is it possible that all of these regulations, the no-pen/no-lunch rules, all of the nonsense about educators and leaders being prohibited from simultaneously having consulting agreements is all just a huge anti-Dick Lindstrom thing?

Well…why didn’t you say so? We can fix this thing right tidy-like. I want to make contributions to my field that will stand the test of time. I want to be known as a clinician/investigator/consultant who always put his patients first before any and all other considerations. I want colleagues to look at a new technology and have the first words out of their mouths be: “What do you think Darrell White thinks about this?” And not for nothing, I wouldn’t mind having those vintage consulting contracts. In a word, I want Dick Lindstrom’s old job. Who wouldn’t?

Because we all need SOMEONE who’s willing and capable of being Dick Lindstrom when he finally turns 60…

Sunday Musings 12/5/10 (By Request)

Per a request from my Crossfit friend, Jake Parent.

Sunday musings (tough audience version)…

1) TSO. Trans-Siberian Orchestra. Crank it up.

2) Game. Couple of rather large deer strolling through the backyards in Bingoville today. Not sure who’s more more frustrated, my neighbor the hunter or my (electric fence restrained) border collie.

So close…so close…

3) Competition. Funny thing about our big competition, the Crossfit Games. Seems they keep changing. I dunno, constantly varied, or something like that. Four years, four very different set-ups. Four very big jumps in participation. Just when we get used to thinking about the last one, along comes Dave and Coach and WHAM it’s something different.

Ya gotta listen to the whole statement, though. Funny, that. Seems there will be two ways to get to the Regionals, either through an online qualifier, or (here’s the cool part for the community) through a qualifier that is certified and run by a Crossfit gym. Imagine, coming to a city so near you it’s actually YOUR city…taDAH…a sectional qualifier. I’m having a really hard time figuring out how this is a bad thing.

More people participating in more places…nice job HQ!

4) Wistful. How I feel about my own part of the Crossfit world as it’s grown. Once upon a time this particular part of our world, the Main Page and the Comments section, was the center of the Crossfit world outside of Santa Cruz. Affiliates, garage CF’ers, and solo Globo guys like yours truly were all here. Lurkers and posters alike, the Main Page was where it was at.

Now? Not so much. An enormous amount of the community, its people and its energy and its growth, is now in the 2500 Affiliate gyms scattered around the world. Both in “real” space and cyberspace, the local CF gym is the center of the community, the hub for the gym members.

Much of the rest of the community we remember, and to be sure much of the Affiliate community, can now be found on and around Facebook. Same folks. Same very positive vibe. Same energy and enthusiasm. It’s nice, frankly, just a bit…fractured I guess is a good word.

Neither good nor bad, I guess. Growth happens. Things evolve. There’s still an important role for the Main Page to play, else Coach and HQ would move on, too. I’m just a little bit wistful (or whiny, if you dislike musings), I guess, maybe a little bit lonely as my little part of our world seems more and more to be less and less as far as the communal aspect of Crossfit is concerned.

5) Gift. Mrs. Bingo and I are doing a little shopping. In truth she does most of the shopping for the bingo progeny; every now and again I try to find something to surprise everyone, even “Mrs. Santabingo”, but she really carries most of the load.

It’s funny, but for a guy who really hates surprises I really like it when Mrs. Bingo gets just exactly what I needed or wanted but just didn’t know I needed or wanted. A gift like that represents a very deep understanding of the gift receiver, a level of caring for that person that is something beyond the ordinary or regular. The gifts aren’t always big, not at all–they’re just always perfect.

After many years of not exchanging Mrs. Bingo and I will be able to gift one another this year. I am a coward; I will seek to be told what she wants or needs, and I will then do everything in my power to try to make it happen. I simply lack the imagination to create a gift giving act that reflects the deep knowledge I have of my better 95%, so I will express my caring through a very extended cross-examination. She will resume right where she left off 5 years ago when we last exchanged, surprising and thrilling with the perfect gift.

This is really a (typically) long-winded way of saying “it’s the thought that counts”, isn’t it? Large or small, expensive or not, when we have a gift-giving occasion we have an opportunity to express our feelings by demonstrating that we do, really, know what it is that makes our loved ones tick. We HAVE listened and watched.

Only 19 more shopping days until Christmas.

I’ll see you next week…

Half Right On A Malpractice Case

They got it half right. The jury that is. The jury in the malpractice case in which I just served as an expert witness got it exactly half right. Kind of like our whole medical malpractice court system if you think about it. A young woman had a bad outcome in one of her eyes following eye surgery, an outcome that has caused her quite a lot of unhappiness, quite a lot of difficulty. The jury was quite correct in recognizing this, and also quite correct in recognizing that this woman was going to need some financial help in order to make this difficult situation even a little bit better. In order to make this happen the jury found the doctor who performed the surgery guilty of medical malpractice.

Only one problem with that, though: no true malpractice actually occurred.

Herein lies the essential, fundamental problem with our medical malpractice tort system as it is presently constituted. Every single malpractice case is a “zero–some game” in which the only way that an individual who has been injured or otherwise suffered a bad outcome from some medical experience can receive financial help is for some doctor (or hospital) to lose a malpractice case. As an aside, the plaintiff’s attorneys, the lawyers who represent the victims of medical misadventure, must win the case in order to be paid. (The full–disclosure necessary here is that the only people who are guaranteed to be paid are the defense attorneys and the expert witnesses on both sides of the case.)

I’ve actually been up at night, literally losing sleep every night since the conclusion of this trial. That’s actually kind of odd, and doesn’t really make any sense at all because I received rave reviews for not only my testimony but also for the strategy suggestions I made over the four years it took to bring this case to its conclusion. Indeed, even the court reporter went out of her way to tell the defense team what a great job I had done. It’s kind of like getting all kinds of pats on the back for making 10 receptions for 200 yards in a football game your team goes on to lose–pretty empty feeling despite the fact that you did your part well.

What then, exactly, is medical malpractice? In the civil court system in the United States medical malpractice requires that two things have occurred. First, a doctor (or hospital) must commit an act of COMMISSION (do something) or an act of OMISSION (fail to do something) that falls below the Standard Of Care. This failure to meet the Standard Of Care must then result in some kind of harm to an individual. To be extremely technical and to–the–letter correct, the failure to meet the Standard Of Care is malpractice, and the resulting harm is malpractice liability. No need to get all tied up in that kind of detail; let’s just call the whole thing medical malpractice.

The Standard Of Care is a difficult concept. In effect, the Standard Of Care is defined as that care or medical decision-making that a preponderance of (most) similar practitioners would provide in similar circumstances at that time. Pretty nebulous, huh? Not a terribly rigid, hard, easy to put your hands around definition, and it’s a moving target on top of that. The Standard Of Care is an ever–evolving thing; new research findings, new technology, and new patterns of care will all combine to create a Standard Of Care that may be different today than it was even last year.

In this particular case there was never any question that it was a medical procedure that caused this patient to have such a bad outcome. There was never really even any question about the technical quality of the work performed by the doctor. No, what it all came down to was a question of whether or not the surgery should have been performed in the first place, and thus came into play that subtle little part of the Standard Of Care, the difficulty in describing to a jury of non-–physicians the difference between the Standard Of Care today and that of some years ago. The lawyers for the patient did a brilliant job of burying the jury with the details of HOW the complication arose, the difficulties that have arisen because of the complications, and the uncomfortable interactions that occurred between doctor and patient in the months following the surgery. They confused the jury about the difference between “could have done” (more than the Standard Of Care) and “should have done” (Standard Of Care). The lawyers were able to bury the fact that the Standard Of Care was followed by the doctor in question because at the time of surgery the PREPONDERANCE of similar physicians in similar circumstances at that time would have done the SAME THING.

The jury got it half right.

There, in a nutshell, is everything that’s wrong with our present medical malpractice tort system. In order for this woman, obviously harmed by this procedure, to receive some award so that she can do certain things that will make her life easier, she and her team had to “beat” a doctor and win in court. And oh yeah, she’ll also have to give 40% of whatever her award might have been to her lawyers. I think that’s a big part of why I’ve been having trouble sleeping. Not the lawyer payment thing, but the fact that a doctor who (in my opinion) practiced within the standard of care must now have a black mark against his name so that a patient can get some money that I frankly think she deserves.

Maybe a better analogy of my role in this “competition” would be something more like this: I was the consulting coach brought in to suggest an additional element to a figure skater’s program. Assuming that everyone in the competition was as conversant with the subtleties of the rules involved I suggested that the skater add an elegant, understated movement that would be obvious to any experts on the panel of judges, the jury as it were. Unfortunately, in our American system of medical malpractice, that’s not the case, and the opponents eschewed subtle elegance in favor of multiple quad jumps. The skater I assisted performed totally within the letter of the rules, but was penalized because the jury, the panel of judges, was not really an expert panel and missed the added element. And so he lost.

I DO wonder though what my reaction would have been if the opposing skater who landed all those quads had been the one who lost. Would I be up at night over that, too?

You are currently browsing the Random Thoughts from a Restless Mind blog archives for December, 2010.