Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for March, 2013

All For Lowering Healthcare Costs (Until You’re Sick, That Is)

The onus for reducing healthcare costs has been placed squarely in the middle of the backs of physicians. At the same time, physicians are being graded on how well they “satisfy” their patients. Rock, meet Hard Place. Hard Place, Rock.

Two recently published studies referenced pretty much everywhere have shown that individual patients specifically do NOT want to take cost into consideration when it comes to making decisions about their own care. In addition they also do not want their physicians to give any consideration to cost concerns when diagnosing or treating their own illness. Indeed, when given the choice between two treatments of nearly equal efficacy, study subjects overwhelmingly chose the more expensive option for themselves even when the difference in efficacy was very small.

While the authors of the articles citing these studies were shocked at these findings, the only surprise in my mind is that anyone is the least bit surprised by any of this.Think about it. You will personally pay little to none of the difference in cost of the treatment out of your own pocket for a treatment or a test that someone has labeled “better” or “more effective”. You’re telling me you’re not gonna choose that one? Please.

The two great forces aligned against one another in the “Healthcare Reform” debate advocate respectively: market-based incentives in which a patient is given better information in return for shouldering more of the financial decision-making and the importance of the quality of the exerience, and top-down command and control strategies in which both carrots and sticks are applied to doctors in an attempt to get them to provide better care with a more friendly consumer experience while at the same time spending less money. Physicians must provide more and better for less, and must do so under the same zero-sum malpractice game of “GOTCHA” rules we have now.

All of the responsibility for lowered costs with better outcomes and a better quality experience for the patients is shouldered by docs in Obamacare. Accountable Care Organizations (ACO) are lauded for paying physicians a set salary rather than by work done. Unless, that is, you do less work, quality notwithstanding. Getting great outcomes, following best practices, and receiving high satisfaction marks get you a pay cut if you see fewer patients, generate lower test fees, or do less surgery. The Rock.

Play by the rules, see your prescribed load of patients, get great outcomes and practice to the letter of evidence-based medicine, but fail to get those high customer satisfaction marks? Ah…welcome to the Hard Place. Your pay depends on satisfying your patients. Meeting their expectations both for their experience as well as their care. You know, those same patients who only care about the cost of someone else’s healthcare, not theirs. Fail to order the test that rules out the 0.00001% chance of that rare tumor on Anderson Cooper Live last night? BZZZZZT. Bad doctor. 1 out of 10 on the patient satisfaction survey and a trip to the principal’s office to learn about your pay cut.

Man. It wasn’t enough to be in the crosshairs of every plaintiff’s lawyer under the sun (so Doctor, isn’t it possible that you might have saved this patients vision if you’d ordered that MRI to evaluate her headache?). Nope, now we are responsible for balancing the Federal budget while simultaneously giving every patient whatever care they’ve seen on Dr. Oz (“PET Scans–your doctor KNOWS you need one if you have a headache! You could go BLIND!!”). It’s a lot to ask of your doctor.

Unless, of course, it’s someone ELSE’S headache.

 

Open Drama

Wow. Just…wow. Quite a bit of strum un drang around the 2013 CrossFit Open, eh? Says here it’s really nothing new, the drama and the controversies. Re-runs of stuff from Games of yesteryears, just playing on more screens and viewed by more people who have more time on their hands than sense in their heads.

Yah…I just went there.

What’s got so many panties in a bunch? Let’s see. Everyone who has a great score must be a cheater. Of if they didn’t cheat they surely must be using PED’s of some sort. This canard took flight in Games 3 when a qualifier was first put into play. Funny, though, that you never hear this coming from any of the athletes who are likely to rock the Regionals (check out Freddy Comacho on FB, for example. No whining from that 3 times Games competitor). Seems there are a whole lotta folks shooting off their fingertips before they shoot off any neurons; if the mere possibility has somehow crept into THEIR head, well then, it must be a dead-on FACT. Because they just know, ya know?. Never mind that year after year it all just seems to work out even though year after year the Games grow bigger, change, and improve. Anybody think someone who should have been in the top 15 in any Regional got bumped out by a cheater last year? Really?

What else? Oh yeah, fairness. It’s not fair. Somehow, somewhere, someone at HQ is just out there doing stuff that’s…that’s…unfair. There’s a conspiracy here. Really. Gotta be. Just because someone has a limited frame of reference regarding what it takes to pull off something as audacious as an Open competition with >150,000 entrants, surely they know all the better than the rest of us. And the newer they are to CrossFit the better they know. Naturally. To be fair there are some folks who sincerely try to follow all the rules, do their very best in that effort, and for whatever reason they mess up. That’s truly a bummer. I really mean that. But how do you do anything other than invoke a strict enforcement of the rules for everyone, regardless of sincerity in the mess-up? How do you measure fairness if you allow even a bit of color into a black and white process? Fair tends to be hard.

Which brings me to the most important part of this whole harangue: there are real, live people involved here. Just like you. Just like him. And her. People who are trying their best on all sides of every issue. Doing the workout. Judging the workout. Administering the Open. Watching literally thousands of videos. And not for nuthin’, reading all of the vitriol being vomited through cyberspace and befouling our little corner of the planet. Listen, I’m no pollyanna. I know there really are a tiny few people who are trying to get over. They really deserve all the  venom you can dispense. But it’s rare. There really aren’t that many of them, and they always seem to do something to draw attention to themselves. Have at ‘em. My pleasure.

For everyone else, though, let’s have a little perspective. Expand your frame of reference to include the notion that it really IS fair. That almost no one is trying to cheat. That even the very best athletes are approaching this in almost the same way as you and I, as a challenge to be met. An opportunity to participate in the collective, the community of our CrossFit. That every PERSON is doing his or her best to put forth something that they can be proud of. Something that will put a smile on the face of a Brother or Sister CrossFitter. Every athlete. Every judge. Every HQ staff member. YOU.

Stop. Think. There’s a CrossFitter on the other end of your post.

 

Character Assassination

The White family lives by a very small number of credos, the most frequently stated one being: “less said, sooner mended.” We approach conflict, gossip, grudges and all types of ‘drama’ with this in mind. It’s amazing how often silly stuff, however hurtful or harmful, simply dissipates into the mist if you don’t talk about it or don’t respond to it. “Less said, sooner mended” works almost all of the time.

When it doesn’t work, or at least when we have opted not to invoke it, is when there is a clear effort at character assassination afoot. This is very different from gossip, however mean spirited. Character assassination is the purposeful placement of a negative untruth followed by the carefully planned encouragement of the propagation of that untruth until it becomes the default descriptor for the target of the character assassination. In effect it is premeditated murder of someone’s reputation.

You cannot ignore this.

How, then, to know the difference between simple gossip and true character assassination? Easy, I think. Gossip responds to “less said, sooner mended” before it reaches anyone whose opinion you truly value; character assassination sows seeds of doubt in an ever tightening ring of your relationships. Once this is identified and confirmed “less said, sooner mended” must be abandoned in favor of any and all manner of responses that might be necessary to defeat the attack.

Our lives are filled with gossip and drama. It is part of the human condition it seems. Upon leaving high school the vast majority of us will never be the victims of an attempted character assassination; we should approach almost all situations with this in mind, and accordingly consider “less said, sooner mended” our default setting. Life is easier and dramatically less stressful and more pleasant in this mode.

If, on the other hand, you sense those doubts coming closer within your circles, if you sense that every “less said, sooner mended” only frees that carefully planned untruth to grow unchecked…well…then you must commit. You must run TOWARD the story armed and ready to destroy that untruth with no reservations about any possible collateral damage as you move to its source. It should be clear from your response that you will brook no retreat along your way. Your adversaries in this battle you did not choose should know without doubt that the only regret at the end will be theirs.

So the White family continues to live by its long-time credo of “less said, sooner mended”. We encourage others to do the same. Life is easier because of it! Let no one mistake your kindness and gentle nature for weakness, though. Be clear that you know the difference between mere gossip and true character assassination. Let it be known that you will ignore the former, but fully commit to fighting the latter.

With no reserve, no retreat, and no regrets.

 

The Three “R’s” of Commitment

“No reserve. No retreat. No regret.” Three separate entries into the bible of a young missionary when he, in order, committed to his mission, arrived in a foreign land, and heard his own fatal diagnosis at age 25.

That’s commitment.

Think about how this might work in your life. You’ve got something before you, some task, a challenge, maybe just CrossFit Open 13.3. You’ve got it, whatever ‘it’ is, and it’s within you to triumph. All it takes is a full commitment to the task.

No reserve. No doubts or reservations at the outset. You’re in. In for the whole thing, right from the get-go. No retreat. You’re gonna go forward and fulfill your obligation, complete the task, reach the goal. And finally, regardless of the outcome, no regrets. You put yourself on the line. Accepted a challenge. Made the effort and accepted all that came with it, win, lose, or draw.

The “3 R’s” of commitment. No reserve. No retreat. No regrets.

 

Nothing Amazes Anyone Any More

We’ve lost the ability to be amazed. As a society, as a people, North Americans not only fail to be dazzled by things that are downright amazing, we have actually become quite blase about, well, pretty much everything. That sense of wonder at the new we celebrate in children is leached out of our kids at ever younger ages. Our ability to be awestruck has atrophied, and any sense of awe, wonder, or amazement that we DO experience is so fleeting that it’s almost as if it was never there.

How did this happen?

This idea, this observation has been stewing in my subconscious for a couple of months now. It popped its cork yesterday after a couple of experiences I had starting last week. The first, interestingly, actually involved seeing people who actually WERE amazed. I flew to and from Providence to visit my folks last weekend. On the way out I sat in the last seat in the plane (doorman to the restroom), on the way back in the very first seat (Walmart greeter). On both legs of my trip I was seated next to 45 year old men taking their very first trips on a plane. Imagine! 45, and never on a plane. These guys were simply awestruck at the notion that they were drinking a Coke inside an aluminum tube that was cruising at 35,000 feet. One of them took about a hundred pictures of the clouds out the window. Those guys were amazed! I let myself get swept up in their experience; it really IS cool, and not even just a little bit amazing, that I could get to my folks 750 miles away in less than 90 minutes!

Experience #2 occurred in my office on a one-day post-op day. Medicine in general, and certainly my field of ophthalmology in particular, is a victim of its overwhelming success. Indeed, this is not too different from the airline industry. We deliver the goods time after time, on time, without a hiccup. So frequently, in fact, that in those rare instances where things are rocky, or there is a complication, we view the outcome as only slightly less horrific than an airplane crash. Even a fantastic outcome, one that would have been so unlikely just a few years ago, is now viewed as some kind of a disappointment if it fails to meet the outlandish expectations of an audience that has been numbed by routine success.

Take, for example, cataract surgery. I had a patient with a very large cataract, a very small pupil, and a flaccid iris–a set-up for a very challenging surgery, one that a few years ago had a 10X increase in complication risk. Per our protocols the patient was offered several choices of lens implants, and the expected outcome (visual acuity, need for glasses, etc.) for each of these was discussed and explained multiple times by multiple staff members and doctors, all according to our protocols. Some of these implant choices were entirely covered by insurance, and others included fees for which the patient was responsible. These, too, were covered in detail several times by several staff members. In this particular case there was even a second, extra (no charge) visit to the office specifically to discuss these options and the associated expectations following surgery.

So how’d it turn out? The staff and doctors were turning cartwheels when we discovered that the one-day post-op distance vision was 20/20 without any glasses! Imagine our surprise and chagrin when patient and spouse sad glumly in their chairs at the news, not the least bit excited. In fact, the majority of the visit consisted of patient and spouse grilling doctors and staff about the fact that the patient could no longer see up close without glasses. This despite the many counseling sessions about implant choices and post-op expectations in a patient who could not pass a driver’s test with or without glasses prior to surgery. Not a word about how amazing it was that such a challenging surgery resulted in the ability to now pass a driver’s test without glasses!

You might fairly ask if I was amazed by this? Sadly, no, I was not. It’s not enough for the airline to bring you in on time and safely. Nope, now you had to be flown first class on a free ticket and arrive early to simply be satisfied. To be amazed one would need to have somehow been transported to and from the S.S. Enterprise by Sulu personally.

Manned flight, up and down with nary a hiccup each and every time. Cataract surgery that improves your vision 99.9% of the time with nary a hiccup. Joint replacements that allow you to play tennis. GPS in your car that directs you to within a foot of your destination. Neurosurgery while you are awake. Cell phones, for Heaven’s sake! Sometimes you fly first class or see 20/20 without wearing your glasses! Come on…that’s amazing! Right?

Amazing…

UConn and the Demise of the Big East

Saturday’s Providence College/UConn game marked the effective end of the Big East Conference. What brought about its demise? Success. Money. The promise of more money. And a profound lack of historical perspective on the part of schools like UConn that have failed to remember from whence they came, and how they’ve come to their present state.

Once upon a time UConn was a sleepy little state college lying in a sleepy little cowtown in Nowhere, CT. UConn had no athletic history to speak of; it played its games against the likes of UVM, UNH, URI. UMass and UMaine. Heck, the athletics in that group couldn’t even sustain football across the board–UVM dropped the sport in 1974. Not a lot has changed at the other schools. The campuses have grown a bit, enrollment has expanded a bit, but the athletic programs maintain their status as a pleasant diversion accompanying the educational process.

But UConn? Noooo, not UConn. You see Dave Gavitt invited UConn to join the Big East Conference in 1974 and the world tilted. Millions and millions of dollars have poured into Storrs and the campus is virtually unrecognizable to graduates of my era. Enrollment, building, and the endowment have soared. UConn is now a “football school” and it departs the Big East, leaving the largely Catholic “basketball schools” behind as it chases ever more wealth. Success has been found.

End of story, right? Little school makes big time. All is right in the world. Right? Hmmm…I dunno. You see, it’s basketball that has driven this success, and it was basketball that created the Big East. It was basketball and the Big East that made Storrs big enough to find on the map. Basketball, and a bunch of originally like-minded “Basketball Schools” that brought measures of success and wealth to every school in the conference, albeit not equally.

What’s been lost? Tradition. History. The “kindredship” of a group of schools that were of a different ilk, or more accurately different ilks when we compare them with “Football Schools”. The Big East was a kind of special, the first grouping of schools assembled in the pursuit of athletics based NOT on football. There’s a certain absence of something like gratitude in the dissolution of the Big East in the pursuit of football riches. It feels almost like UConn has lost its institutional sense of its own identity.

Will UConn find those riches as it chases wealth for wealth’s sake, forsaking history, tradition, and a sense of who and what it has been? Tune in, I guess. There will be lessons to be learned by other institutions that have grown and become successful within an ecosystem of like-minded institutions with a common tradition and history. Are the presumably greater riches to be found in leaving behind the history, tradition, and culture greater than the wealth to be found in the history, tradition and culture?

Tune in, indeed.

 

 

Resolve

I landed on “Cool Hand Luke” while surfing yesterday. Man, was Paul Newman something, or what? For all of his faults, and despite being guilty of whatever landed him in that prison camp, Luke was resolved to fight the injustice of his existence. He was resolved not to lose the essence of who he was, despite the hardships imposed on him by those who would break him, break his will, make him relinquish that which made him, well, COOL.

Movies are usually an escape for me. I’m not often prompted to terribly deep thought while watching one. But I wondered, what of my life that occasionally seems so hard is actually hard enough that it bends me from a true course? So hard that it ultimately makes me forsake the essence of that which makes me…me. And if it is, indeed, that hard, how long could I hold out against the constancy of the difficulty, like Luke, before I broke?

Luke, knowing that he may finally be broken, seeks answers in the church he forswore. He looks to the ceiling, challenging Him, demanding an answer. Why is this? What do you want? What am I supposed to do? Luke opens the door, stands there, framed. “What we have here is a failure to communicate”. A last act of defiance, or a capitulation? Against who? To who? One is left to wonder: did He answer?

And if He did, what did he say?

 

Medical Time Travel

CrossFitters have taken up the cause of health, given the charge of improving health and preventing decrepitude. There will always be a need for what we can call “real medical care” or sickcare (you know, rather than healthcare). After all, stuff happens. I’ve been plunged into the abyss of American sickcare as I help shepherd my Dad through a prolonged exposure.

Much has been made of the tremendous costs of the most modern medical care. There was a 20 page article (20 pages!!) in Time magazine about this last week, about inflated charges and financial gamesmanship and whatnot. True enough. Indeed, I’ve read the theory that sickcare in the U.S. was pretty darned good 10, 20, 30 years ago, and we spent much less money for it back then. Why not just use, say, 1980′s sickcare as our standard? Weren’t we pretty healthy then? It sure seemed like we could at least afford sickcare then, both on the personal and societal levels.

Here’s the rub: I saw 2013 vintage care this week, and I saw something that approximated 1985 or so. The “time travel” between 1985 and 2013 was a real eye opener. No one in their right mind would trade the best of what we have today for “1985 is good enough”. Trust me. That particular “time travel” trip was a nightmare.

Do we as a society, country, and/or economic ecosystem need to find some way to bring some sanity, some rational economics to how we buy and pay for our “sick care”? You bet. We here in the CrossFit world are on the right track as we seek health, seek to avoid the need for sickcare. But man, I gotta tell ya, if you are sick and you need to be cured, you want to be right here in North America.

And you want to be be here today, in 2013.

 

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