Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for June, 2013

A Giant, Smaller

When did my Dad get so small? Close your eyes. Think of your Dad. What does he look like? How old is he with your eyes closed? He’s younger, isn’t he? And bigger. MUCH bigger.

I spend most of every day in the company of people decades my senior. I’ve watched some of them age over 20 years or so. There are a few with whom I’ve bonded, who I remember and can conjure up an image if asked. I never appreciate the change in size in them, though.

It’s a strange phenomenon. It’s uncomfortable, no? There really IS a physical change that occurs as we age; we really DO shrink physically. No, it’s more than that when you look at your Dad, more than the physical decrease in size, the loss of vigor and all that goes along with it, the stuff I might actually notice in my patients. What makes it so striking when it’s your Dad is that it’s more than just physical, but a diminution in all dimensions and domains including the one inside your head.

He WAS strength when I was a kid. Literally, a rock. Immovable and unshakeable at all times. Unmoved by excuses or explanations when he knew he was right, or if he MIGHT be right. The final arbiter of discipline (“wait ’til your FATHER gets home…”) in a very traditional family, every thing about the guy was just huge.

When did he get so small? It’s almost scary, you know. He was the guy who stood between me and everything that might be dangerous, at least figuratively. At least in my mind. It’s hard to reconcile the guy I just saw in the hospital in RI with my Mom, and the guy who’s there–right in front of me–when I close my eyes. So small now, almost frail. That classic love/fear thing now replaced with something more like love/protect. Does he see it, too? How small?

Will I see it, when I’ve become small?

 

Sunday musings, On Father’s Day

Sunday musings (on Father’s Day)…

1) Perfectionist. “His sense of pride was often too much for his ego to handle.”

2) Gift. This morning, chez bingo, there was an exchange of thanks, an exchange of “Happy Father’s Day” good mornings. The easy, traditional one came my way from Mrs. bingo, of course. I, in return, sent one right back to her.

Think about it for a moment. This “Father” thing is impossible without the participation of a mother. Oh sure, you can toss your genome at a vessel and take home a package, but to be a real Father on the ground, “in country” so to speak, you must have a mother along for the ride. The ride is most often better, smoother and easier, if both of the front seats are occupied.

If you are a Father somebody gifted you with that child. Carried him or her for 9 months, the ultimate “weight vest”, before handing you the job of Dad. Maybe did it more than once, too! Give her a hug today. Thank her for a Happy Father’s Day.

3) Memories. Most of us have (or had) a Dad who played a role in our lives. Mostly good, often hard, unfortunately not so good in some cases, but undoubtedly memorable in all cases. We have memories. At some point memories are all we have.

Most families have a “thing”, a certain activity or place or topic around which memories orbit. Maybe it’s a vacation spot to which your family returns as inexorably as the swallow of Capistrano or the Monarch Butterflies of Brazil. For some it’s not the location so much as what transpires there. Think family dinner here where the memories are of nightly discourse covering anything from poetry to pugilism, a travel of the mind more than the body.

When it comes to Fathers it’s often a case of the child inheriting the father’s chosen sport. As I think of this a hundred images appear of tiny children tagging along as their Dad does whatever it is he does. Invisibly tethered to their father by sharing his time with his passion, all the while being infected by that passion themselves. I see little girls in oversized wellies holding their Daddy’s hand, his other cradling a shotgun, as they trudge through a marsh. A Dad’s bare feet submerged just off the dock as a tiny son’s size 2′s dangle feet above that same pond while bobbers float just out of view.

For us it was golf, for my brother and me at least. Father’s Day meant getting up an hour or so before Dad, cramming in random calories, and then walking to the caddy shack for another Saturday loop. Except on this Saturday the caddy master tossed us a bone and put us in my Dad’s group. We were pretty good caddies, my brother and I, and my Dad was a more than pretty good golfer. He made sure to make his game with other of the better golfers on Father’s Day. Good caddies always make for better golf, and 4 good golfers squired by 2 good caddies makes for a very good round. Those are some good memories.

We grew to be good friends on the golf course, my Dad, my brother, and I. On one magical morning Ranbingo and I became men, at least in the golf sense. One Saturday morning (sadly not a Father’s Day) we headed to the first tee with Dad not as caddies but as real golfers. Partners in his foursome, with caddies of our own. In time we were joined by a brother-in-law as we towed our Dad along on a decades long golf odyssey. We’d found our connection, and like the little girl in her Wellies and the little boy with dangling toes we kept ourselves tethered to our Dad through his passion.

And we made memories.

That’s all that’s left now, the memories. We’ll not try to remember what we have now. These newer memories will not sing as sweetly and so we will try to erase them as soon as they arise. Rather, we will try to share those other, older memories with Dad as the tether frays. Until that one day when we hold our end of the tie and it lies quietly against our side, empty, nobody there to whom we are tethered.

If we are fortunate we reach out a hand and it is filled with tiny fingers, and we walk to wherever tethered to tiny little legs that struggle to keep up as they chase our passion with us. We feel the stillness, the emptiness on the other side where we were once tethered ourselves. If we are very fortunate we realize that maybe we still are. Tethered, that is.

Tethered to the memories of when we were the child of a Father so gifted.

Happy Father’s Day.

I’ll see you next week…

Posted by bingo at June 16, 2013 6:24 AM

 

Perverse Economic Incentives II: Ignoring Best Practices

You’ve heard this before: the more solutions you have for a single problem, the less likely it is that the true solution has been discovered. Once a real, conclusive solution is discovered it is accepted and implemented by essentially everyone who is presented with that particular problem. This process occurs unfettered in an open market or open system, and the cost of a particular solution depends on a combination of need for the solution and the economic incentives that exist to solve the problem.

Unfortunately, in healthcare in the U.S. this “rule” is not always the case.

Here’s a story about a solution that is NOT being used to the extent it should because private surgery centers are punished financially if they do the right thing. This example is truly a case of perverse economic incentives violating what we think of as a law of nature, that the discovery of a solution for a vexing problem will be adopted by all who suffer the problem if it is shown to be superior to all other solutions. Let’s look at the “Floppy Iris Syndrome” (AFIS) in cataract surgery.

The iris is the colored part of your eye, and the pupil is simply an opening in the iris, much like the shutter of a camera. The pupil is dilated prior to cataract surgery so that the cataract, a clouding of the lens that sits in back of the iris, can be reached and removed. Six or Seven years ago cataract surgeons began to be ambushed by pupils which spontaneously constricted or shrunk like a pursestring closing, or by an iris that started to billow like a parachute placed over a fan. Dubbed the “Floppy Iris Syndrome”, it turned out that it was caused by exposure to a certain class of medicines used for the seemingly unassociated problem of urinary retention in men with enlarged prostate glands; it has since been found to be caused by an increasing number of other medicines. It was a disaster. The complication rate for surgeries with AFIS was 10X or greater than those with a normal iris and pupil.

The search for the cause was important because cataract surgeons could now be forewarned that they might encounter AFIS during surgery if their patient had ever been on one of the medicine culprits. Once the cause and the extent of the problem were known the race was on to find a solution. Unfortunately, all of the intra-operative tactics we’d used in the past to handle small pupils were largely ineffective against AFIS. In fact, some of the standard ways to address a small pupil actually made the surgery MORE difficult because of the floppy, flaccid iris. Every week brought one or two new ideas to add to the dozens already on the table, proving the rule that many solutions means that no true answer has been found.

Enter Dr. Maluygen and his marvelous eponymous ring. The Maluygen Ring essentially solved the entire problem by simultaneously expanding the pupil and stabilizing the iris, and it was both vastly superior to all other solutions available and technically within the capabilities of pretty much every cataract surgeon. Bingo. QED. Kudos, heartfelt thanks, and a bit of profit to Dr. Maluygen and the company that marketed his Ring, right?

Not so fast there, Cowboy. Every week we STILL see articles on how to deal with AFIS in surgery despite the fact that not a single surgeon has stated, on or off the record, that there is anything that is as good as the Maluygen Ring. Here is where the perversity begins. It turns out that only hospital owned surgery centers can bill insurances for additional or special items used during surgery, and the $125 that the Maluygen Ring costs is extra and therefore not reimbursed. The majority of cataract surgeries in the U.S. are performed in private surgery centers, mostly owned by surgeons who operate in them. To begin with, private surgery centers are paid roughly 60% of what hospital-owned surgery centers are paid. $125 represents in most cases 50% or more of the gross profit (before interest, taxes, depreciation, etc)  generated in a case.

That’s right, there is a 50% financial penalty for using the best and safest method to avoid a preventable complication.

It’s no wonder that the owners of surgery centers continue to look for an alternative solution to the problems cause by AFIS. In a misguided attempt to save money, Medicare has led the charge to pay independent surgery centers less than hospital owned centers, and along the way has stripped the independent centers of the ability to pass on the cost of items that represent the “best practices” for certain situations. Rather than use the acknowledged superior solution (the Maluygen Ring) we continue to see inferior techniques utilized despite the fact that they often prolong the surgical case and fail to completely solve the problem. All because policies are created by non-clinical personnel who are only  empowered to save money.

We should be mindful of these perverse economic incentives as our American system of curing disease undergoes an historic upheaval. Do we really want doctors and others considering the economics of utilizing true, proven best practices? Do we really want non-clinicians creating policy that turns medical decisions into economic ones?

 

Perverse Economic Incentives I: Ignoring Evidence-Based Medicine

Incontrovertible data does not always lead to the expected outcome. Take for example the much-trumpeted call for “evidence-based medicine”, choosing courses of action or care patterns that have been shown to be beneficial with regards to outcomes, reduced complications, or reduced cost when no benefit has been proven. The recent movement in which several national physician organizations have been asked to identify procedures or tests that should be eliminated for lack of proven efficacy is a presumed “no-brainer” way to reduce the cost of healthcare. In my eyecare world routine pre-admission testing for cataract surgery has been singled out as unnecessary, a waste of time and money for almost everyone involved. A New England Journal of Medicine article from 1990 is cited which unequivocally  shows no benefit to the patient or the cataract surgeon. The data comes from the NEJM. From 1990. This is only a tiny bit removed in both historical context and gravitas from a couple of stones and a guy named Moses. Why are we even talking about this in 2013? Why isn’t this already a done deal?

Ah…there it is…”a waste of time and money for ALMOST everyone involved.” Some very powerful someone has an economic incentive that does not rest on either an outcome or on safety. Someone is getting paid for all of those EKG’s and blood tests for pre-admission testing prior to cataract surgery (I am a cataract surgeon; it isn’t us),  and they have found a way to interpret various and sundry Medicare and OR accreditation documents in such a way that pre-op testing is mandatory. This blatantly ignores the evidence because the evidence ignores the economic incentives: a hospital is getting paid for pre-admission testing. All those patients are being robbed of their time, and every one of them who has an “abnormal” test result is then directed down the rabbit hole to chase a “cause”.

I know, I know…you’re shocked. SHOCKED! As bad as that example may be, and as perverse as it is that the champions of evidence-based medicine ignore the evidence when money is on the line, a story of a hospital doing something extra to get paid more is kinda boring; it just seems to happen all the time. In the private world of free-standing surgery centers that are not associated with a hospital pretty much everyone gets the joke about pre-admission testing and would do pretty much anything to be able to quit. You see, the private surgery centers don’t get paid the same way and pretty much lose money on pre-op testing. If they could get away with it they would all drop pre-admission testing for cataract surgery. The barrier is the economic incentive for the hospitals that own surgery centers and their influence on how regulations are interpreted.

In the face of data that provides a pathway to cost savings in healthcare, evidence-based medicine will only be utilized if the incentives are such that the invested players stand to gain, or if lights bright enough and cries loud enough arise to point out the perversity of the economics at hand.

 

 

The CrossFit Games Effect and the Traveling CrossFitter

Do you travel at all? For work or for fun? If so, do you drop in on local CrossFit Affiliates for a WOD? Some folks do this just for fun on their home turf, bop around and visit local Boxes for variety, community, whatever. What has your experience been like? Did you feel welcome, regardless of your experience or your expertise?

The answers to this question will likely drive the conversation about our community’s next iteration. You know, CrossFit.com to Affiliate to international phenomenon, or something like that. What I hear is mostly something along the lines of “everyone was really friendly and I was welcomed by the owners”, and the collective experience of Clan bingo has been just that. I don’t think I’ve ever heard anything other than that from any CrossFitter who can reasonably be described as “average” or more advanced.

There is a somewhat newer experience we hear of though, one that has become a bit more common as the Games have grown, and it usually comes from the less experienced or less talented CrossFitters. There are some Boxes that are focused on coaching only those folks for whom the Main Page CrossFit.com WOD’s as Rx’d are considered the CrossFit “starter kit”. Kinda like “unless you can do 95% of .com WOD’s as Rx’d we don’t have room for you” stuff. Pretty harsh, especially if you are an average CrossFitter (like me) and you are not aware of this before arriving at the garage door and getting ambushed.

By and large the CrossFit Games are a unifying force for our community of CrossFitters. One need only look at the FB pages of CrossFitters attending the Regionals these last few weeks, littered as they are with posts and pictures of their experiences. The universal thread is the thrill of meeting like-minded individuals en masse, the ease of talking with people who don’t need a translator to interpret the lingo. The advent of competition at an international level seems to have had a different effect on occasion in some quarters.

We have had a culture of inclusiveness, “CrossFit is for everyone”. The work being done by the mad scientists behind the curtain at HQ is very much geared toward measuring and enhancing the effect of CrossFit on the middle of the Bell Curve and below, attempting to answer the questions surrounding fitness as a measure and producer of health for the masses, not just the elite performers. This “CrossFit is for everyone” ethic typically extends to the classes at most Affiliates in which the Newbie just out of his on-ramp class does a scaled WOD on the platform next to last year’s Regional Team competitor. Boxes have traditionally been open and welcoming (for a drop-in fee, which is cool) to all traveling CrossFitters looking for a dose of the CrossFit Rx in the company of the like-minded.

I’m not saying that this has changed so much as maybe just saying I’ve heard a canary or two around the mines as it were. A chirp here, a squeak there. Nothing really, as long as the stories of average CrossFitters who felt unwelcome remain rare enough to be considered a kind of “urban legend”. It’s important to remember that the Games-worthy athlete is the exception, even in gyms that consider themselves the birthing grounds of such rare and wonderful creatures.

The true power of CrossFit and the true measure of CrossFit’s worth is STILL the fact that CrossFit really IS for everyone. It’s not the “man bites dog” phenomenon of a victor at the Regionals coaching and cheering for the stragglers, it’s the fact that the faster and stronger do that at every CrossFit class at every Affiliate every day. Allison Belger talks about the shared struggle as the foundation for our community and this is partly true; what builds the community is the support that radiates from the fittest to the still unfit, the message that you really can share this sruggle with us. The community is functional in much the same way that our movements are functional, from core (members and owners) to extremity (visitors, newcomers).

While we are all blessed (or cursed) with different abilities and potentials we shouldn’t forget that we were all once new to this wonderful CrossFit thing, too. The beauty of it all is that we are still more alike than we are different despite the fact that there are now so many more of us. Wanna know my “Fran” time or 1RM Deadlift before I jump into your 5:30 class as a visitor? Sure. No problem. Just use it to figure out how I’m gonna fit in, not wether I’m gonna be allowed.

Because ya never know, if you do I might be sitting right next to you at the Regionals cheering for that woman in your Box who kicked my a$$ in the WOD and then stood right next to me and cheered me on to the finish.

 

 

A Friend Who Will Tell You The Truth (About Yourself)

Everyone should have a friend who will tell them the truth, specifically the truth about themselves. At least the truth about how the world views them. It’s impossible to accurately observe our own footprints; we need someone to show them to us.

This is not to say that one should form an opinion of one’s self or one’s self-worth solely on the basis of some external view. Hopefully our friend speaks kindly to us out of love and caring in the hope that the truth will lead us to a better version of ourselves, or allow us to feel better about the present version.

I have such a friend, and we recently had such a talk. It turns out that my doubts about the man I am now are unfounded, that I have grown into the type of man with whom others genuinely wish to gather, despite my fears to the contrary. It can be hard to sit still for such a compliment, uncomfortable to hear it no matter how lovingly it is offered, the urge to demure nearly overpowering.

How I have arrived here is quite another story, and a painful truth that my friend offered as well. In my younger years, a time filled with the external measurable trappings of success, I thought I’d already reached a place where people of all shapes and sizes were comfortable and happy in my company, and I in theirs. Hmm..turns out, not so much. No, it turns out that I was much too pleased with myself, too pleased myself with having achieved that visible success. I held myself apart, above. I was liked, but mostly because those to whom I would be compared were less likable. Ouch.

Would I have heard my friend if she told me this back in the day? I don’t know. I doubt it. A massive dose of humble pie was probably necessary, not only to hear and listen, to be ready to hear and listen, but certainly to have become who I am today. The details of my humbling are not really relevant, it was the lessons taught by humility that matter. Chicken? Egg? Does it matter? I do wish that she, someone, had told me then, though.

Why does it matter now? Why is this not simply a case of a friend congratulating me on growing up to be a better adult than I once was? Some times we get a mulligan. A do-over or a re-start. I may once again achieve a kind of success with all of the visible trappings, and the truth my friend shared is not just a pat on the back but a kick in the pants. A warning that I should do a better job this time around.

Everyone should have a friend who will tell them the truth. Each of us should care enough to listen.

 

The CrossFit Games: Defining Moments

“Defining moment”: a point at which the the essential nature or character of a person, or a group, etc. is revealed or identified.

Buzzfeed reported that Rich Froning signed an endorsement contract with Oakley, calling it a “the defining moment in CrossFit’s history.” Think about that for a moment. The signing of a single endorsement contract by Rich is being called THE defining moment in CrossFit’s, not the CrossFit Games’ mind you but CROSSFIT’s entire history.

I prefer to think of Rich’s Oakley signing as just one more milepost along the maturational highway of the CrossFit Games, CrossFit as sport. When we eventually have a Nike sponsored athlete or a Gatorade commercial (hmmm…who do you want to see with the fluorescent perspiration cascading down the body after a clip of butterfly PU?) then we will know that CrossFit the sport has broken through to the masses, not unlike that snowboard kid–what’s his name, the Floating Eggplant or something like that–getting an Amex commercial in the Olympics OFF season.

No, I think there actually have been a couple of defining moments this past year or so, one that is CrossFit in general and bridges the CrossFit/Non-CrossFit divide, and one which is specific to CrossFit, the sport and is confined for the moment within the CrossFit community. I don’t think either one of them is a promotional deal.

The first one is easy: CrossFit, Inc produces and sells the CrossFit Games to ESPN. Now THAT, boys and girls, is a defining moment. There is no Oakley contract for Rich, heck there’s probably no Reebok without the gut check Greg Glassman (universally know in the CrossFit world as simply “Coach”) and the CrossFit HQ staff made when they went it alone at the Home Depot Center for the 4rd rendition of the CrossFit Games. I’d had some conversations with Coach that winter as he worked through the various options available to CrossFit as media companies started to circle the new phenomenon that was CrossFit (my role and impact were trivial; I was simply a sounding board as Coach thought out loud).  Year 1 at the HDC was live-streamed to CrossFit Nation for free, and done so at a substantial financial loss.

Signing that ESPN deal is the very essence of a defining moment: CrossFit and Greg Glassman would control all things CrossFit, including how its signature event would be produced, and they were willing to not only walk away from silly money to do so, they were willing to LOSE money.

Think Adidas is happy about that? The Reebok/CrossFit Games and the Reebok/CrossFit deal are also a defining moment for the second largest athletic company on the planet, let alone just CrossFit. The international awareness of Reebok and its growing association with the pursuit of fitness may actually save the original Adidas deal to purchase Reebok, thus far a money loser. Reebok benefits from the buzz generated by CrossFitters talking about CrossFit, something we are known to do on occasion! Reebok has been re-defined in part as a fitness company. Now that the CrossFit Games are on “The Deuce” almost all of my conversations about CrossFit occur without the need for an introductory explanation, a true paradigm shift for CrossFit. I’ll bet that’s changed for most other CrossFitters, too.

The other defining moment is an internal one and involves CrossFit the sport, the CrossFit Games, for both participants and CrossFitting spectators. It speaks to the growth and continued maturation of both the sport and CrossFit. Each year the Games season has had an “issue” that in retrospect has made perfect sense as it related to the particular stage of development of both CrossFit and the Games. We had entries cut off at a particular number without a qualifier, and CrossFit Inc. was excoriated by the excluded. We had locally-run Regionals which generated controversy about WOD choices, and CrossFit HQ was accused of favoring certain Affiliates and athletes. We had the first Open and the surprising number of participants straining the resources of the Games staff, which was taken to task as unprepared (in truth, the volume and growth was impossible to forecast). We had Regional venue variability and therefore presumed issues of fairness. All of these were acknowledged by HQ, and ALL of them were resolved in each subsequent year. None of these, however, constituted “defining moments”, so provincial was each one.

Now we have folks at home making rules calls. Evaluating judges’ calls no differently than we see people talking about balls and strikes, one foot inbounds or two, charging or a block. This feels an awful lot like the “Big Time”. The event and the audience have now grown so big, and both have become so sophisticated, that this year people are talking, arguing,  about pretty darned subtle judging issues. The Games have grown and CrossFit has separated along the lines of those who compete in the Major Leagues and those who compete for fun (if at all). Not unlike golf or tennis or any manner of endurance sport, the divide between the 0.1% and the rest of us now exists in CrossFit, too. As far as The Sport of Fitness (R) goes, we are now all witnesses.

The gulf between Games Athlete and CrossFitter is no less wide than that which exists in any professional sport you can name, and its existence or significance does not rest on an endorsement contract. The power of this defining moment in my opinion (no endorsement, here or ever, from HQ) is that we have reached a point where we all understand the nuance of CrossFit to the degree that we are knowledgeable enough to comment on judging. We watch the events and we care enough to argue calls. At the Games, at the Regionals, and at the Open. The fact that some of us choose to do so may or may not be a good thing, but the depth of knowledge that is now present across the spectrum of people doing CrossFit, manifested by our collective awareness of the act of judging, is a significant defining moment for CrossFit, the sport.

So best of luck to Rich and all of the athletes going through the Regionals right now. Congrats to Rich on signing a landmark endorsement deal, whether or not it is a “defining moment” for CrossFit (I loved his Oakley toss to the crowd at 13.5 in Santa Cruz, by the way!). Good luck to anyone who wants to buy a pair of Rich Froening Oakleys though–in my day job we sell the brand, and let’s just say that they haven’t figured out the inventory/customer service thing.

But mostly, best of luck to all of the judges at all of the Games events. Let’s remember that every year HQ has evaluated the Games experience and come back better the next, solving each year’s issue as the Games grow into next year’s. This year will be no different. Each one of those judges is you, and they will be back with you in the Box next week in the never-ending struggle of you vs. you.

Each of you looking for your own, personal, CrossFit “defining moment” each time you walk through the door.

 

 

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