Secular Tailwind
“Well Hannah, we really think ABC, Inc. is poised for a big uptick. We see them riding a strong secular tailwind in the 3rd quarter with earnings to follow”
Excuse me? “Secular tailwind?” Seriously, WTF is a secular tailwind? Does the presence of a secular tailwind mean that there must be a secular headwind hiding out there somewhere? And how about the “secular” part of this weather front? Secular always seems to be accompanied by sectarian. You know, like Sunni’s and Shiites. The yin to someone’s yang. Heathens and infidels on one side, true believers on the other. If a “secular tailwind” is good, how bad is a “sectarian headwind”?!
For those of you who haven’t been paying attention, I not only play a doctor on TV, I also play one in real life. We doctors have been vilified for using impenetrable language to make ourselves look oh so very smart, all the while confusing the heck out of our patients and making them feel unintelligent. Small and embarrassed. Kinda like when you ask the wine steward for a suggestion and you just know… you KNOW… everything he said about the wine was pure nonsense, and your wallet’s about to get violated. Heck, at least we doctors had the decency to use opaque phrases in a different language. We really sounded pretty cool and very smart when we said everything in Latin or Ancient Greek.
Not the good folks in finance, though. The don’t even really SAY anything. They’re just making S__T up. “Secular Tailwind.” Seriously, how do they say stuff like that and keep a straight face? Maybe it has something to do with the fact that everyone who watches or listens to those financial shows is doing so by choice; unlike a patient in his doctor’s office who has some kind of illness to be sorted out, the people watching CNBC or MSNBC are voluntarily tuning into Cramer and his buddies. Not a soul in that audience needs to be listening. Their reward is to be insulted.
It turns out that the relative “literacy” rate for medical information is roughly akin to the vocabulary of an eighth grader. In other words, if I choose to use words or phrases that would not register with the average eighth grader a substantial percentage of my patients will not understand what I am trying to get across. Real research has been done on this stuff and reasonably so; it’s important to understand what your doctor is trying to tell you. Many of us in medicine really do get this, and really do try to neither speak above or speak “down to” our patients. Gone are the days of multisyllabic jargon sandwiched between words from a dead language.
Imagine if that wasn’t the case. Even worse, imagine what it would be like if physicians and other caregivers acted like all those financial talking heads and not only tried to confuse you but just blatantly made crap up while doing so. “Well Mrs. Jones, I’m afraid there’s a involitional reservoir of hard fluid residing in the retrosplenic attic which appears to have suspended all glomerular transport underneath. There are a number of ways it could have gotten there, and of course there’s no guarantee that we are right, but we are pretty sure it was blown there by a Secular Tailwind.”
Don’t worry, though. We’ll just start a little IV Novena…
Panera Bread Cares (A Random Thoughtlet)
While driving to work this morning I had NPR on the radio as usual. The Business News segment was featuring the Panera Bread company and its “Panera Bread Cares” program. Briefly, Panera has converted about a dozen of its formerly for-profit stores into non-profits owned by the Panera Foundation. There are no prices in these stores, only “suggested donations.” Approximately 20% of patrons donate more than the suggested amount, 60% pay as if it is regular price, and the rest pay little or nothing.
Needless to say, the folks from Panera were more than a little self-congratulatory about this enterprise, and I think they have some reason to be so. Their stated goal is to raise awareness of “middle-class food anxiety”, not so much to provide food to the poor or the homeless. I imagine that the paying customers might be a little less prone to continue patronizing a store which all of a sudden started to be populated by the various and sundry homeless, especially those who look the part. Still, I do think this is an interesting experiment along the lines of Radiohead and music but for charity rather than as a business model.
Here’s the rub: a Professor Somebody from someplace opined that it is “exceedingly rare” that a business has a charitable venture that is indistinguishable from its for-profit core business. I wish I remembered the guys name. He intimated that it might actually be unique, not seen in any other business. Right. About that. This is the self-congratulatory part that rankles. Unique, as in only one, like never before seen?
Hardly.
How about the countless private doctors’ offices and clinics that have been seeing and treating patients for little or no payment, a phenomenon that began decades ago and continues today? Have we become so jaded about doctors and healthcare that an economics or business professor can state, presumably with a straight face, that a company offering to give away its core product in its usual setting is unique and almost unprecedented?
Come on now.
I’m reminded of a story one of my older partners used to tell. Dr. Scheie, namesake of the Scheie Eye Institute at Penn in Philadelphia, was a pioneer in cataract surgery. Every one of his patients had the same experience in the operating room itself, and Dr. Scheie personally did every single surgery; no one was denied surgery by the great Scheie, regardless of their ability to pay. Where they spent the next several nights (this was in the days of sand bags and immobilization) was determined by what, if anything, they did pay. Regular patients, those who paid the “recommended donation”, were the majority of the patients and they stayed in semi-private or double rooms. Those less well off who paid little or nothing were tended to in a dormitory like ward. There were two private rooms reserved for those who were of more substantial means. When asked what surgery would cost if one were to spend the night in a private room Dr. Scheie would reply: “you should pay what you feel you should.” The eye clinic never lost money.
I think the idea and philosophy behind the “Panera Bread Cares” is pretty cool, but let’s be real about both the phenomenon and the real rationale underlying these “pay what you can/want” stores. Panera is getting enormous publicity and goodwill from a trivial number of store conversions. It is getting great feedback and outsized credit for something that is so common in medicine that business professors seemingly forget that and get on NPR and say stuff like Panera Bread Cares is so rare that it might be a one-off. They are giving away bread bowls, for Heaven’s sake.
Doctors have been giving away something much more valuable to those who can’t pay every day for decades.
Sunday musings 9/2/12 (From Savannah)
Sunday musings…
1) Savannah. Cool town ya got here.
2) Volume. Heard on the street last night:”Ya, but how many is that in ‘dog beers’?”
3) Bogart. “The problem with the world is that everyone is always a couple drinks behind.” Humphrey Bogart.
Bogart, an accomplished drinker, is also making a statement about a general atmosphere of tension and angst in his world. While I don’t necessarily condone his solution, now or then, his observation is spot on, now AND then.
Things are generally better than we are admitting out loud to others, generally better than we are admitting to ourselves. Really. To see this shouldn’t necessarily require beer goggles.
4) Ghosts. Savannah is populated by hundreds, maybe thousands, of ghosts. In truth if we met any last night I either didn’t notice or don’t remember. They, the ghosts that is, are all said to be sad or angry. If Savannah does indeed have ghosts it stands to reason that they ALL aren’t angry or sad, and that got me to thinking about ancestors.
Have you ever examined your heritage? You know, looked at what’s swimming in your gene pool, and where it’s been through history? There’s probably a ton in there, probably a ton of information that is worth knowing. History is awfully cool, a rich and vibrant panorama that can be viewed from any spot and examined in either direction. Your OWN history is like this. You should know your own story.
Some of your heritage may still be around, their panorama moving ever slower as they spool toward the end of their part of the story. Are they happy? Are they fulfilled? Have they imparted all they, and you, need? If they were to leave this life, if there be ghosts, would they be those quiet, happy types, or the sad angry ones that provide fodder for tour guides “crawling” the haunts of Bogart and his ilk? Time grows short for your living heritage, for them and for you.
If there be ghosts, might you be wise to learn their stories before they cross over?
I’ll see you next week…
Posted by bingo at September 2, 2012 6:50 AM
Sunday musings 8/26/12
Sunday musings…
1) Substantiate. Among the definitions or meanings is “to make more substantial.” Could use more of this.
2) Wedding. Mrs. bingo and I are once again in San Diego (nice town ya got here, by the way), this time for a wedding. Not just any wedding, mind you, but a wedding that took place on the deck of the Midway. Whoa. I can’t begin to describe the chills, the raised hair on the back of the neck thrill when we realized that we were actually on the elevator that brought countless aircraft up from below, and that we were descending to meet the bride.
Seriously, thrill of a lifetime.
3) Promotion Class. Did you know that each year a defined number of Admirals (and presumably Generals in other services) is promoted as a class? Me either. These classes will gather on occasion, but they usually go their own ways throughout and after their careers. Kinda busy, you know, keeping the free world safe.
The groom is one of these Admirals, one of 12 in the Class of ’99. Including him, 8 of these men and women were in attendance (as well as an Admiral from ’00 and the General husband of an Admiral). Awestruck doesn’t begin to cover the collective reaction of the other guests.
What was striking, to me and to most, was the camaraderie on display in this particular group. They’d done this before, been assembled by choice many times before, and this time came from all over the globe to share in a comrade’s joy. In their Dress Blues they moved among us with a grace and a certain dignity that was palpable, while simultaneously cavorting like college classmates who snuck away to the beach. I searched for words to describe what I saw last night, and found one this morning.
I spent the evening in the company of 8 (+2) substantial men and women who provided lessons in honor, loyalty, and gravitas simply by being together in the room.
4) Home. Where do you live? Morgan Freeman: “Everyone lives somewhere.” Do they? Do you?
Where you live is more than where you are domiciled at the present moment. The distinction between “house” and “home” is real, is substantial. Home requires effort; house requires a checkbook. A house demands upkeep of the walls, the various and sundry systems and furnishings, but a home demands an on-going commitment to what is contained within those walls.
Home also seems to contain a notion of place. A “where are you from” kind of statement or sense. You’ve committed to a certain zip code, learned the rules of the road so well that you move through that larger space in a continual comfort zone. It might be described as simply as knowing where to find eggs for emergency muffins on a rainy Sunday morning, this notion of “home in place”.
I wonder, and I readily confess that I worry about my friends who have multiple “homes”. Does home travel with them from place to place, simply injected into the particular space they occupy at any given moment? Maybe. I know that I am always “home enough” whenever I happen to be accompanied by Mrs. bingo, but still, I’ve needed a map every day here in SoCal.
“Everyone lives somewhere.” Indeed.
I’ll see you next week…
Posted by bingo at August 26, 2012 8:52 AM
Sunday musings 7/29/12
Sunday musings…
I think this is a good day for me to give you my “book report” on Allison Belger’s book “The Power of Community” in which she looks to the field of psychology to explain why it is that this thing we call the “CrossFit Community” was born and has grown.
It turns out that we humans are “pre-wired” for community. There is a stimulus, or a set of possible stimuli, that have a greater effect on this “pre-wiring”, that make for a more powerful urge to form and join together as a community. In our case as CrossFitters it is the combination of shared suffering, actually shared suffering that we have willingly subjected ourselves to, and the near universal support that we offer one another during our travails. We are vulnerable when we suffer; we seek the company of others who not only understand our suffering, but who see us in that vulnerable state and offer support. Rather than take advantage of us at our most vulnerable they seek to support us.
Allison points out that this occurs in the small space of the CrossFit Affiliate, in the slightly expanded space occupied by groups of Affiliates in a particular area, and by CrossFitters spread out around the world and connected by that same shared suffering and freely given support. “The Power of Community” shares many, many stories to illustrate both aspects of this stimulus. We come together, become a community, and by and large remain so. I think Allison nails the what and the why from a psychologists point of view. I enjoyed the read immensely.
Ah, but there’s more to this community thing, though, isn’t there? Why is it that the community aspect of CrossFit has continued to grow even as the community has grown to include so many people encompassing so many differences? Why is Affiliate number 4000 just as “bought in” to the whole community feel as Affiliate number 40? Why does that continue to happen?
That’s the $20MM question, isn’t it? You see, every aspect of the CrossFit community is voluntary. CrossFit the fitness program is free. Heck, I did it for 5 or 6 years by coming right here, 3 on/1 off. Didn’t pay a dime, and yet because I was a CrossFitter I was a part of the community. You can do CrossFit any way you’d like, you just have to raise your hand. The water’s cold and the current’s rough so you’ll have to work hard, but if you jump in we’re all here to help you swim.
Even the whole Affiliate system is really voluntary if you think about it. How many of us haven’t gone to a gym where trainers are teaching classes that look just like “Fran”? When you decide to Affiliate you are simply deciding to join a different part of the community, and frankly there’s really not a whole lot you are required to do in oder to do that. A little money. A few rules about the trademark. That’s it. Heck, this is about as free of rules and regs as any business I’ve ever come across. Pick a color…any color! Territorial restrictions? Nah…may the best gym win.
Joining a CrossFit Affiliate is simply choosing who you wish to have lead your tiny little micro-community. Open a CrossFit gym and what you have done is nothing more or less than chosen who you want to lead your larger community. It’s all there, all laid out in front of you. Want the freedom to create YOUR version of a community built around shared suffering and supporting one another during times of vulnerability? Your business with your rules and your version of entrepreneurial spirit? It’s harder to do it this way, I think, than to have strict rules on programming, branding, product placement and sales, but that’s CrossFit, eh? It’s harder.
But just like CrossFit when you succeed in this setting it’s you who reaps the benefit. Once you’ve anted up, placed your table-stake, it’s you who will reap the rewards of hard work, innovation, inspiration. It’s really a whole lot like every other part of the CrossFit community–you’ve chosen to call your gym a CrossFit gym, chosen to become part of that particular part of the CrossFit community.
That’s the “Secret Sauce” of CrossFit. We have all chosen to do this. We’ve chosen this very hard fitness and health prescription and from that we’ve become a community. Some of us have chosen to open places where people can do CrossFit, and more than that they have chosen to pay the very small price to call those gyms “CrossFit”. The “Secret Sauce” is that we are all volunteers, here of our own accord, and everything about the way CrossFit, Inc is run makes it easy for us to volunteer. If you don’t understand this, if you don’t realize that the “Secret Sauce that binds the community is there because each one of us puts it there, you don’t really get us at all.
There are 20 Million reasons for each one of us to realize that, too. 20 Million reasons to think about how easy it has been for us to choose to be a part of this community whether we are Affiliate owners, Affiliate members, or members of the cyber-gym here on CrossFit.com. 20 Million reasons for us to share our thoughts on how well the folks we’ve chosen to follow have done in leading us, to think about how this particular way of doing business has led us to our personal successes.
We are a community. We have 20 Million reasons to proclaim what that means to us.
I’ll see you next week…
Posted by bingo at July 29, 2012 11:50 AM
Sunday Musings 7/22/12
Sunday musings…
1) Date. Happy Birthday to the founder of CrossFit. Many more to come.
2) Secular tailwind. Heard on MSNBC. What does that even mean? How can people rag on medical people for using medical terms when BS like this is spoken? At least my stuff means something.
3) Gym sign. “Tired of being Fat and Ugly? Just be Ugly; Come to the Gym.”
That there’s pretty good.
4) Failure. “There are no failures, only feedback.” (Unknown). I like that, pretty much exactly as stated. I’ve written before that in order to learn, to progress, to succeed, it’s probably NECESSARY to fail as long as the failure is examined and parsed for the lessons to be learned. The quote is inaccurate and loses its essential truth if one encounters failure and simply walks away from it, leaves it behind.
Examining a failure in oder to obtain feedback that will prepare you for the next attempt allows you to experience the ultimate way to fail: Fail UP.
5) Practice. I read about a couple of athletes who do the same thing in their training: they practice winning. That’s right, each training session they do something they are good at and make sure they succeed in order to get accustomed to winning, to make winning feel normal. A decathlete, a golfer, and a basketball player I think it was.
Makes sense, I think. Visualize all of the first-time winners you’ve ever watched in any type of event. The biggest opponent they faced as the match wound down was sitting right between their own ears. Doubt, fear, a palpable sense of “what am I doing here” born of being in the foreign territory out front, bourn like a yoke attached to a freight car filled with anxiety.
I’m quite sure there are dozens of ways we can do this in our CrossFit world as we do our WOD, whether we do them simply for the fitness benefit of do them on the fields of competition. I also know that we learn how to win, to defeat our fear, our weakness, our natural tendency to turn away from the difficult and the uncomfortable simply by doing CrossFit.
That, in and of itself, is a little exercise in the practicing of winning that carries over into the game of life.
6) Random. You know where this one’s going. Another random act of heinous, senseless violence just occurred, only not the one you are thinking of. I just got home from several hours at a local hospital ER caring for the victim (1 of 3) of a random beating outside a bar last night in Cleveland. While they will live, this vicious, ugly act will cost this person the use of an eye.
How should we, as individuals and as a society, respond to last night in Cleveland and Friday night in Colorado? The larger societal question is almost certainly bigger than we can handle here, and I’m pretty sure it’s bigger than something a tiny voice like mine might answer. But I think we can tackle the question of how we can or should respond on a personal level, as an individual.
We should live today and tomorrow and the next day just as we lived last week and last month and last year.
For these acts are the doings of madmen, of people who have somehow lost that part of themselves that makes them fully human. We are empathetic creatures on both a micro level (I gaze down upon my patient on the ER gurney) and macro (we shrink in horror at the story on the front page). Those who have committed these acts do not look upon their victims and see the same thing that you and I see; they do not look upon another being with whom they share vastly more then the total of any paltry differences and see a version of themselves, another person. How could they? How could they see another person and still do what they’ve done? By disregarding the humanity of their victims they relinquish their own. We gaze upon them, or we should, with little more than that which we would summon as we looked at any animal that savaged a person.
We react to these random tragedies by going about our daily business, going to work, to a ballgame, to a movie just as we would have done last week. We maintain, and should always maintain, a situational awareness of our surroundings, but we defeat these madmen by not letting them make us afraid. If they change us at all we win by becoming more open, more friendly, more generous. We who remain become serial perpetrators of an entirely different type of random behavior: Random acts of kindness.
And we win.
I’ll see you next week…
Posted by bingo at July 22, 2012 7:49 AM
Sunday musings 7/15/12 From the Games
Sunday musings (from the Games)…
1) Hall Pass. Yup. Got mine. The whole weekend to hang at the CrossFit Games. With “The Heir” and Lil’bingo. Yup.
2) Cyber-gym. Once upon a time in CrossFit land most of the people who did CrossFit congregated here, on the Main Page of CrossFit.com. This cyber-gym has since expanded, kinda like an Affiliate that got so big it needed a bigger space, and now it includes stuff like FB and Twitter. Many of us have forged a very cool kind of friendship or kinship through the shared suffering of CrossFit in this cyber-gym.
It’s especially cool to actually meet these folks in real life. For real…like shake hands and hug kinda real. At the CF Kids Teen Challenge I met the near-OG who once upon a time went by “Cougar” around here along with a half dozen other women who’ve met the same way. Very cool pic floating around FB as proof.
Full frontal hugs had by all.
3) Vetted. Bumped into Kelly Starret. You know, budding author about to be published (do look for his book, out in early 2013). We got to chatting about our community and the word he used to describe it was “vetted”.
“I know everything about you once I know you are a CrossFitter. I know who you are. I know who you hang out with. I know the kinds of choices you make, good choices. I already know we will be friends. You’ve been vetted, simply by telling me you are a CrossFitter.”
I really like that word and all it stands for in this context. There is an assumption of good will extended from all CrossFitters to all CrossFitters. We are not surprised in the least when we meet yet another really nice person with a great story. Astonished yes, but no longer surprised. Like today when an honest-to-goodness real-life American hero spent 20 minutes talking with my boys after just having met them, sharing words of encouragement and inspiration (you and your fiance know who you are–thank you).
Indeed, I like that word and how Kelly used it so much I think I’ll buy him a dinner at a place called “Lola”!
4) Community. I’ve been reading Allison Belger’s book “The Power of Community” in which she dissects the CrossFit Community from the perspective of both a CrossFitter and a psychologist. I’m reading and re-reading parts so I’m not going through it all that quickly–I’m enjoying savoring the gems and jewels I’ve been finding there, and I’m sure that I will share more than several of those once I’ve mined it fully.
Every anecdote so far elicits a knowing nod. I struggled a bit with the question of “why”but I think I’ve figured it out. You know, as in why does CrossFit create such a strong community? Again and again, on a micro (Affiliate gym) and macro (the CrossFit Games gathering) level.
The science is cool: it turns out that we as creatures are probably wired for community, wired to become a part of a community. What it takes for this pre-wired state to become operational is some trigger or stimulus. The most exciting applied neuroscience now extent is in the realm of my day job where the brain part of the vision system can actually be made to change, to get better, if the stimulus that causes maximal activity in a neural pathway is repeatedly applied.
Ah… now we’re getting somewhere. Our stimulus is the willful acceptance of discomfort, and more so the shared experience of that discomfort in an effort to better ourselves. There is obviously something about this particular stimulus that fits right into that pre-wiring for the creation of a community. Dr. Belger’s book not only gave me an expanded vocabulary to describe our community, what our CrossFit community looks like, but it also helped me answer the the question of “why” it happens.
Whether in the cyber-gym or a Box, the stimulus for community lies in the willingness to pay the price to move beyond your perception of what is possible; once having done so one seeks others willing to do the same.
Having found them one always seems to be at home.
I’ll see you next week…
Posted by bingo at July 14, 2012 10:30 PM
Sunday musings 7/8/12
Sunday musings…
1) Wimbledon. Breakfast at Wimbledon. Why thank you, yes, I think I will.
2) ESPY. Kyle Maynard is up for an ESPY. Go find a place to vote for him.
Now.
3) Life? Billy Ray (not his real name, of course) turned off his implantable defibrillator (ICD) yesterday. Billy Ray is 44.
In my day job I was asked to evaluate him for a problem in my specialty. I was told he was about to enter hospice care and assumed that he was much, much older and simply out of options. I admit that I was somewhat put out by the request, it being Saturday and the problem already well-controlled. Frankly, I thought it was a waste of my time, Billy Ray’s time, and whoever might read my report’s time, not to mention the unnecessary costs. I had a very pleasant visit with Billy Ray, reassured him that the problem for which I was called was resolving nicely, and left the room to write my report.
44 years old though. What was his fatal illness? What was sending him off to Hospice care? I bumped into his medical doc and couldn’t resist asking. Turns out that Billy Ray has a diseased heart that is on the brink of failing; without the ICD his heart will eventually beat without a rhythm and he will die. A classic indication for a heart transplant–why was Billy Ray not on a transplant list? Why, for Heaven’s sake, did he turn off his ICD?
There is a difference between being alive and having a life. It’s not the same to say that one is alive and that one is living. It turns out that Billy Ray suffered an injury at age 20 and has lived 24 years in unremitting, untreatable pain. Cut off before he even began he never married, has no children. Each day was so filled with the primal effort to stop the pain he had little left over for friendship.
Alive without a life. Alive without living. Billy Ray cried “Uncle”.
I have been haunted by this since I walked out of the hospital. How do you make this decision? Where do you turn? Billy Ray has made clear he has no one. Does a person in this situation become MORE religious or LESS? Rage against an unjust G0d or find comfort in the hope of an afterlife? Charles DeGaulle had a child with Down’s Syndrome. On her death at age 20 he said “now she is just like everyone else.” Is this what Billy Ray is thinking? That in death he will finally be the same as everyone else?
And what does this say about each of us in our lives? What does it say about the problems that we face, the things that might make us rage against some personal injustice? How might we see our various infirmities when cast in the shadow of a man who has lived more than half his life in constant pain, a man alone? The answer, of course, is obvious, eh?
The more subtle message is about people, having people. Having family, friends, people for whom one might choose to live. It’s very easy to understand the heroic efforts others make to survive in spite of the odds, despite the pain. Somewhere deep inside the will to live exists in the drive to live for others. The sadness I felt leaving the hospital and what haunts me is not so much Billy Ray’s decision but my complete and utter understanding of his decision.
Billy Ray gave lie to the heretofore truism that “no man is an island”.
Go out and build your bridges. Build the connections to others that will build your will to live. Live so that you will be alive for your others. Be alive so that your life will be more than something which hinges on nothing more than the switch that can be turned off. Live with and for others so that you, too, can understand not only Billy Ray but also those unnamed people who fight for every minute of a life.
Be more than alive. Live.
I’ll see you next week…
Posted by bingo at July 8, 2012 7:17 AM
Hoisting Another White Flag: Generic Medications
The great Dick Lindstrom recently posted an editorial on the challenges faced by doctors in a world that is focused solely on the cost of medication, one in which pressure is brought to bear on both doctor and patient to use an inexpensive generic at all times. Dr. Lindstrom reaffirms his career-long position that only one factor matters in the complex decision making process that is medicine: what is best for my patient’s health is my sole concern. Indeed, it is important for each physician to fight for this outcome, to fight for the person who sits before us in the exam chair or beneath us on the operating table. When a clinical difference exists between the expensive branded medicine and the cheaper generic we are honor and duty bound to prescribe and support the better medicine.
Sigh. It’s just all so tiresome, this battle. We physicians certainly did not choose this fight, and frankly most of us have no dog in the fight other than the best interests of our patients. I wrote PREVIOUSLY that the notion that pens, penlights, and candlelight dinners prompt doctors to become shills for pharmaceutical companies is farcical and offensive. Come on…I’m gonna look for a reason to prescribe some new eyedrop because someone dropped off a couple of pens? That’s all silly enough, but the battle has escalated with the entry of insurance company and government programs that automatically switch to a less expensive “therapeutically equivalent” medication and then require doctors to personally run the gauntlet necessary to “justify” their clinical decisions.
We are on the receiving end of the same kind of stuff that big companies use to defeat smaller foes in court: we are bombed with paperwork. Not only that but it’s carpet bombing, indiscriminate deluges of time bombs meant to bludgeon doctors into submission. There’s collateral damage, just like in carpet bombing, only the casualties are more subtle. Forcing doctors to be a part of this irreparably damages the doctor-patient relationship, making it more of a commercial interaction as doctor becomes ombudsman for patient.
As Dr. Lindstrom exhorts, I’ve been fighting the good fight. Dr. Lindstrom doesn’t need this fight. He’s a living legend who has earned the right to stand aside from these types of petty issues and to choose to put his considerable gravitas to work on stuff that has to be more fun. Yet he willingly takes on this battle and I’ve followed his lead. Standing my ground and insisting on newer branded meds when they are superior to older, cheaper generics. It’s getting to me, though. I’m tired. My staff is tired.
I surrender. Up goes another white flag.
I’m going to surrender in the battlefield of Glaucoma. Why Glaucoma and not cataract surgery for instance? I’m tired and beaten up, but I’m neither a hero nor a coward, not a sentient nor an idiot; I don’t need to be a seer, some kind of morbid Karnac the OK, to know the outcome for either cataract or Glaucoma. I’m declaring right up front what is going to happen, how it will affect my patients, my staff, and me, and what the ramifications will be for American healthcare. I’m surrendering in Glaucoma because I can, continuing to fight in cataract surgery because I must.
In my 27 years as a physician only one paperwork/government regulation/billing issue has ever resulted in better care of my patients: the requirement to do an extended Review of Systems for a particular kind of visit resulted in the identification of major side effects from glaucoma eyedrops. Indeed, this was a total surprise and led to a rapid change in the way we took care of Glaucoma patients. Older medications, effective or not, were replaced by newer medications or laser because the newer treatments were both more effective and freer of side effects. What will I find this time?
Timoptic (topical Timolol) was introduced in the early 1980’s. It was a Godsend. Nothing less than a miraculous savior of vision, keeping legions of patients out of the operating room and saving thousands and thousands of people from certain blindness. It’s been off patent for decades but is now no more than a third line treatment. Why? Tons of side effects, some subtle (decreased exercise capacity, erectile dysfunction) and others less so (my friend essentially killed his very first Gaucoma patient in year one of the Timoptic era by prescribing Timoptic and causing 1st degree heart block). It’s really cheap now, but who can write this Rx and look themselves in the mirror, white flag or not?
We know that the Lipid class of Glaucoma eye drops is the most effective group of pressure lowering medications. The original, Xalatan, dethroned Timoptic in less than 2 years. Lower eye pressure and no systemic side effects and a new treatment paradigm was nigh. The worst side effect was a permanent darkening of the iris in 9% of patients, the price to pay to save your vision. Xalatan is now available as a generic (latanaprost). There are 3 newer, stronger, more effective Lipid medications, all of which are branded and all of which are 2-4X the cost of latanaprost. They all reduce eye pressure on average 2-3 points more than latanaprost.
I’ll start here. Starting next week every new glaucoma patient who opts for medical treatment will start on latanaprost. On top of that I will change every patient on a branded lipid to latanaprost if they risk losing insurance coverage for their drop. I will not respond to any insurance company challenge. If pressure reduction is inadequate I will follow my standard protocol and I will offer a second medication or glaucoma laser treatment, both of which are standard of care. If a second medication is chosen I will write for the generic second line Rx, an alpha-agonist. The generic and the brand alpha-agonist have equal efficacy; the generic has a 35-40% unacceptable side effect rate compared with the brand’s 10-12%. The generic cost is ~1/4 of the brand.
My staff and I will take the time necessary to inform my patients of these side effect issues, a time investment that will be a laughably small fraction of the time it takes us to fight the paperwork wars for Brand coverage. I will document this up the wazoo, noting every treatment failure and every last little side effect, jotting down every incidence of patient non-adherence. I will gear up for more glaucoma surgery, both laser and incisional, because I remember how much more of both I did in the days when Timoptic was king, in the days when version 1.0 of today’s medicines was so hard to take due to side effects. I will have this all on hand when we start to read of the new golden age of Glaucoma surgery.
I will be ready to answer the critics who accuse eye doctors of doing too much Glaucoma surgery.
Who’s Keeping Score?
Who keeps the score in your life? Come on…none of that “I just live day-to-day” nonsense…we ALL keep score. Money, house size, free time, successes of the progeny, number of followers, all simply proxies for hits, runs and ERA. I guess the better, more actionable question is really “who do you allow to keep score?” Let me explain.
It’s my contention that the score is ALWAYS kept. It’s inescapable. Not only that, but many people keep a running scorecard going on you. Your parents, siblings, children. Co-workers and neighbors. Friends. Everybody is paying attention and everybody is keeping score. It’s not all bad, of course, because many times folks are only counting the goals, runs, and touchdowns and ignoring the flubs and errors. It’s OK to be consciously unconscious of these particular scorekeepers because for the most part these people are engaged in a “non-zero sum” game in which victory for all is the goal, for all. They are probably cheering for you in some way, shape, or form.
It’s the OTHER scorekeepers who use the score as a weapon, who compare the scores, compete to win in a “zero sum” game, who may or may not have your permission to even be IN the game, let alone keep score, who can wreak havoc and render destruction on the playing field. These people insist on a game in which someone must lose in order that someone may win. +1 -1 = 0. They always see the game, every game, in these terms, and they want you to see it that way, too. They insist, demand, that you not only keep score in this manner, but that you also accept them as the scorekeeper.
Here’s where you get to choose, where I think you should exert your right to choose. You may seek, as I do, to convert as many of the games in your life into “non-zero sum” games, ones in which EVERYONE may triumph, as you can. Or, you can decide that this is pollyana-ish folly and view the world always through the “zero-sum” prism. Or some combination of the two. Your call. When you have a choice, though, what I DON’T think is optional is to allow anyone else to wield the pencil that keeps the score on your particular game but you, or maybe a very, very small subset of players intimately close to you. Think about it…how could you ever win, or even tie, if it’s “zero-sum” and someone else is keeping score? Why is that? Because the scorekeeper also makes the rules. Always. Why allow that to be imposed on you if you could choose otherwise?
In many ways letting someone else anoint themselves your scorekeeper is to hand over to them the right to determine what makes you a success or not. Heck, they’ll even chime in on whether or not your “score” should make you happy. Scorekeeper is just another word for “judge”, and scorekeepers seem to love to pass judgement. Should your success, your happiness, be defined by someone who seeks to impose their right to make that call?
I re-learn this lesson, slowly and painfully, again and again, over and over. My advice, offered freely and without condition, is that you should try to be smarter than I am, learn it once, and refuse to give up the pencil. Don’t let someone else decide that they get to choose the rules and keep the score on you.