Random Thoughts from a Restless Mind

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.

Transparency is the new buzzword in medicine. Systems should be transparent with regard to prices, if not costs. Doctors and other providers of healthcare services should publish their costs and fees, too. Various ratings and measurements have been developed in an attempt to measure that nebulous and elusive entity “Quality”. Calls have been made for transparency here as well; hospitals, doctors, and others are browbeaten to release any and all manner of quality measurements so that we might create something one could call an “informed patient”.

The first, and therefore most important challenge in the quest to measure quality is to agree on a definition of just what quality is. Like all rational discussions the first order of business is to agree on terms and the terms of engagement.

Let’s take the question of evaluating the quality of an individual surgeon. What are the salient metrics? Are we concerned with only outcomes? You know, success rates, complication rates, stuff like that. Is there more to the measurement? Should we be concerned with EFFICIENCY, the ability to obtain high quality outcomes in a more timely manner? How about VALUE, the soft and difficult to measure combination of quality and COST? In this day and age of “economic credentialing” in which doctors, hospitals, and other providers are held responsible for the cost of care, not only on an individual basis but also a societal one, it seems as if value is an inescapable aspect of quality, at least in the eyes of our government and the people who actually pay for healthcare.

Quality measures will be different for surgeons of different stripes; we will want to evaluate different complications and their rate of occurrence for an ophthalmologist versus, say, a cardiothoracic surgeon. Even similar adverse events like infection rates will have a different meaning across specialties. One classic example of a surgical complication is post-op infections. From my limited reading about heart and chest surgery it appears that the post-op infection rate is around 1-2%. This would be scandalous in eye surgery where the post-op infection rate is 100X lower, closer to .01-.02%. Stuff like this should be fairly easy to uncover, or at least you’d like to think so. It turns out that even this metric is rather hard to come by since multiple doctors will participate in the treatment of post-op infections, and literally no one offers up these stats uncompelled. Similar issues apply to specialty-specific complications (vitreous loss, graft leak) for similar reasons.

Right away the difficulty of measuring quality is obvious: even the simple quality measures appear to be something other than simple to discover right now.

Outcome measures are even trickier. Since I know eye surgery best let me stay in that arena and use cataract surgery as my example. For our discussion let’s assume that we have magically been granted unfettered access to every eye surgeon’s charts (and that they are all legible, and that they all contain the same basic information). It should be a rather simple proposition to draft meaningful criteria–let’s say “how well do the patients see after cataract surgery.?”  Would that it were so. The answer to that very simple question–how well do you see after surgery–depends on several variables, and further varies if you ask the question slightly differently. How much improvement did the patient achieve compared with pre-op? How fast did the improvement come? How well does the patient see without eyeglasses?  Is the patient more or less dependent on eyeglasses following surgery? What level of vision constitutes a success? Does the surgeon get the same results with complex cases?

I imagine these issues are not specific to ophthalmology. I can see the same types of questions and complexities in orthopedic surgery, for example. Think about hip replacement–along with cataract surgery and cardiac bypass surgery, hip replacement is arguably one of the most significant medical developments when we think about the quality of life enjoyed by an older person. What defines success in hip replacement? How long do you allow for success to occur for it to be deemed one for the  “win” column? Do we give bonus points for speed in the OR, both from a patient’s standpoint and an economic one? How about a surgeon’s ability to achieve the same level of success in a thin 70 year old tennis player and an obese, cart-riding smoker?

Seriously, if docs can’t come to an agreement about what constitutes “quality”, how can we in good faith measure it? Furthermore, if we WON’T define it we have no one but ourselves to blame when some nameless, faceless 30 year old sociology major in D.C. does it for us.

Nobody asked me (again), but as long as I’m here let me offer up a 3-part proposal to measure and promote quality using surgeons as a theoretical template. Let’s start with a thought exercise borrowed from CrossFit. Fitness training using the CrossFit methodology involves high intensity exercise while trying to maintain near-perfect movement and form. One is shown three targets from a shooting range. The first has random bullet holes all around the bullseye, the second has every shot dead-on perfect, and the third has 95% of the shots within the center bullseye and 5% on-target but not perfect. Which one represents the most desirable CrossFit training strategy?

In CrossFit the answer is “C”, 95% accuracy with the misses still close because this represents the optimal combination of form (accuracy) and intensity (speed). Is this directly applicable to surgery? Well, that depends on how far outside the bullseye the misses land, doesn’t it? And in surgery I think we also need a more accurate measurement of intensity; we need a clock. Speed matters, from both a medical standpoint and a financial one. The shorter a surgery lasts while still hitting the target, the less physically and mentally taxing it is for the patient, and the fewer costly resources (OR time, staff time, doctor time, supplies, etc.)  you are consuming during surgery. All things being equal, the surgeon who achieves the desired outcome faster without increasing her complication rate is the better surgeon.

Put surgeons on the clock.

A successful outcome must be explicitly defined for each common surgical procedure. Pre-operative factors that reduce the likelihood of success should certainly be taken into account (e.g. a morbidly obese cart-riding smoker and hip replacement), but care needs to be taken so that a measurement can’t be gamed (two guttata do not constitute a corneal dystrophy and increased likelihood of swelling) in order to work with a lower standard. Surgical societies should show some spine and make a call, define what constitutes a high-quality outcome, regardless of the howling that will emanate from the mediocre and the incompetent. It’s gonna happen anyway, and physicians making the call would be orders of magnitude better than MBA’s and philosophy majors.

Lastly, quality should be measured, publicized and praised, and those surgeons (and other doctors) should be explicitly rewarded with as many cases as they can (or wish to) handle. They should also be paid more. Once we decide what constitutes quality we can measure it and publish the data. People will understand this, just like they understand the data in a box score. Why is it so OK for the baseball player with the highest batting average or lowest ERA to be paid more based on his success, yet somehow the most efficient surgeon who has the best outcomes is labeled a “money grubber” who must somehow be doing something wrong if he is also very busy? We want that high batting average guy at the plate in the 9th inning of a tight ballgame, and we pay him more because of his higher quality outcomes. Why aren’t we doing the same thing with surgeons? The very least we can do is stop accusing surgeons of being successful!

It’s time that we apply basic theories about quality to medicine in general and surgery in particular. Indeed, it should be easier to do it with surgeons. Make a call–define a successful outcome. Pull out a stopwatch. Faster, more efficient surgery is less expensive and generally less taxing physically for patients. Once the data is available be transparent and publish the results. I know what Miguel Cabrera is batting this year; my patients (and potential patients) should know my “batting average” in the OR. While I hold out little hope of being heard on this last point, uncountable articles support the benefit of the carrot at the expense of the stick when it comes to promoting excellence. Higher quality should beget higher pay. At the very least we should stop with the assumption that the busy surgeon is somehow “getting over”, guilty of somehow gaming the system (eg. doing unnecessary surgery) until and unless proven innocent.

She may just be better.

Sunday musings…

1) Jobs. Need more. ‘Nuff said.

2) Job. “The best job is the one you don’t need. That way you have permission to do what needs to be done. You can always do the right thing.” Sheri Lansing (?)

3) Life. “We’ve added years to life, not life to years.” George Carlin.

My bid is that those of us who are doing CrossFit add quality years to our lives. We can expect our senescence to be much freer of decrepitude than that of our predecessors, which will allow us to spend less time simply checking the required boxes of our days.

We are also adding a communal life to our years, at least those of us who are members of an Affiliate gym or who engage the online CrossFit community. I’ve had more substantive   conversations about more varied topics with the people I’ve met in the CrossFit community than I have in my medical community. We engage one another. We join together in our WOD’s, join together in living.

We cram just as much life into every time domain as we do work in our WOD.

4) Anniversary I. We did “Haddie”, the memorial WOD for our beloved pet that left us this time last year. The WOD included Burpee PU and runs; Haddie had a stroke in her spine and for the last two years of her life would continually fall while running, only to pick herself up and keep going. Tough chick.

Pets, dogs in particular, teach us some valuable lessons. We learn responsibility because they depend on us for the essentials of life. Every day we see what unconditional love looks like when we are smothered in puppy love upon awakening. Heck, we get it when we return from a 90 second errand.

And we learn how to say goodbye. Our pets teach us that life is finite. Our love cannot change that, nor can theirs. Before we say goodbye to our people we typically have to say goodbye to one of our dogs. It’s a lousy, ouchy lesson; it’s a measure of their love for us that they typically handle it so much better than us. We are left with memories, and even here our dog teaches us about remembering our loved and lost.

Who, after all, really remembers anything truly bad about their dog?

5) Anniversary II. Mrs. bingo and I just celebrated our 27^th wedding anniversary. My “Better 95%” and I have been together 30 years in all. Pretty cool. Actually, VERY cool. One of my CrossFit buddies noted that my ROI on that 5% I contribute is pretty huge!

Marriage is hard work, and given the atmosphere around here right now it’s probably not very cool for me to offer any advice, so I’ll just channel the grace offered to me on this occasion by another CrossFitter. Robin hoped that “[our] wedding day was the day that we loved each other least.” If CrossFit is seeking to become a better you tomorrow than the you of yesterday through the work you’ve done today, perhaps we can say this about marriage:

Seek to have more love tomorrow than you did yesterday by loving more than you ever thought possible today.

I’ll see you next week…

Crossfit. Constantly varied functional movements performed at high intensity. At 52 years of age I am nearly the athlete I was in my twenties. How can that be, you might ask? Well, while I am not truly as athletic as I once was, I believe that I am more FIT than I ever have been. This is allowing me to participate in athletic and other physical endeavors that I really have no business thinking about at my age. What kind of athlete might I have been if I trained in my teens and twenties the way I train in my forties?

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

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

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

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

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

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

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

I was hooked! My fitness went through the roof. My waist size shrank. My cholesterol plummeted. Three days on and one day off for 6 1/2 years and I am as fit as the day I graduated from med school at age 26. World class fitness based on workouts that typically last 20 minutes or less utilizing functional movements performed at high intensity. Competition? Yup. Me vs. me. Every day is a competition in which the opponent is yesterday’s version of Darrell, and victory is achieved if tomorrow’s version is just a little bit better than today’s.

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

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

How many more peaks might I have reached?