Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘doctor’

Customer Service: The Ohio DMV vs. Your Eye Doctor

It was the smile Ms. DMV Lady. No question, the smile told me that you chose to ruin my day when you had a lay-up chance to make my whole weekend, that you did it on purpose, and that it made you incredibly happy. In any other circumstances I’m sure I would have smiled back at you; that’s what other human beings tend to do when they see such unbridled joy on someone else’s face.

That trip back was my third one to the DMV, but there was no way for you to know that. You did see me on the second one, though, and you clearly remembered me. I forgot my license at home so I couldn’t do what I needed to do to transfer the title for my tiny little beater of a boat. Not only that, but there was nothing you could do to help me at that point, and I totally understood that. It was my fault entirely, so I didn’t ask anything of you on that visit because I knew that there was no way that you could help me, no matter how much you might have wanted to on that particular visit. I was really frustrated for sure, but I didn’t direct any of that at you, or anyone in the DMV.

Nope, it was the return visit where you could have made my day. My wife and I hurried home, got my ID and then hustled back. Did you notice that? Did you notice that we were both there? It’s really hard to free up two people who work full-time during your hours of operation. Definitely not your fault, that. We’d already tried to pull this off the week before and been thwarted, and here we were back for a second time with you, third time total. Now was your chance. We approached the desk with obvious relief on our faces. If we were successful this time we would still have to visit the DMV one more time (you only do titles; another location would do the license), but at least only one of us would need to take off work. You took the title transfer again–you looked at it in detail the first time and couldn’t possibly have missed this–and told us that the previous owner had filled it out incorrectly. He signed it in his name alone, instead of his name as “trustee”. That’s it; he forgot to put “trustee”.  You could have tipped us off before we went home for the license. You could have just noted it and let it pass. Nope. You said that we would have to bring it to him to fix before you could transfer the title.

We were equal parts dumbfounded and devastated, and it showed clearly on our faces. Here it was again, your chance to make our day. There was nothing nefarious about the prior owner’s mistake; it was a simple oversight in how he described the ownership. God, it was such an easy fix. It was right there, right in front of you for the taking. I held out my hands and pleaded softly and quietly for mercy. No disrespect toward you or your staff or your department, and no sense of entitlement or demand for action. A very simple request and a very quiet plea that we had acted in good faith. Your response? “You forgot your ID the first time, Sir.” I simply held out my ID and very softly said “but I went home and got it without saying anything, and here I am. Please, we’re really trying hard here and really could’t know.”

It’s a legal document was all you said. You had a duty to protect the State of Ohio, you said. It was then that I responded, still quite quietly mind you. I shared that the couple you had just chosen not to help were a doctor and a nurse. That we routinely put our family second as we care for patients in need. Nights, weekends…no matter. I asked if I could fill out your customer service survey, either on paper or online, explaining that I am evaluated on the care I provide and the experience that my patients have under my care. Oh my…the look on your face was priceless. Utter shock. Not once in your life, it seemed, had it ever occurred to you that it would be possible that you would be accountable to your customers. “We don’t have anything like that, Sir.”

Then came the smile.

Seldom have I witnessed such a pure, unadulterated expression of joy. You had chosen to ruin my day, and having succeeded you were not just pleased, you were infused with a visceral joy. It started in your eyes as realization crept in, and then it spread to every muscle in your face. Like I said above, it was the kind of smile that is almost always returned by another human being; we are wired to share such joy, after all. Alas, ’twas not to be for you and me. It was all I could do not to vomit on your threshold when you somehow found the strength to break through the grip of your ecstasy to wish me a nice day.

You will see me again, Ms. DMV Lady. Three times we’ve tried to get our little 1971 boat licensed, and it looks like we will need to make two more stops to accomplish that. It most certainly won’t be at your particular DMV location, though. Just thinking about that makes me nauseous all over again. No, you will see me again on my turf, as a patient. Karma, if nothing else, is imbued with a keen understanding of irony, a truly wicked sense of humor. In all likelihood it won’t really be me, personally. Even karma would find that too outlandish, an irony simply too delicious to believe. In reality you will need someone who does what I do, and you will need them in a manner and a sense that is identical to how I needed you.

I noticed that you are very nearsighted, and you have an inflammatory disease of your eyelids called blepharitis that often causes an acute type of particularly unsightly pinkeye (you are not my patient; this is not a HIPPA violation). Perhaps your son is getting married this weekend like mine. You didn’t know that, did you?  No, of course not. You broke your 3 year old glasses. Your prescription is out of date and you can’t just walk in to Lenscrafters and get a new pair, and your vision insurance only covers me. It would be a shame to have to wear broken glasses to enjoy this wonderful day. Or maybe that ugly, uncomfortable pinkeye bubbled up and there you are all red and gooey, two days before the whole fam damly shows up for the wedding. Nether one is truly an emergency, and failing to take care of either one right away will not cause you any harm whatsoever.

Let’s make it even more realistic. You know, like my return trip to your office. Let’s say it’s just before closing time, and the only way to get your glasses or your medicine is if a doctor gives the OK to see you right away. No matter what you see on the billboard, you won’t get an appointment at the Cleveland Clinic or UH. No, it will be a private doc like me. We always try to help. The Doc will know your story. How? Well, through our staff we always know the story because it always makes a difference. Would it have mattered to you that the reason I so desperately wanted that boat licensed was so that my son–the one getting married–could take his cousins and his friends out on his wedding weekend? We’ll never know; you didn’t ask.

There you will sit with your non-emergent problem that is only barely even urgent except for how much it means to you personally. Do you have any idea how easily the doctor and staff can slow-roll this even now, after you are in the office? They can follow protocols to the letter, check every preferred practice pattern box and follow every single insurance billing protocol, your chart and super bill as clean and proper as the illustration of a perfect boat title as you wait for your insurance to authorize your vision care visit, or pre-approve your expensive branded medication, and ruin your weekend.

In short, they could be you, ignoring the very real person with the very real need who stands before them asking for help. Or they can see you, hear you, and so easily choose to help you. Which, of course, is exactly what they would do. They will call the insurance company to get your Rx authorized, or they will give you samples of the medicine to carry you until you get pre-approval. Because you see, Ms. DMV Lady, that’s what every single one of us is supposed to do when we are on the other side of the desk from someone who needs our help and we are truly, safely, and easily in the position to choose to help them. It’s the decent thing that decent people do for others. When they can either make your day or ruin your day, it never crosses their mind that they even have a choice. It’s funny, when they know a little more about how meaningful it is to you that they helped, they really feel good about that.

Which is why after you have been helped, after you get what not only what you need but what you really want, you will be surrounded by people with the huge smiles of joy that come from doing the right thing. You’ll undoubtedly smile back.

Will you know why?

 

 

 

 

Equal Pay for Equal Work: Medicine is the Perfect Laboratory

The endless debates about the “Pay Gap” between men and women in the United States drones on. Today is “Equal Pay Day”, kinda like “Tax Day”, the day when you stop paying the government and instead start paying yourself, only it’s the day when the “average” woman supposedly has to wait for before she starts to make what a man makes. It all makes for great spectacle and epic barstool arguments for the same reason that people argue about who’s greater, Michael or Elgin, Kareem or Russell, The Babe or Barry: there is no proper, standard way to measure the issue at hand. On a barstool arguing “greatest ever” you never agree on either the definition of “greatest”, nor can you account for the vast differences in historical eras.

So it is with the pay gap. No one agrees on what constitutes work, let alone equal work.

This creates the maddening situation in which we find ourselves now whenever this comes up for discussion. Absent a meaningful definition of either “work” or “equal” we are left with folks on all possible sides of the issue simply choosing whatever statistic will support their deeply held beliefs about the issue. It’s crazy, actually. I read a dozen citations today and each one was so deeply flawed that it couldn’t stand the scrutiny of the middle if you velcroed it to the  50 yard line. Work is invariably conflated with “hours worked” with no discernible effort made to investigate something like intensity, or the measurable work performed per unit of time. “Equal” work is just a quagmire of competing opinions with, again, no effort whatsoever at objective measurement. How can you have a discussion that is meant to conclude with some sort of actionable agreement when all you do is pull numbers out of the ether and throw them at each other?

While engaging in a sorta, kinda conversation about this on Twitter it struck me that I actually live and work in the perfect laboratory to investigate the issue of the Pay Gap between men and women. You see, we have reams of objective data that can be evaluated. We all, men and women, do exactly the same things if we have the same jobs. Not only that but we have a unit of measurement for that work, the RVU. If Dr. Darrell does a cataract surgery and Dr. Dora does a cataract surgery, we have both done the same job. We can even determine the “intensity” of our work, our output if you will. A simple survey of hours worked per day can generate the metric: RVU/hour. Better yet, don’t take my word for it in a survey, just look at that heretofore meaningless and useless EMR and look at the measured time Darrell and Dora took to do their work. The OR record is a precise measurement of how much work we did per unit of time.

This is powerful stuff. Work is defined. An appendectomy is an appendectomy. A Level 4 New Patient Office Encounter is a Level 4…you get the idea. You get to compare apples to apples, heck, you get to compare Honeycrisp apples to Honeycrisp apples. It doesn’t matter if you are a man or woman or transgender. White, Black, Brown, Yellow, Red (did I miss anyone?), Millennial, Boomer and everything in between, work is work and an RVU is an RVU. Heck, you could gather all of the information about the work without anyone knowing who did it until after it’s all together. We could have a big unveiling when we lift the blinders and see who did what and how much they did. Seriously, how cool is this? It would almost be like science.

Let’s do be a bit serious for a moment. Imagine what kind of information we could acquire and what kinds of questions we could ask and answer. For sure there will be very reasonable concerns about how much we will be able to extrapolate from medicine to other areas of employment (advertising, investment banking, etc.), but it’s a great place to start. The question of the Gender Gap is primary, but how about looking at work across the generations. There is a “feeling” in medicine, certainly among crusty old folks in my generation, that younger physicians of both genders work fewer hours and do less work per hour when they do work. Is that true? It sure looks like it would be easy to answer that one, too.

There are actually a number of other issues in medicine that would be clarified if we had this kind of data, at least insofar as the work done is concerned. For example, how do private practitioners stack up against salaried physicians in large groups? Is there a correlation between how those salaries are determined and the intensity of work done? We can also look at value, work done per dollar paid (again, assuming equal outcomes). Where are we getting the best bang for our buck? For that matter, with the EMR’s that never sleep we can actually look at the responsiveness of doctors to their patients in urgent or emergent circumstances. Is there one group (men vs. women, private practice vs. employed) who are more responsive?

Having a discussion that is based on hard definitions of terms and data-driven rather than belief-driven opens up a whole world of meaningful inquiry.

Once upon a time I was among the highest paid physicians in the U.S. I worked insane hours, and the intensity of my hourly output was off the charts. In a word, I earned every penny I made, and the fact that I made more than another ophthalmologist had nothing to do with the fact that I was a man. Funny thing though–I now make a fraction of what I once made because I don’t work as much as I once did. The intensity of my work is similar; I still do as much work per unit of time, and my ability to perform at this high level of intensity is still greater than 95% of my peers, I just work fewer hours. What are we to say about women who do what I do, work more hours than I do, and yet do less work? Is there a gender gap in pay if I make more money than they do? What are we to say about my ambitious female colleagues who work more hours than I and work at the same intensity? I’m firmly stating that they should make more than I do. Is that the reality on the ground?

In medicine we have the ability to answer this question in a very objective, non-ideological way. I don’t know if what we find will be something we can extrapolate to other jobs, especially if we find that pay is directly related to actual work done in a domain where work can be both defined and measured. But hey, it’s a start. And it’s way better than just playing emotional whack-a-mole with how we value what we all do.

 

Sunday musings 3/27/16

Sunday musings…

1) Crenellate. Create multiple indentations on an otherwise smooth edge.

No reason. Just a cool word.

2) Eyelash. The normal lifespan of a normal eyelash is approximately 5 months.

Nope. I didn’t know that, either.

3) 16.6. Recovering from surgery from a non-CrossFit condition, I sorta kinda did a couple of the 2016 Open WODs. At some point over the rest of the year I will eventually do them (hopefully Master’s Rx), but for now I’m about to embark on CrossFit Open 16.6: constantly varied functional movements performed at relatively high intensity, with the intension of improving my work capacity across broad time and modal domains.

The CrossFit Games Open 2016 is an interesting and fun diversion, one that gives us a common experience across time zones and geographic variance. For me, though, the real magic happens in the other 47 weeks, the 47 week experience that you could call “16.6″ and heading into “17.0″.

That’s why I’m here.

4) Easter. Does it strike anyone else as odd, or something like odd, that it is only the two major Christian holidays (Christmas and Easter) that have superimposed, widely followed non-religious traditions? Try as I might I find no such superimposition on such equally important annual religious observations like, say, Ramadan or Yom Kippur . More so, if you do a little digging into the Easter Bunny’s origin you find that in his original incarnation he, like Santa Claus, kept a ledger of “good and bad”, with the good receiving eggs/candy/gifts. While I have no insight into why this might be, I find it odd.

In the Christian world there is no more important celebration that Easter. Indeed, the very concept of Easter is as difficult and complex as that of the Trinity. Judaism and Christianity share the Old Testament, and presumably therefore share a belief in the same Deity. It is in the interpretation of the Messiah that most people understand the difference between the religions (interestingly, the Koran recognizes J.C. as a significant prophet), but the more profound difference between Christianity and all other religions as far as I can see is the chasm that faith must leap to accept both the Trinity and Easter miracle.

While I am best described as having faith in a deeper, greater Presence, I am not a very religious person any longer (this makes Grambingo very sad). However, not unlike the CrossFit we all practice here, it is instructive to note the secular attempts to nullify the religious aspects of both Easter and Christmas, while noting how hard it is to hold tight the two beliefs that are the crux of Christianity.

For those who do the hard work of Christianity I offer a heartfelt and sincere Happy Easter.

I’ll see you next week…

–bingo

Measuring Health Part 3: Emotional Well-Being “W”

2016 is an Olympic year. We will hear stories, as we do in every Olympic cycle, of the extraordinary physical accomplishments of Olympians in sports which require otherworldly amounts of what we in the CrossFit world would consider “Fitness”. Strength, speed, and agility. Uncanny feats of coordination and accuracy, some performed over distances and times that are so far beyond the reach of the average human as to defy credulity. Many of these athletes, certainly the ones we will meet through the intercession of NBC, will match our expectations of the happiness that must certainly accompany such outsized achievements. Mary Lou Retton, anyone? Indeed, what we will see on our screens will fairly scream “Healthy”.

But there will be others, too. And for all of their physical fitness, expressed so dramatically for our viewing pleasure and patriotic zeal, the lack of emotional health will make it obvious to anyone that they are not healthy. Bruce Jenner, anyone?

Remember our proposed definition of “Healthy”: Able to perform in all ways at the farthest limits of one’s potential capabilities. Health is therefore the state in which no infirmity is, or can in the future, impede this ability to fulfill a potential. It takes but a moment to think of how mental illnesses such as depression, bi-polar disease, and schizophrenia can be hidden from view when examining only physical metrics. There are examples all around us. The woman who partners with a 1400 pound horse in the rigorous, physical tasks required to compete in the three-part test that is eventing, so poised and accomplished in the arena, who retreats to solitude outside the barn because she is incapable of overcoming her anxiety around people. The outdoorsman who in his manic phase performs feats of strength and endurance others can only marvel at, and then plunges into the depths of depression from which he cannot see the noon-day sun. Much more prosaic and much more common is the individual who continually increases his or her fitness by any and all measurements due to a deeply held sense of low self-worth, perhaps even self-loathing, pursuing an unreachable ideal and always falling short.

A truly universal measurement of health must include some element of emotional well-being. Let’s call it “W”. You could certainly call it the “Happiness Factor”, and some undoubtedly will. I imagine criticism directed toward this to take the form of “Happy Face” mockery. No matter. Well-Being is a better term for this part of our equation because it encompasses more than whether or not you are happy, whatever happy may mean to you, when you are measured. Are you content with your circumstances at the moment? Do you have the ability to persevere under duress?  What is the state of your relationships? A recent study of Harvard men carried out over decades found that both happiness and longevity were tied quite closely to the quantity and quality of your relationships with family and friends. Where are you in your pursuit of your goals, your dreams, and how do you feel about that? How much stress do you perceive in your life and how are you managing that? All of these make up what one might think of when we consider Well-Being.

How, then, should we go about measuring ‘W’? Remember, all of our tests should meet the dual imperatives of being accessible to pretty much everyone, and as inexpensive as possible. We could certainly use something like the classic anesthesia “smily face” pain scale, relabeling the figures, but this feels too simplistic and too momentary to be truly applicable. Our measurement should require a bit more thought than that. I have to admit here to countless hours of internet crawling trying to find a validated test of emotional well-being that has a track record in a heterogenous group that mirrors our population; most have been utilized in very specialized populations (e.g. soldiers) with a very specific research interest. Those that might apply must typically be purchased.

John Pinto is a well-regarded consultant in the world of my day job, ophthalmology. He has long had a list of clients that spans the gamut of pretty much every measurement you could think of in a group of doctors. Men and women. Young and old. Fantastically successful doctors and those that could only be described as spectacular (if unexpected) failures. As part of his quest to better understand his clients in order to better serve them, John used a questionnaire that measured emotional well-being. He found that external measurements of success such as volume of surgeries, income, and professional acclaim did not always coincide with his clients sense of success, their emotional valuation of their professional lives. These were certainly variables that mattered, but his happiest clients were not always his wealthiest, and his least happy not always those who had less. The assessment he used is the best one that I’ve been able to find, notwithstanding the fact that it is not free.

(http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg511 ).

I am not wedded to the Psychcorp assessment and would happily review any alternatives. Especially if they are free! As is the case with ‘M’, our traditional health metrics like blood pressure and serum lipids, I expect a vigorous debate as to the relative weight of ‘W’ in our final Health Index. My bias is that ‘W’ is a current factor with a greater impact on health, and it should have a correspondingly greater weight in our formula. Let me start the “bidding” with double; however the final formula shakes out ‘W’ should have twice the value of ‘M’.

Mental health is an inextricable part of health. It must be included in any serious definition and measurement of health. Our variable is “Well-Being” or ‘W’.

 

Measuring Health Part 2:The Traditional Metric ‘M’

Any measurement of health must provide some sort of predictive value with regard to the likelihood that one will remain healthy. While the entire idea of screening tests is fraught with controversy–both false positives and false negatives bring with them real risks–there are still a number of health measurements in the realm of traditional medical care that have a proven value when trying to predict downstream adverse health events. The trick, of course, is to decide which ones matter, filter that group to come up with tests that are as close to universally available as possible, and then decide how much weight each particular test in the group of survivors should receive in the single cumulative metric that is then created. This measurement, call it “M”, will be one of the variables in our calculated health measurement.

Let’s start with the simplest of all medical inquiries, a medical history. More specifically, let’s include a brief family history in our calculation of M. While it is becoming increasingly easy to obtain a very accurate genetic profile that identifies very specific health risks, these genetic tests are both controversial and expensive. Until the very real societal issues of knowing your exact genome and the risks it includes have been worked out by both ethicists and elected government, we should take a simpler and more narrow approach and ask two very simple questions: Has anyone in your family died from heart disease? Has anyone in your family died from cancer? Equally simple follow-up questions (How young were they? What kind of cancer) would allow us to add risk (reduce M) or ignore the historical note since the disease is not hereditary.

From here we move to an equally spartan individual medical history. Again, just two questions in this part: Do you smoke? Do you drink alcohol? The negative effect of smoking on an individual’s health, both in the present and future tense, must be accounted for in any measurement of health. It weighs so heavily on what we know about future risks that we will see it as a negative integer in M. Too many studies to count exist pointing out the deleterious effect of excess alcohol consumption to count. One compelling study, The Eight Americas Study in PloS One, found alcoholism to be the single most powerful lifestyle variant after smoking when predicting the life expectancy of groups studied. A recently published study of Harvard men found that alcoholism was the greatest second greatest influence on the happiness of the men studied, just behind the presence of loving friendships. Unlike smoking, however, there is a volume component to alcohol consumption. Indeed, a modest intake actually INCREASES longevity, while no intake DECREASES longevity. So M will see a small bump from moderated alcohol intake, an equally small decrease for teetotalers, and a dramatic negative effect from heavy alcohol intake.

So far we’ve managed to obtain some variables underlying M through the use of simple inquiry, costing only the time it takes a subject to fill out a questionnaire. At least two other variables are as accessible and inexpensive: blood pressure (BP) and a measurement of body habits. Once upon a time you had to visit a doctor or hospital to get your blood pressure checked. Now? Heck, for $20 you can buy a reasonable accurate BP monitor and take your BP at home! Minute Clinics in pharmacies, health clinics in the workplace, and coin-operated machines in the local Mall now make it easy to get a BP without visiting a doctor. While there is ongoing controversy in the medical world about what constitutes Hypertension it is safe to say that health risks are higher with a systolic pressure >140 and a diastolic >90. Above or below these levels is our toggle for M, positive or more healthy for lower and the opposite for higher BP.

Using body habitus is controversial, mostly because the measurement that is routinely utilized is so inadequate. The Body Mass Index, or BMI, is wildly inaccurate when it is applied to the fit. 4-time winner of the CrossFit Games Rich Froning, arguably the fittest man on the planet, would be deemed obese at 5′ 10″ and roughly 195 pounds with a % body weight fat of around 4%. Ridiculous, huh? The temptation, of course, is to use % BW fat as the preferred method of measuring body composition risk, but measurements that are accurate enough to be useful tend to be very expensive and difficult to access. On the other hand, all you need to determine the waist/hip ratio is an 89 cent paper tape measure and a calculator. A waist/hip ratio of >1.0 is associated with an increased risk to health from myriad metabolic illnesses including diabetes and heart disease, especially in men. Greater health in M for measurements under 1.0, and progressively less as that number increases.

It is impossible to utilize all that modern medicine has to offer when it comes to measuring health without spending a little bit of money. Several simple blood tests can be obtained with or without the input of a physician. The presence or control of diabetes can be ascertained with a HbA1c and a fasting glucose level. In the presence of a normal HbA1c an elevated fasting glucose may indicate a problem with insulin sensitivity, so it is important to include both. While it is far from settled whether or not it is cholesterol itself which is responsible for heart disease there is simply too much evidence that serum lipids can help predict cardiac events to leave them out of any health measurement. Our basic health index should therefore include the basic measurement of total cholesterol, HDL, LDL, and triglycerides, and M should reflect the negative effect of elevated Total Cholesterol, LDL and triglycerides and the positive effect of a high HDL.

How should we put all of these together to come up with our traditional health variable, M? This one is fairly simple; there are a number of “risk factor” measurements online that are good models. I envision a rather simple form on which one would add up weighted values for the measurements above, arriving at a straight forward mathematical sum. The final formula is being developed with the assistance of cardiologists at my medical school alma mater, the University of Vermont.

 

Measuring Health Part 1: Rationale, Definitions and Background

In 2010 I had a bit of an epiphany. At the time I was a bit over 4 years into my CrossFit journey. It became painfully obvious that the genius that Greg Glassman had applied to physical fitness–a definition of fitness that invited measurement, and in turn the critical evaluation of the efficacy of different fitness programs–was nowhere to be seen in the fields of health and medicine. Indeed, an informal survey carried out in person by my friend Dr. Kathy Weesner and I made it clear that the majority of physicians couldn’t come up with an actionable definition for health despite the fact that we are charged as professionals with helping our patients become “healthy”.

At around this time Coach Glassman published a theory that health was precisely defined as “fitness over time”. In CrossFit Fitness is work capacity across broad time and modal domains. Fitness over years could be depicted as a 3-dimensional graph with axes time, work, and years. As I thought about his thesis, that a backward looking view of an individual’s fitness as defined by CrossFit was a proxy for health, I found myself with the feeling that the definition was intriguing but incomplete. In response I took it upon myself to develop a broader definition of health, one in which fitness was a primary, but not the sole marker or metric. That April I submitted a draft of my definition of health along with a new, broader base of proposed tests that would generate the data that could be used to measure an individual’s health. Over the years it has become clear that Greg and I are more in agreement than not, but a key CrossFit employee at the time had a fundamental disagreement with my thesis, and consequently the article was rejected by the CrossFit Journal. I published my draft here on Random Thoughts later that year.

For almost 6 years I have been mulling this over, threatening to return to the problem of defining and then measuring health in much the same way that Coach Glassman defined and then measured fitness. The quest was derailed by all of the usual time sinks of mid-life. In a humorous irony, the majority of my real, true free time was consumed by the task of helping my sons run their CrossFit Affiliate gym. It is time, now, for me to finish what I started in 2010 if for no other reason than to establish the provenance of the theory.

In order to effectively address any issue whatsoever it is first necessary to have a clear understanding of the definition of terms that may be important to the discussion. I made a similar statement in one of my earliest posts on the importance of understanding the difference between health, healthcare delivery (medicine), and healthcare finance. Here again I fall back on the genius of Greg Glassman: just as one cannot evaluate either fitness or fitness programs without first defining what it is that you are discussing when you say “fitness”, one must first have a definition of “health” before one can begin to measure it. What exactly is “health”? What does it mean to be healthy?

Let’s return for a moment to the physician survey that Dr. Weesner and I did in early 2010. During face-to-face meetings we asked groups of physician colleagues to give us their definition of “health” or “healthy”. The majority of the answers couldn’t have been less inspiring or more disappointing. Indeed, the most common answer was “I don’t know”! Not very comforting, that. The second most common answer was as anticipated: health is the absence of disease. In our American medical system of “disease care” this is an understandable response, of course, but as the basis for the development of a true measurement of “health” it is obvious on its face that this definition has never translated into any actionable metric. Why? Well for one it fails entirely to take into account the very real importance of “fitness”, the expression of health. More specifically, like fitness as a proxy for health, “absence of disease” also fails to address a key requirement for any measurement of health: there is no forward-looking predictive value to simply stating that you have no disease today.

A measurable, actionable definition of health is one that takes into account the degree that disease is present or absent at any given time. It must address physical fitness; to be without a named disease but to be unable to walk up a flight of stairs should not ever be construed as “healthy”. Of equal importance to these factors, any definition of “health” that will generate a meaningful metric must have a predictive value. Your Health Value should provide some measurement of your future likelihood of being disease free and fit. Our little survey of our physician peers did produce just such definitions. Given these requirements I propose that the following are actionable definitions that can be used in healthcare to create measurements in precisely the same way that Greg Glassman’s definition of fitness is used in that realm:

HEALTH: The state in which no infirmity of any kind suppresses, or has the possibility of suppressing the ability to express the full extant of an individual’s potential capacities.

HEALTHY: Able to perform in all ways at the farthest limits of one’s potential capabilities.

With these definitions we can move on to developing a “health metric”, one that can not only assess our present degree of health, but can also predict to some degree our ability to remain healthy. I believe this metric has three component parts: physical fitness as defined by CrossFit, well-being or emotional health, and a factor that addresses traditional or standard medical factors such as blood pressure, cholesterol, genetics and the like. Furthermore, I predict that these three variables are as evident and as logical for “health” as Coach Glassman’s definition is for fitness.

One can have an otherworldly degree of fitness as defined by CrossFit, but what good is it to have a 500 pound deadlift and the ability to run a 4:00 mile if your physical achievement is driven by self-loathing? By the same token, in addition to having a normal result in every conceivable medical test your countenance is as sunny as an 8 year old on vacation, your disposition so Zen-like that the Dali Lama himself wishes he were as happy and serene, but you can’t walk a mile. This surely cannot equal healthy. You are a world-champion long-distance runner, and yet you drop dead from a heart attack, unaware that you have a cholesterol of 800. Fit for sure, but hardly healthy. Fitness, well being, and modern health metrics all have a role in an actionable Health Measurement. Vigorous debate will be necessary to parse the relative weight given to each of these factors, but as I first proposed and wrote in April 2010,all three are clearly necessary components.

In short order I will offer follow-up posts that delve more deeply into each of these three components. I will include suggestions for what and how to measure them. I will conclude with a re-statement of my proposal for a single measurement of health with my suggestion as to the relative weight of the three variables, hopefully inciting the above-mentioned vigorous debate. By doing so I wish to document the originality and timeline of my proposal, acknowledge the intellectual debt owed to Greg Glassman for inspiring me, and reassert my contention that healthcare cannot reach its fullest potential without first agreeing on both a definition of health and how to measure it.

 

 

 

Fitness as Health Marker

The human body as a machine is an endless source of fascination. Designed at this point in evolution primarily as a vehicle to carry a brain, our bodies can withstand famine, thirst, and physical stress beyond what our brains can imagine. When one part starts to fail we have a series of “fail-safe” backups in many cases that allow us to carry on. Interestingly, the greatest harm to our “vehicles” is actually excess (gluttony) and lack of physical stress (sloth).

Kinda Biblical, eh?

There is a complex daisy chain of effects that can ever be traced back to a cause when our bodies begin to break down. My own musculoskeletal system is failing me miserably, and it has taken the eventual unavoidable breakdown of one of those fail-safe mechanisms for me to finally figure out the original cause. Last month’s programming with its emphasis on our core was the last straw.

For the better part of a year I have struggled on and off with progressively worse failures of accessory muscles for mid-line stabilization. The posterior chain (gluteus maximus, hamstring, erector spinae) precisely balances your anterior chain (rectus abdominus) in maintaining a rigid core so that you can do, well, everything. Progressive movement failures in the gym (massive retrograde numbers in lifts, need for major scaling of loads) has now given way to rather plebeian challenges: spasms of the gluteus medius, priformis, and obturator (not to mention that rat bastard the extensor fascia lata) which sometimes drop me in the simplest of movements.

My initial reaction, of course, was to address what must be a weakness in these accessory muscles due to inattention. Surely this would be all that I needed to return me to my previous level of physical prowess. Naturally, since these “failures” were actually the fail-safes going down, accessory work on these muscles only worsened the problem by OVER-working the already overburdened.

How, then, did I figure it out? Well, as I noted, the chariot that rolls along carrying our brain is ever set to do its job, and eventually it sends up a signal when all of the backup systems failed. A tiny little dull ache appeared in my lower abs, an annoyance that escalated to Def-con 1 whenever I braced my anterior chain for any task whatsoever. There was no difference between a back squat or a “bear in the woods” squat–I could not use my abs to secure my midline, and guarding against the pain had shifted that burden to all of those little helper muscles.

A tiny little tear born in an area of inherited weakness turned out to be the cause. My friend the general surgeon describes the defect as “a dime with aspirations of becoming a quarter.” A half-dozen really smart folks had failed to see it, all of them equally fascinated by the epic failure of my Piriformae. And so it is that I will engage the knife as I seek relief on behalf of my accessory warriors such that they may return to their proper roles behind the front line of the midline stabilization battle.

What’s the point of all this sharing you ask? It’s pretty simple, really. Very basic. Each one of us is, or should be, engaging the CrossFit prescription of strength and metabolic conditioning aligned with proper nutrition in the pursuit of better daily function. Better, clearer thought. Stronger, leaner, faster bodies. In order to do so it is necessary that we are ever aware of those bodies, ever vigilant in our pursuit. CrossFit provides us a metric that allows us to monitor the machine that transports our brain. My performance began to suffer. I stalled, then backed up. Measurable and observable that I was failing at repeatable. To discover the root cause I eventually used the degree and manner of those failures to work back to the source. I think fitness as we describe it is best seen as a real-time marker for health. CrossFit approached properly is the thinking athlete’s fitness program, the inquisitive athletes health monitor.

Now to be fixed and resume my quest.

 

How You Treat the People Who Serve You

In my day job I work in the ultimate customer service business, medicine. Ever listen to how people address folks on the providing side of the customer service continuum? Do you ever stop to listen to yourself, or think about how you will sound before you speak? Fascinating. In North America we are moving ever more swiftly to an economy that is majority a service economy; we don’t really make stuff so much anymore, we help people use stuff someone else made, or provide assistance based on a knowledge base or skill set. Listening to people on the receive side of the customer service equation is fascinating.

I’m prompted to this line of thought by three interactions at my day job, SkyVision. Three individuals not so much requesting a service but demanding it, doing so with a tone that implies not only a deep sense of entitlement but also a deeper lack of regard for the individual who will provide that service. Both in tone and content, the to-be-served make it clear to the service provider that he or she is there to serve only them. In fact, the server’s only reason to exist is to serve, as if the to-be-served were some kind of different, superior version of the species. It’s quite loathsome, actually.

I spend every waking moment of each working day on the “serve” side of the equation, whether I am at SkyVision plying my profession or CrossFit Bingo coaching. Having achieved some measure of expertise in both it’s very rare that I am on the receiving end of this type of behavior, but it does happen. More often is the case that it is someone lower on the org chart who gets this. The receptionist, phone operator, or check-out person who gets this “lower life-form” treatment, not the doctor or business owner.

Life can be hard for these front line people in a service business. There’s not only a “customer is always right” mentality on the other side of the interaction but also a sense that being a customer who will get what they want is as much a human right as Life or Liberty. That’s what it sounds like, anyway, if you are off to the side listening. No matter how frustrated one might become from a service situation gone wrong it’s important to remember that there is no continuum in the relationship when it comes to the inalienable rights, nor is there any evolutionary hierarchy across that desk or over that phone line. Being served if you are the customer is not a right at all, not even one up there with the pursuit of happiness. Server and served both have the right to life, liberty, etc.

In a funny little side note, the more effort I (and my partners and staff) make to be better at the whole customer service thing, the less tolerant I am when I am on the receiving end of poor customer service. Actually, I should be a bit more specific on this point: I am much less tolerant if I am being served by an organization that openly preens about its excellent customer care but won’t deliver. Heaven forbid if I detect a cynical lack of effort, either institutional or on a more personal level, when the expectations that I’ve been led to have are mis-met because of this. The harder we try and the better we get at providing an excellent customer experience at SkyVision the less likely I am to choke down indifferent service or a lack of effort when I’ve been lead to believe (and paid for) something extraordinary. The difference, though, is that I initially engage with the expectation that all I have to do is be polite and kind to those folks charged with taking care of me; my first shot across the bow is not to treat them like serfs.

Danny Meyer, the great NYC restauranteur, is probably closest to correct when he says “the customer is not right all of the time, but mostly right most of the time. A customer [only] has the right to be heard.” How you express yourself when you are on the “receive” side of the customer service experience is not only an important measurement of how you value the person across from you providing the service, but frankly is probably also a predictor for how likely you are to be successful in being heard. It’s instructive that none of the three SkyVision clients who made difficult (bordering on unreasonable) requests in an unpleasant manner were accommodated because doing so would have required an extraordinary effort which may not have been successful in any event. After being treated a some sort of sub-human primate, who would make such an effort?

Sorry, no pithy statement to wrap this up. In the end we all want what we want, and we all need to be heard. It helps to look at the person on the other end of the service divide as if you were looking in a mirror. Would you say that, like that, to the person in front of you then?

 

Doc or Trainer: Owning Your Own Job

We are starting to see some turnover among the OG CrossFit Affiliate owners. Some, like Skip, were in literally on the ground floor, and a successful Box rode them into the sunset (enjoy your retirement!). Others, like Steve and Kelly, have nearly 10 years into ownership as they approach both mid-career and mid-life. They turn over a highly successful business and take on the role of “Founder” (can’t wait to see what’s next for you!). Some owners have left the CrossFit fold and changed the name and structure of their gyms. There have certainly been some closings, typically folks who either didn’t really know what it was they were getting in to, or found that being the owner of a job is more than they bargained for.

As such, the successful CrossFit Affiliate is much like every other small business where the owner is also operator. My day job is like that: if I don’t show up for work no revenue is generated. A huge percentage of small businesses run just like this. What you own is not so much a business as it is owning your own job.

With all of the talk of exercise as medicine lately, it’s interesting to compare and contrast the megatrends at work in the fitness industry and medicine when it comes to practitioners. In medicine we are in the midst of what is nothing short of a diaspora with physicians leaving the private practice of medicine for employment in ever-larger organizations. It should be noted that this phenomenon is in direct response to government action. Men and women who once owned their job, with all of the responsibilities (payroll, rent, etc.) and freedoms (hours of operation, client experience, etc) now work is settings where process and protocol is dictated to them, and fidelity to the organization has primacy.

Thanks to CrossFit and the CrossFit Affiliate model, the megatrend in fitness is exactly the opposite. Trainers have been unleashed from the corporate environment where salesmanship is the most highly regarded skill, and put in charge of a job where outcomes drive the business. Affiliate owners are the new private practitioners of fitness, in charge of everything from programming to toilet paper.

A certain tension has always existed between large medical organizations and smaller private practices. It should come as no surprise that similar tensions exist between CrossFit and its Affiliates and large fitness businesses and their partners. Large organizations crave control and abhor independent competition. Indeed, for those behemoths the only thing worse than independent competitors is being shown up by them. You know, like getting better surgical outcomes or having clients who look like the crowd at the Games. Large organizations often turn to government to suppress this type of competition and make the megatrends flow their way.

There are several important points to be made from this comparison. First, of course, is that every Affiliate owner and every member at every Box should fight alongside HQ is this battle. Trainers get better with more experience, not with more certificates.
Trainers who own their jobs also own not only their outcomes but everything about the experience of their clients. Just like a private physician. I’m biased, of course, but this is well worth fighting for.

For those fortunate enough to train people for a living the reality is that you don’t, and likely never will, own a business. There are very few large CrossFit businesses. For every CrossFit NYC or CrossFit Eado there are 3 or 4 hundred boxes run primarily by the owner. What you own is your own job. You’ll need initiative, passion, and resilience. A thick skin is helpful, too, because you’ll get plenty of feedback on that job. With a little luck you, too, may one day leave behind something significant enough that there is someone there to carry on when you leave.

There’s some turnover in Affiliates. At the moment nothing like a trend exists. Owning your own job is not for the faint of heart, and some will find it not their cup of tea. Others, like the OG’s above, will leave for that next thing on the horizon. What mattered is that they had the opportunity to own a job and took it, creating something that will live after they have gone.

The best boss is the client (or patient) who chooses you. The chance to work for them is worth fighting for.

I’ll see you next week…

Sunday musings…The End of Volunteerism?

Sunday musings…

1) Supercilious. What you call it when the punctilious escalate.

2) Fears. “I’ve started harassing the guards at the borders surrounding my fears.” How one of my patients has described her late-in-life efforts to get outside her comfort zone.

Everything about that is cool.

3) Volunteerism. In our world of ever-increasing transparency, willful or otherwise, how long will the phenomenon of volunteerism in support of any type of organization that generates revenue in excess of expenses be expected to continue? An obvious example is the CrossFit Games of course, but that’s hardly the only, or even the best example. In the sports world alone there are organizations that hold events on a nearly weekly basis that cannot be run without the toils of volunteers who work for the pleasure of being involved.

Think about it. Track and swim meets, road races, so-called adventure races, now and for as long as such things have been held. Heck, even all of those huge soccer festivals that dominate the weekends in my little corner of the midwest, run by volunteers and providing the revenue stream for the coaches of “elite” travel teams. Local fitness competitions run as a revenue generator by a Box owner. All kinds of stuff like that.

By no means is this phenomenon unique to the world of sports. In my day job I am a physician in private practice. As such I have provided specialty coverage and care for the ER at several local hospitals over my 25+ years in practice. This type of volunteerism was such a normal part of the medical landscape when I graduated that neither I nor any of my peers ever gave a single thought to why we did it. It simply never occurred to us that the hospitals could not function without our participation, nor did we ever really think about the egregious imbalance that existed in the deal, the docs so far on the losing side that the “D” in MD could have stood for “Dupe”. As the hospitals have grown ever larger, generating ever greater “excess revenue” by paying their employed doctors for work they still accept (and expect) from others, the volunteers have revolted.

I begrudge no one the pursuit of profit, even hospitals. Indeed, I have, and will continue to volunteer at events local and national for the same reason most other folks do: to feel a sense of belonging, to be a part of a whole. I might even continue to provide emergency coverage at the local hospital. Sometimes, though, I just wonder whether some tiny societal tipping point has occurred, disrupting the jewel that is the bond between organization and volunteer.

To offer your services without compensation one must believe in the mission of an organization or institution. That mission may be maximizing profit, and rightfully so. One should not find it surprising, though, when no one volunteers for that kind of enterprise.

I’ll see you next week…

Posted by bingo at August 16, 2015 8:02 AM