Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘health’

The End of the Age of Volunteerism

Ladies and gentlemen, we are gathered here today to mourn the death of the Age of Volunteerism. While there exist tiny spaces where true volunteers live and thrive in a bilateral exchange of freely given goodwill, by and large volunteerism has been extinguished by the actions of its historical recipients. Sunday marks my last day ever of hospital ER call, the end of 2 years of receiving token payment for making my expertise available following 25 years of doing so for free. My experience is typical, as is this denouement.

Once upon a time all of your doctors were in private practice. We all had tiny little cottage businesses, did our work, and billed you or your insurance company for the work we did. Some of us worked in tiny little groups, but it was the rare doctor who was part of a large group or business whether in a big city or out in the country. Even the slickest Madison Avenue internist was basically a country doc, just with a better, more expensive wardrobe. In addition to having a greater familiarity with our patients we also enjoyed a very clubby relationship with all of the other doctors where we practiced. There was a collegiality, a sense that we were all in the struggle together. Folks who shirked their duties, foisting them off on other docs, were quickly educated about proper protocol or left to toil alone.

Hospitals were different, too. Local or regional, they were hardly the gargantuan mega-businesses they’ve become. The org chart was shallow, and most local doctors were on a first name basis with the few administrators on the hospital payroll. You took call for the ER as a volunteer; the ER respected that you were donating your skill and your time and handled everything it could before calling you. Same thing for consultations. Your colleague only called you if they couldn’t figure out a problem or ran out beyond their scope of practice. There was a faint air of apology with each request, and a definite unspoken appreciation for the help that would be given. You helped because you were appreciated.

This is really no different from all manner of volunteerism in America. Smallish, closely knit organizations depending on the goodwill and generosity of members of their community pitching in to ensure success. Think local memorial 5K races, or CrossFit Games Regionals in the days before ESPN or the Home Depot Center. Countless small private schools that depended on the largesse and time offered by the families who sent their children there. You gladly accepted the opportunity to volunteer because you knew that without you the organization would not be able to function. You also knew that the recipient of your generosity not only appreciated your contribution, they really had no other options. Not only that, but if that organization somehow existed in your professional space you knew that it would never, not ever, abuse the trust necessary for volunteers to continue.

What happened? Money. Money and size and the distance that they create between an organization and its volunteers. Let’s go back to the hospital and the ER for a minute. Where once your efforts as a volunteer were deeply appreciated and those efforts rewarded with respect and care for your time and your expertise, the growth of employment of doctors by hospitals opened a gap between colleagues. No longer was there the esprit de corps, the shared notion that the primary target of our efforts was the patient was replaced by so very many doctors by the reality that they worked first for a business as faceless and uncaring as GM. Work that was once done by your colleague was now pushed to the volunteers whenever possible. It’s cheaper that way. Worse, boxes to be checked by the employed (to maximize revenue and minimize risk) meant demands made of volunteers, not requests. Worse, still, were discoveries that some “volunteers” were more equal than others: they were paid.

Innumerable examples are there for the picking. Some times it was just a case of laziness. Other times the insult was a clear effort to dump work on the volunteer. A critical care fellow requested a consult for acute narrow angle glaucoma. For those of you not medical this is one of the few “drop everything and go” consultations in eye care. When I arrived in the ICU I found a young patient with a black cornea who was mildly uncomfortable. I did what every highly experienced specialist does when they start a consultation, I asked the patient: “Hey, what’s up with your eye?” Turns out they had a blind, painful eye as the result of a surgical mishap, and surgery to remove the eye was already scheduled. Their discomfort was because none of the eye medications had been ordered; the fellow never asked. No doctor (or nurse) would have allowed this to happen in the Age of Volunteerism.

While this is nothing short of tragic in health care, it was inevitable once medical businesses were incentivized to grow ever larger. It is not confined to health care by any means. How do you think that volunteer at a Spartan Race feels when he learns how much his “team leader” is being paid? Have you ever “discovered” how much the Executive VP of your favorite professional organization is paid? As a people we Americans are generous to a fault. That generosity usually continues right up until we discover that we have been duped, and even worse that we have been purposely duped by the people who run the organizations for which we volunteer.

And so we gather here to mourn the passing of the Age of Volunteerism. Like so many things of wonder and goodness there remain pockets of resistance, little oases where the goodwill, honesty, and appreciation beget the kind of ebb and flow that made things so much better, kinder, more collegial at the apex of Volunteerism. My friend Tom Gardner was just named the president of the Society of Alumni of our Alma Mater. Tom has given tirelessly of his “spaces”, his timespace, brainspace and emotionalspace to help shepherd tiny Williams College as it flows on though time. Is this truly different? A tiny refuge from the Zombie Apocalypse of corporatization of all things to which we once volunteered?

We can only hope. Hope that Tom and those like him who continue to find places and causes where their volunteerism is met with what we in medicine have had to bid farewell. We can only hope that there will be places where being a volunteer means receiving the respect and appreciation and even a kind of love in return for what we have given. We can only hope that there will continue to be places where the incessant drive to grow ever bigger, size measured on a spreadsheet rather than by heart, will be resisted. For if it can happen in medicine, if volunteerism can be killed in what is arguably the most noble of all endeavors, I fear that it is doomed everywhere.

We mourn the end of the Age of Volunteerism. We wait with equal parts sadness and fear for arrival of whatever comes next.

 

Sunday musings 8/26/18

Sunday musings…

1) Vicissitude. Fancy word for weather, especially if you need a particular weather pattern at any given moment.

2)) Hero. To be a hero one typically demonstrates courage in the face of personal danger, usually involving the selfless decision to put others before self. As a young man I find it hard to argue that this doesn’t describe John McCain. One could certainly disagree with the positions Mr. McCain took as a politician in the second phase of his life, but one would be hard pressed to argue that he hadn’t done enough in the service of his country over 60 some years.

RIP John McClain. Citizen. Patriot. Hero.

3) Health. CrossFit, Inc. has pivoted. Some among you will rejoice, for the direction that appears to be taken is in line with your own philosophy and goals. Those here who revel in the challenge of elite fitness will no doubt feel that this is a betrayal, a clear step backwards and toward mediocracy. I have a few friends who remain employed at CF, Inc. and they would doubtless like to hear me speak out in favor of this evolution. At the same time there are a few friends who are quite dear to me who would much rather I simply declare my days living in CF nation over and move on. CrossFit in all of its iterations has changed, and so, too, have I.

For many years I have written around this time of the year, just after the completion of the Games, about the peculiar and poorly understood triad that has comprised what we all know as “CrossFit”. It is a business, CrossFit, Inc., one that has as its charge the necessity to be self-perpetuating and to provide for the financial well-being of its owners. This should be self-evident, but over the years commentary has often come up that seeks to present CrossFit the business as some kind of public good. It is not, nor has it ever been. CrossFit, Inc. has succeeded over the years as a business, and in so doing it has made decisions that outsiders have both lauded and loathed. For many, how they interact with the company we call CrossFit is determined by who has been affected by these decisions and how. A pivot has occurred; you and I did not have a vote. CrossFit, Inc. will likely continue to prosper.

Second among the three traditional pillars of CrossFit is the Sport of Fitness. With the possible exception of aerobics competitions in the Denny Terrio age (the spandex!) and that old ABC series The Superstars (O.J. in a boat!), CrossFit likely deserved wears the mantle of the founders of fitness competition. Beginning with a friendly barbecue and leading up to a multi-day tiered competition shown on live network TV, there is no doubt that fitness competition is now here to stay. Early announcements suggest that the pivot will dramatically lower the direct involvement of CF in the competition season, but that CF will have the ultimate say at the highest level. No one you or I talk to has any real idea what this means, and supposition along those lines is wasted effort until we are all told exactly what CF has in mind by CF. The CrossFit Games have changed often over the years and they have changed again. Full stop.

Where most of us come in contact with CrossFit is in the third priority: fitness as a conduit to health. It surely seemed as if this was the least important of the three parts of CrossFit, at least until this past week, but it has always comprised the massively overwhelming majority of participants. Whether on CrossFit.com or in a local affiliate, almost everyone fell under this category;  most of those who thought they were part of the Sport of Fitness were fooling themselves at their own risk. With the creation of a CrossFit health movement and an L1 program for CrossFitting physicians, CrossFit, Inc. appears to be signaling that its public face will now be directed here. Note that I say “appears” because I am no more in the know about this than you or anyone else.

This is a good thing.  To de-emphasize the competitive aspects of CF is to re-emphasize the health aspects of CF that were outlined in “What is Fitness” in CFJ #2, the seminal thesis that brought so many of us here in the first place. I wish we could all go back and look at the threads on the old Message Board, 95% of which had to do with getting healthy. How will this affect the kind of CrossFit we see coming from CFHQ? Again, who knows. CVFMAHI has undergone countless lines of evolution outside of the direct umbrella of CrossFit. Individual trainers have gone out on their own and modified CrossFit in ways that reflect what they learned training people themselves (think James Fitzgerald, once known as OPT).  Entire movements with companies attached have been launched to provide clients with what they feel is a better way. A perfect example of this is The Brand X Method and the Martin family who are without a doubt the world leaders in youth fitness. Who will be right? Who will thrive?

Who knows?

In the end the entire conversation has changed over the last 10 years, and more people are sitting at the fitness table than ever. The line between healthcare and fitness continues to be a bright dividing line. Barriers continue to exist between the fitness world and both public health and public education. Will this pivot at CrossFit, Inc. start to blur those lines, or at least build bridges across them? Will we see some other organization, perhaps one that began within the CrossFit universe but now exists as a separate, growing galaxy like Brand X share the load or even take the lead?

The only constant in CrossFit in the years that I’ve been here is change. Change brings with it opportunity. My prediction: this turns out pretty well for CrossFit. The fitness world is much, much bigger than it was 10 years ago. One would do well to listen very carefully when CrossFit directly addresses this pivot publicly. This will also turn our pretty well for people who may have been part of the CrossFit world but are no longer associated with any of the 3 parts of CrossFit outlined above. One would also be well-advised to closely watch the direction taken by the Martins and others in the fitness world as well. There will be many benefits that come from that one, big original idea. They will come from many places.

After all the Theory of Relativity was simply the on ramp to what we now know as Quantum Physics. The highway of fitness progress is now fed by a growing number of on ramps that come from many directions.

I’ll see you next week…

–bingo

Sunday musings 8/12/18

Sunday musings…

1) Krispies. All of my snaps and crackles now have pops.

2) Relevant. “Who wants to be relevant? It just takes a lot of work.” –Andie MacDowell

In this day of social media driving said relevance I think Ms. MacDowell is spot on. When relevance is measured by something as ephemeral and lacking in any type of substance as retweets and follows, her take is prescient.

True relevance is substantive. Or should be.

3)  Games. What are we to make of the massive gap between the top 5 men and women and everyone else? What is it that separates them so completely from the rest of the very best? Is it just me or is this fundamentally different from all of the other truly individual athletic sports?

4) Summer. For anyone with school-aged kids summer if officially over. August 1st has come and gone, the CrossFit Games are over, and football camps are open all across America. Heck, school starts in parts of Ohio on Wednesday, and didn’t I see kids heading to school last week on FB?

Sorry, that’s all wrong. School is meant to start after Labor Day. Too much work too soon for kids who aren’t taking part in feeding a family.

5) Screening. It appears that I am a health tracker recidivist. Why? Well, it certainly has nothing to do with the truly actionable nature off the information a tracker gives me, because to date only heart rate variability (HRV) has any value and at that it appears only in elite athletes. No, I’m just having some fun with mine, playing around to see if my little n=1 studies might come up with something that might move my needle for some reason or other.

That, and they are fun to write about.

Screening for health risks is potentially a big deal, the across the board lack of success thus far notwithstanding. The most recent best example of that coin is an article published this month in the NEJM on cardiac testing of elite soccer players in England. Performed at age 16 between 1996 and 2006 the screenings were undertaken to see if an EKG and Echocardiogram could predict cardiac events that led to early death in athletes who compete in sports with “strenuous exertion”. In all more than 11,000 athletes were tested, the vast majority of whom were declared healthy.

1 in 266 were found to have an underlying, silent abnormality that put them at risk for sudden cardiac arrest. Most of these were Hypertrophic Obstructive Cardiomyopathy (HOCM), the same entity that was responsible for the tragic death of Boston Celtic Reggie Lewis. 2/3 of those who were found to be at risk had surgical procedures which allowed them to safely return to play; it appears that they are all alive and well. Of the originally screens players 8 did in fact die from cardiac arrest, but here’s the kicker: only 2 of those 8 were assesses as being at risk. The other 6 went through the screening and passed. Overall the results equal a risk of 6.8 deaths per 100,000 athletes.

What does this mean in the greater context of health screening? In general the problem with health screening of all kinds (remember, I am in the midst of a classic American cardiac health risk screening process at the moment) is the combination of inaccuracy as noted above, coupled with a fraught cost/benefit ratio in almost all instances. Believe it or not, though, the cost of screening relative to the accuracy and ultimate effect may be the lesser of the problems inherent in screening. Two of the athletes screened and found to be at risk refused to give up soccer and were among the cardiac deaths. You might ask if they were mad to have continued to play, but I would counter that it is quite likely that all they had as a means to provide was soccer; to not play was to choose to go hungry. Imagine an inner city kid destined to be a Lottery Pick in the NBA screened and told they could no longer play the game that would surely set them up financially for life on their rookie contract alone?

Not to mention the deep psychological issues inherent in being told that you are no longer the one, single thing that you have self-identified since early childhood. That’s rough.

One of the very first diseases one used to learn about in med school was Huntington’s Chorea, an inherited disease in which the afflicted exhibit violent, uncontrollable movements (chorea) before eventually dying a rather unpleasant death  (any med students here? Is that still true?) Why? Well, partly because it’s such an interesting tale, equal parts detective story (the original cluster is in a tiny town in England) and history lesson (many of the townsfolk in England emigrated to Salem and were on the wrong end of the Salem witch trials). What makes this interesting in the context of screening is that Huntington’s Chorea is the first disease for which a single gene defect was identified, making it possible to screen with 100% accuracy to determine if you, like Woodie Guthrie and his siblings, would be so afflicted.

Would you want to know? Remember, even in this age of SPLCR technology there is still no cure for Huntington’s. Is there a difference between this and the cardiac risk of HOCM in athletes? How about the rather mundane and ridiculously common risk associate with elevated serum lipids? Given that there are things one can do to mitigate the risks in the latter one should probably answer “yes”, there is a difference. But emotionally, on an individual level, is there? That’s a really hard question to answer. I personally know families with Huntington’s and HOCM. Some family members get tested as a matter of course. Others, for any number of reasons, choose not to do so. In your life you know dozens of people who really need to be screened for diabetes and cardiac risk from elevated serum lipids who prefer the relative comfort of ignorance.

Who is to say who’s right?

In the end this is a question that is going to become more and more common as testing becomes both easier and less expensive. We are soon to see a lab test for HOCM which will be less expensive than an EKG/echocardiogram and more accurate to boot. The calculation will change as well because on the heels of this test is the likely approval of a gene therapy that will reverse the abnormality and presumably remove the risk. For some reason Huntington’s Chorea has defied this happy ending, but it has to be just a matter of time before it, too, is curable. Before any universal agreement is reached on screenings in general you can depend on tons of controversy which each new development. I shudder to think of the coming shit show that will be wrist-worn trackers that can detect afib in real time.

Who knows what kind of mischief I will manage to get into with my little HRV monitor?

I predict I’ll see you next week…

 

–bingo

 

DNA Always Wins

DNA always wins.

In the fitness world, and sometimes even at that tiny intersection where fitness and health or healthcare cross paths, there is a recurring theme: you can’t out-train a bad diet. For whatever it’s worth, I think that’s true. Having said so there is a dangling little assumption that hangs off the back end of our axiom, that if you are fit and follow an evidence-based nutrition program that you will inevitably be healthy. Indeed, every worthwhile fitness program I’ve ever encountered pretty much says just that. “Fitness in 100 Words” on CrossFit.com was my first exposure to this as a mission statement. Loads of folks from the substantive (The Brand X Method) to the frivolous (The Biggest Loser) support this logic as the foundation of health-based fitness. For the most part it is true, and for most people the combination of general physical fitness and solid nutritional strategy results in health.

Except, you know, the whole Jim Fixx thing.

For all of you puppies and kittens out there Jim Fixx was the original running guru in the United States, the author of The Joy Of Running. You could make a case that only the late, great Jack Lalanne was a more influential historical figure when it comes to promoting health through exercise in the U.S. Jim Fixx was responsible for the surge in interest in running as both exercise and as sport, and his writing launched an era in which U.S. runners were competitive on the international stage in ALL distances from the mile all the way to the marathon.

As it turns out Jim Fixx may also be the single most influential non-medical individual in the history of the cholesterol theory of heart disease. You see, Fixx had hereditary hyperlipidemia. Despite his epic running history he was found one day in his running shorts at the side of the road, dead from a massive heart attack. Blood work at the time of his autopsy revealed a cholesterol of 750 or something like that, as well as other elevated serum lipids. His healthy diet, his outsized VO2 Max, and his prodigious training schedule were no match for his DNA. He died with epic fitness numbers, a single-digit bodyweight fat %, and coronary arteries that were so clogged red blood cells had to pass single-file. You can trace many of the USDA dietary guidelines and literally billions of dollars in research to the death of Jim Fixx.

Why bring up Jim Fixx now, in 2018, when we know that hyperlipidemia is a significant part of the cardiac risk story, albeit not the whole story? Well, we should harken back to the beginning of my thoughts: DNA always wins. While you can reduce your health risks by adopting a healthy, evidence-based diet and couple that with an exercise program that produces a comprehensive degree of fitness, you cannot escape genetics. Why at this particular moment? Yours truly just got all of his lab work back and despite 13+ years of a clean Zone diet and varying degrees of devotion to functional fitness, most of my serum lipid numbers have continued on their ever-upward march and have now reached a level where they simply must be addressed by modern medicine.

To do else wise would be madness.

I must confess that this is deeply disappointing. Quite frankly it feels like failure. At 58 I am relatively lean and strong, albeit a bit under-trained in the aerobic domain. Why didn’t this inoculate me from the need to take medication to lower my LDL? In the last couple of days I have chatted with my docs locally (both of whom are close friends who care about me) as well as really significant, nationally recognized experts in the science of health and cardiac risk mitigation. There is a consensus; nay, the voting was unanimous across the board. Don’t be stupid. Continue my program of fitness and nutrition and take the meds. We’ve now moved on the the minutia of choosing which one, a not-trivial discussion to be sure, but one that is less than earth-moving, you know?

Some years ago while proposing a unified theory of health on my personal blog I received an advance copy of Coach Greg Glassman’s definition: if fitness is WCABTMD then health is Fitness Over Time. As a physician and scientist I readily saw the value of this concept. However, I also saw and pointed out the deficiencies inherent in such a narrow definition. For example, any definition of health must explicitly address mental health. Over the years I have championed the term “well-being” and have suggested several metrics that can be used to measure this state of mental and emotional health. Mind you, I was openly mocked at the time for this, here and elsewhere. If you have followed the conversation in the CrossFit world since you will see an evolution of thought along this line, though. “Well-being” has been openly discussed in various ways as an integral part of health in most medical, health, and fitness communities. I like to think I played a small role in that.

I wrote before, then, and subsequently over the years that any definition of health must be more than a snapshot of how “healthy” you may be at any given moment. You may have a 2.5X body weight deadlift and squat, run a sub 5:00 mile and do “Fran” in under 3:00, but can you truly be declared “healthy” if you also harbor a malignant tumor in your gut or are running around with an LDL of 175? Like it or not, any comprehensive definition of health must be able to provide some degree of probability that you will remain healthy in the future. It must have some predictive value. Traditional health metrics–blood pressure, lipid levels, family history, etc.–added to a measurement of fitness and well-being do just that.

In practice such a value has proven elusive for a number of reasons, none the leasts of which is the difficulty in designing a truly measurable variable for fitness that would be accessible to the masses. Once such a measure exists the rest is just math, right? It will be necessary to determine the relative value of our three variables–fitness, well-being, and risk predictors–and then plug them into a formula to kick out something that we might call “True Health”. While this is still “pie-in-the-sky” stuff I am convinced that it is only a matter of time before it is a reality. To do my part I have tried to enlist new “partners” like my brother-in-law Pete, the cardiology savant, and others.

But for now there are lessons to be learned from Jim Fixx, and yes, once again there is a teachable moment in my little epiphany and “Sunday musings” this week. You can’t out-train a poor diet. A healthy diet of any type combined with a program of functional fitness meant to produce general physical preparedness that includes both strength and metabolic conditioning is the optimal strategy. Even here, though, you cannot escape genetics. DNA always wins. Good, bad, or in between, your DNA talks to you in the language of traditional health risk metrics.

Your DNA doesn’t care how fast you can run a mile or how much you can bench. I start my new meds tomorrow.

 

Fitness or Sport? A Proper Place For High Intensity Training

The CrossFit Games Regionals were on ESPN yesterday afternoon. What? Wait. No? No, I guess you’re right. It wasn’t ESPN, was it. As it turns out the Games have shifted over to CBS Sports. Totally missed that memo. Of course, I only surf to the Games site once or twice a week anymore so I can be forgiven. Thankfully I was marooned at home with nothing left on either my Honey-Do list or my own Wish List, and ESPNU was all kinds of messed up so I couldn’t watch the D1 Lacrosse quarterfinals. Surfboring around cable I stumbled on the Regionals and received my annual reminder about what CrossFit is and who is supposed to do it.

In short the CrossFit Games as exhibited in this year’s Regionals is to CrossFit as the Indy 500 is to your daily commute: almost everyone needs to do the latter, but almost no one can, or should, do the former.

You could certainly say that I am treading on thin ice by proclaiming that you and I have no business doing anything but gawking at Regionals athletes doing full-on Regionals WODs here on .com. Fine. Here is why I feel this way; the incessant urge to emulate Games-level athletes and to turn every CrossFit WOD into a training session for competition risks the undoing of what makes CrossFit (and other high-intensity offshoots) a potential solution (or integral part of an irreducible Rx, to coin a phrase) in solving the population health problem in Western societies. It really could be as easy as eating fewer processed carbohydrates, being stronger, and training at relatively high intensity for periods of time in the 8-20:00 range. Stronger and leaner with greater aerobic capacity is all pretty much any of us needs.

Everyone who has ever owned a Box or coached a CrossFit class has seen the danger of extending the “you vs. you” competition outward into the “Sport of Fitness (TM)”. Clients who leave a gym because the trainer refuses to teach them how to do a CTB butterfly PU when they can barely do a single dead hang PU. Fledgling CrossFitters who insist on rebounding box jumps instead of stepping down because their times suffer when they do. “Linda” or “Diane” done As Rx’d with rounded lower backs, chins held high because, you know, you gotta Rx the Open WODs if you want to go to the Games. It’s really hard to exaggerate how disheartening it is to listen to a client say they are leaving a gym because they don’t feel like you are the best fit for them. Then you look at their data and discover that they are down 15% BW fat, have doubled their 1RM Deadlift, can now do “Fran” Rx’d in half the time they first did it with an empty bar and a green band, all injury-free.

Form, then consistency, then and only then intensity. This is what you need for fitness. The siren song of competition is strong, especially during our Games season. Shout out to those trainers, both within the CrossFit business universe and out, who continue to hue to this orthodoxy. Functional movements, irreducible exercises performed properly at a level of intensity that is high for an individual, coupled with a diet that is designed to fuel performance in the gym and in life is what we 99.9%’ers need. Distilling this prescription into a measurable and repeatable program is the essential genius of CrossFit. That some of us get to do it as part of a community is that much better; friendships formed through shared experiences, especially shared strife (and what is “Fran” if not shared strife), are also an integral part of being healthy.

After my (ca. 2006) WOD I sat down with some left-over steak and a handful of nuts to see how Dani Horan was doing in the East. A little sore and energized, the only thing that was missing was another CrossFitter there to join me in watching the spectacle.

Optimization vs. Diminishing Returns

Some time ago I wrote about the Minimum Effective Dose (MED), the concept in which we seek to optimize our results with the smallest amount of whatever it is that we are using to achieve that outcome. The quest to find the MED is one that crosses quite easily between my day job (medical) and my own quest for health (CrossFit). A quick mention of Eva T in Outside magazine and the program she uses with her clients made me think a bit more on the MED. The Everyday Math column in the WSJ provided an enhanced vocabulary for the journey.

Sometimes the MED really is a “something” you take. Here one thinks of medicine or food, for example. More often is the case that we are looking at a dose of time or effort. Or perhaps both. In this case we are seeking to optimize the effort as it relates to the outcome, to make the value of outcome divided by effort as large as possible. The rate limiting factor here is the Law of Diminishing Returns, of course: at some point additional effort produces such a small incremental increase in the outcome that it becomes not worth making. This applies to everything from WODs/week (or day) to decorating a birthday cake. At a certain point you just have to feel you’ve succeeded.

How, then, to know when you have reached this optimal level? Eugenia Cheng, the mathematician who wrote the WSJ piece, offers the concept of the “minimal acceptable standard”. Once she has reached this outcome the additional effects garnered from more effort have moved beyond the point where Diminishing Returns kicks in and she simply accepts the outcome. We would call these “minimal standards” goals, but the concept is essentially the same. We want an outcome; setting a target or a goal is step one in optimization.

Cheng then goes on to refine optimization with a discussion about boundaries. One is your goal, of course. In real life others also exist, things like a 24 hour day and a 7 day week and the need to make a living. The dose you choose, both qualitatively (what it is) and quantitatively (how much you get) is unavoidably affected by boundary conditions over which you have less control.In the end no outcome worth getting happens without effort. Health, friendship, or the unraveling of a gnarly math problem–you’re going to put effort in to get your results out.

Maximizing your outcome-to-effort ratio is just another way to say you are seeking your Minimum Effective Dose, in CrossFit and elsewhere.

Mental Health is Part of Health

Some time ago I wrote about creating a way to measure health. Real health. Health that encompasses every aspect of what it means to be alive and well. As a CrossFitter I definitely included Coach Glassman’s Disease -> Health -> Wellness continuum, and I also acknowledged the critical importance of his concept of “Fitness over Time”. As a classically trained physician/scientist there is clearly a place for more traditional metrics like blood pressure, serum lipids and the like, although they may, indeed, be an variable that is ultimately tied to fitness.

Where my thoughts on defining and measuring health seem to depart from most current trends is in the recognition that mental health–emotional wellbeing—is as much a part of being healthy as any other thing we might examine.

Think about it for just a moment. Most of what we would classify as mental illness has as many outward signs that we can see as diabetes and hypertension. Which is to say, none. Yet we—all of us, not just CrossFitters—see nothing but the good in treating diseases like diabetes openly and aggressively. There is no stigma attached to seeking care for your hypertension or your elevated LDL. To the contrary, if someone who loves you discovers you quit measuring your glucose before you bolus your insulin, they are for sure gonna get in your grill.

For whatever reason, mental illnesses are looked at quite differently. No one is asking the person with chronic depression whether she is taking her life-saving medication, for example. We might notice an insulin pump on a friend or family member, but then it’s quickly forgotten. Everyone seems to be very uncomfortable around the young man who has very obvious hand tremors from the life-saving medication he takes for his Bipolar disease. We all seem to be so much more understanding when we have to wait for a response from someone suffering from Parkinson’s Disease than from the young women who has the same symptoms as a side-effect from the medicine that quiets the dangerous thoughts in her head from Schizophrenia.

It’s not even necessary to look only at these kinds of severe mental illnesses when we are examining the importance of mental or emotional wellbeing as an integral part of being healthy. What good does it do to have a 5:00 mile, a 500 lb. deadlift, and a 1:59 “Fran” if it was self-loathing that drove you in the gym to get there? You may be quite accomplished, the envy of your peers, at the peak of whatever life mountain you wished to climb, and yet you cannot feel joy. How is it possible to be healthy without joy? I look at Usain Bolt and what I see is quite possibly the healthiest man alive. My friend Tim, the writer, tells me that Justin Gatlin has nearly everything that Bolt has—youth, fitness, wealth—but the combination of failure to knock off Bolt, and the public disapproval reigned on him as boos from the Rio stands has left him emotionally broken. It’s subtle, but if you look at his face in the blocks of the 100M Final it’s there.

Our complex and conflicted attitudes and feelings about mental illness are especially evident when the topic of suicide comes up. Just typing the word makes me uncomfortable. Even how we describe suicide is fraught with hidden meaning that reflects our discomfort: someone has “committed suicide”. Right? Someone committed an act that we simply cannot fathom, one that leaves the survivors completely without any understanding whatsoever. How could someone DO that? It’s as if every suicide is the same as the suicide of the crooked prison warden in The Shawshank Redemption when he looks out the window and sees his fate arrive in the front seat of a State Trooper’s car.

In reality most of the time it’s simply not like that at all. Nothing about it is simple at all.

The outer walls at the periphery of my world have been breeched by suicide twice in the last couple of weeks. One of them actually does feel a bit like that prison warden. Frankly, I am too conflicted, too aware of the external circumstances and not enough aware of the internal life of the deceased to offer much right now. The other one, however, just stopped me in my tracks when I heard. The loss was profound.It has also introduced to me a new vocabulary that I truly believe provides a starting line from which we can change how we think about not only suicide, but all of mental illness. A friendly acquaintance lost his wife when she was killed by suicide.

We don’t need to know all of the details of the story. Suffice it to say that in the face of a child’s illness she suffered quietly. Too quietly to be noticed. Perhaps she didn’t realize how badly she was suffering, or maybe she was like so many of us and couldn’t bring herself to see her illness for the life-threatening entity that it was. No one will ever know. What is clear, though, is that this was not anything about commitment. Kidney failure may be cause of death in a diabetic, but it is diabetes that kills him. There is no difference here. The cause of death was suicide. Her disease, her depression is what killed this young woman.

Each of us has a very few moments in our lifetimes that forever change us. On the second Tuesday of July in 2006, unbeknownst to me, one of those moments was transpiring in a lonely, dark corner. Joyfully, the moment was a beginning, not an ending. Regardless, once learning of the moment I was changed forever. Now I knew. You cannot see any marks from mental illness, no swollen appendage or insulin pump. But it is there all the same, and it must be acknowledged and accorded the same degree of care as any other disease that may take our loved ones from us. Mental illnesses are real, and they can be deadly. There ought not be any conflict or discomfort in treating them.

We may stop losing so many of our loved ones when start to see emotional wellbeing as part of being healthy.

Adventures in EMR Vol 2 Epilogue: May We Please Have…?

“The essence of Medicine is story—finding the right story….Healthcare, on the other hand, deconstructs story into thousands of tiny pieces…for which no one is responsible.” –Victoria Sweet, M.D.

Being forced out of your comfort zone in any endeavor is always painful. In my experience it is also conducive to learning something new, and at least in my case it is a catalyst for creative thought. What, then, have I learned from our forced-march, point-of-a-bayonet transition from one EMR system to a new one? Are there any lessons to be learned on a broader scale, beyond the walls of SkyVision? Can I take this bowl of lemons and create lemonade that can be passed around the much larger table that encompasses the broad landscape of American medicine?

First off, our collective experience with our transition reinforced my long-held contention that you simply can’t effect change in a system of any type without either being a functional unit in that system, or shadowing those who work in the system you wish to improve. Imagine designing the cockpit of the next generation fighter jet without ever actually either flying one or sitting next to someone while they fly it. Take a look back at my essay “EMR and Underpants”; our information ecosystem was designed by engineers far, far away from the point of care delivery. It’s roughly the same as giving someone the job of choosing what underpants to deliver for your daily wear without ever having seen what you look like or talking with you about how you wear your clothes.

After all of our struggles there does appear to be one, huge 30,000 foot lesson in all of this that should, by rights, become the foundation of the next wave of innovation in EMRs: the spoken word is the goal. What made our traditional scribe process so successful in both efficiency and accuracy was the development of charting based on a spoken narrative. The doctor would dictate exam findings. The scribe would then intuit the various diagnoses from the conversation occurring between the doctor and the patient. While the doctor then went on to outline the plan of action this, too, was transcribed into the medical record. It was a natural and familiar way for all of the players in the room to communicate.

Why can’t I do that with any of the EMRs available on the market? Why is it that I can’t talk to an EMR and have my verbal encounter become what we would all recognize as a progress note? Heck, I’d be thrilled if there was an interim step in which all of the BS clicking we are doing to check all of those boxes could turn into something that looked more like spoken English (although our new EMR is OK and getting a bit better on this). With all of the hundreds of millions of dollars being raked in by EMR behemoths like Epic you mean to tell me they can’t find the resources to make this happen? Please.

You see, the essence of every healthcare interaction is the spoken word. When you have to stop talking or listening you have devalued time. Think for a minute from the patient’s point of view: it doesn’t matter whether it is a doctor of some other kind of worker in the room, once attention is shifted from the patient to the screen quality plummets. Make me a poor man’s AI interface that I can cue verbally to let it know what I’m doing and put it in the right box so that Uncle Sam won’t ding me for being a poor data entry clerk. I’d even be willing to talk to Mrs. Pistolacklioni about her smoking at every 3 month follow-up for her severe glaucoma (a disease that has no increased risk if you smoked, by the way).

While I’m at it, and as long as we are talking about communicating (cue Paul Newman in Cool Hand Luke), may we please find a way for the real medical record to be freely available on every platform? Seriously, how did this one escape the cloistered engineers and double-blinded underwear salespeople? Your Samsung cell phone can call your buddies iPhone and vice versa. An airman flying a MIG 22 can communicate with an inverted Tom Cruise in a 3g dive because there is a single standard for radio transmission and reception. Come on. This is basic stuff, the equivalent of declaring the gage of railroad tracks. You mean to tell me that the same people who think they know so much about how things must be that they have an opinion on the shape of operating room hats somehow missed this? Again. please.

I’m not kidding about the OR hats by the way; some DA administrators simply declared that bouffant hats were safer because they think so and won’t come off that even in the face of randomized control studies to the contrary.

Seriously, go all the way back to Dr. Larry Weed at UVM in the 1980′s and return to his beloved premises. There is too much information to be contained in any one doctor’s head, and doctors cannot avoid their biases and frame of reference when making medical decisions. Having true interoperability across all platforms would allow the free movement of information at the direction of the patient, the person who should be in control of that information after all. (Note: Carbon Health is on to something)

As a society we’ve allowed ourselves to remain captives of the trial bar’s defense of the status quo when it comes to malpractice lawsuits. This, in turn, has prevented us from examining repeating errors to determine if there might be a common thread that could be altered and thereby reduce their frequency. Interoperability would allow just the sort of root cause analysis that is needed, and because it would be done using anonymous information no actionable disclosure would be necessary from the doctors involved. As a bonus this would probably allow us to create true, vetted care protocols for the majority of patients with the majority of problems, and this evidence based care would then have to be admissible in court. All that would be necessary would be for doctors to explain in their chart why they decided to deviate in an individual case if that came up. Bingo, a data-driven solution to defensive medicine, all from better communication.

My new vendor is unaware that I am writing this, but interestingly has invited me to consider joining their advisory board and to speak at their annual convention. Who knows if those invitations will continue to be extended once they read this, but if they are I will have two very simple, very basic messages. This whole medical record thing should be about communication, just like it’s always been from the days of Hippocrates. That, and that Larry Weed was right. Before we go any further forward go back and read Larry Weed.

All we need is a little electronic SOAP to clean up this mess.

 

Adventures in EMR* Vol 2 Chapter 1: Government Forces a Divorce

It’s hard for me to empathize with docs and medical organizations who as late as 2015 0r 2016 lamented the U.S. government’s irresistible demands to electrify the medical record and had not yet done so. Along with the other follies imposed on all quarters in healthcare, the Accountable Care Act (ACA) spawned in the early days of the Obama administration decreed that all care provided to patients covered (paid) in any way, shape, or form by the federal government must be recorded in electronic (computerized or digital) form. More than that, this digital health record (EMR) must conform to the nebulous and ever shape-shifting requirements known as “Meaningful Use” (MU). Armed with 30 pieces of silver on the front side and the promise of slow, withering financial ruin on the back, CMS went about the business of coercing organizations large and small to move from paper to electrons.

Why, you ask, if I am so obviously disdainful of this occurrence, do I find it hard to empathize with folks who’ve been harmed by this process? Well, our group SkyVision Centers (SVC) saw the value of using an EMR at the time of our founding in 2004, back when Mr. Obama was a very junior Senator from Illinois and about to be “discovered”. The concept of an EMR, with the medical record warehoused in a server rather than in a folder, was so obvious to us at the time that we never considered the use of a traditional chart as we developed our bleeding edge business plan. As a University of Vermont grad I had learned about medical information processing at the knee of the great Larry Weed. Indeed, my biggest frustration with the EMR’s available in 2004 (and still to a degree in 2018) was that they did not allow me to do the kind of information processing that I learned from Dr. Weed’s associate Dennis Plante, who taught me about computerized medical decision making in 1984.

Those doctors and those medical groups that were still using a traditional paper chart in 2015, 16, or 17 missed the boat by 10 years; their enhanced pain brought on by their inertia was self-inflicted. More than that, the larger among these groups (I’m looking at you, UPenn) essentially recused themselves from leadership positions that they could/should have taken. As an aside which I will explore in an epilogue to this series, very large early adopters (think Cleveland Clinic, The Mayo Clinic, and Harvard Pilgrim Health among others) bear a significant responsibility for the mess we now find ourselves in by abdicating their leadership role as medical institutions in favor of maximizing their return as business entities in the earliest days of EMR.

Back in those UVM days Dr. Weed built his case from two very specific premises: there is simply too much medical information for any doctor to be able to house it in his/her brain, and decision making based on the data available for any one patient is too easily influenced by a doctor’s frame of reference and biases. Sounds familiar, especially if you spend any time on Twitter and follow folks like Vinay Prasad, Saurabh Jha, and Amitabh Chandra. Dr. Weed clearly envisioned a universe of connected records (mind you, this was well before anyone outside of the government  had heard of the internet) that would allow the free interaction of multiple doctors with all of the information available on any patient. Without using the word Dr. Weed described “interoperability” perfectly. (Note that UVM had all testing results–radiology, lab, etc–available on computers in the 80′s. Sister hospital Maine Medical Center one-upped them with computerized order entry in 1983.)

Mind you, most of this was not really available in 2004 when SVC was looking for its EMR. We just assumed that it would eventually be programmed into a larger system as more doctors and practices saw the light. Our rationale for implementing an EMR at this early time in history was driven by the obvious advantages that it would give us when it came to providing the best possible patient experience when we were taking care of patients with eye problems. Utilizing an EMR allowed us to maximize our efficiency so as to minimize the amount of minutes wasted over the course of a care visit to SVC, fulfilling with our pocket book our mission statement to provide “The Best Experience in Eye Care”. Our specific EMR choice fit seamlessly into our Toyota manufacturing-derived system of workflow and enabled us to vastly exceed our patient’s expectations when it came to the office experience.

We were on the cutting edge. So what happened? Well, in short, Obamacare with all of its regulatory burdens happened. Onerous “quality” measures came and went in the early days of the ACA. My professional organizations as well as the owners of the EMR we’d chosen lobbied vociferously against the implementation of what would have been disastrous burdens on the field of eye care (among other specialties). Back at home we doubled down on our market advantage as the best office experience for our patients and slow-rolled along with our EMR provider as it did the minimum necessary to remain compliant. In hindsight I was clearly choosing efficiency and the maximization of the patient interface with the practice over Larry Weed and the information interface.

We probably could have continued this way if not for ICD-10, the coding change that increased the number and complexity of mandatory diagnosis reporting when billing. For reasons that remain unclear to me our EMR provider could not accommodate the change to ICD-10 in a way that allowed us to properly document our charges for very specific, common eye problems. This is a problem, you see, for eye doctors of any stripe take care of patients who are covered by government-funded programs. Failure to comply now meant penalties that would ramp up to 22% of payments in an industry that routinely runs a profit margin of 25-30%. Each slow step in the right direction was followed by multiple steps backwards and sideways.

We as a group never felt that our concerns and clear business needs were being adequately addressed. Have you ever owned a car that had a serious problem? One that seemed as though it was fixable, at least at the onset? Maybe it was a car that you loved, or maybe it was just a car that was paid for and did the job for you. You put money into the car to fix it and it’s not better, so you spend some more, and then you spend some more. At a certain point you realize that no matter how much money you put into fixing that car you just can’t lose the thought that it’s not going to be enough. You just can’t shake the worry that despite all of that money you are still going to end up on the side of the road at midnight in the middle of nowhere. After months of expensive upgrades that were late in coming it became clear that we could not be guaranteed that the EMR we’d been using since our creation would be able to carry us forward in a financially safe manner by meeting the government’s regulatory demand.

In effect, the U.S. government, through the regulatory demands of the ACA, forced us to initiate divorce proceedings with our EMR. To survive it became clear that SVC would need to buy and implement an entirely new EMR.

Again, you might ask, why can I not empathize with those who are late to the EMR game and suffering the pains of implementing a new EMR into their organizations if we are now in those same, exact shoes? I think it’s a fairness thing, and I fully acknowledge the irony that I am a guy who routinely quotes Scar’s great line “Life’s not faaaiiirrr.” You see, in my mind, we did the right thing way before we had to by spending money we really didn’t have in 2004 on an EMR way before it was mandatory. And we spent. And we spent. As anyone who has ever worked with mandatory software knows, your key critical programs are the gifts that keep giving…to your vendor. For our commitment to providing a better experience for our patients (and admittedly more business for the practice) we would now be rewarded by having the privilege of paying for a whole new system.

And as I will discuss next, paying for the “right” to see all of the information we’d already paid for.

Next Chapter 2: The War of the Roses

 

*Like all good reporting where one hopes to discuss global issues rather than very granular, product-specific issues, this series will not name any products that we have previously or are now using.

Cost + Quality + Convenience = Value

My wife Beth and I had a rather spirited discussion about how we in the U.S. might be able to pay for the healthcare of our citizens. Being ever practical, and also owning the job of writing the checks that pay for the “health insurance” our company offers its associates (including us), Beth in effect is arguing for a national consensus on something we might describe as a baseline ‘value’ for healthcare. Others would label her concept a ‘floor’, but you get the idea.

What Beth intuitively understands is the tension between cost, quality, and convenience. You pick a baseline or a floor level of value and offer that to everyone. With training as a nurse and 15 years in healthcare administration, her idea of what constitutes the sum of cost, quality, and convenience naturally overweights the integers for cost and quality: outcomes should be essentially equal across the board at the baseline or floor level, and the costs of achieving that should be in some way equitably shouldered by something we could describe as “society”. Very practical. A strategy that lends itself to being observable and measurable.

What’s the rub? Well, only two of the three elements that make up value are covered. To obtain an agreed upon level of medical outcomes (mortality, morbidity, longevity, etc.) the cost is covered. Ah, but HOW you obtain those outcomes is still a variable. It is the FLOOR of value that is guaranteed. Our family is experienced a bit of this recently with Beth’s Mom. After a hospitalization she was living in a setting that ws providing excellent care at a reasonable cost, but it was a setting that did not provide any extras; it was old, not very pretty, and she could  have had a roommate. Her (and her daughters’) experience, what we might call “convenience” or  in our formula, was found to be lacking. The girls opted to move her to a nicer setting, one that will eventually involve a higher cost because of the enhancements to the experience, with no change in the already best possible outcome, or quality.

Therein lies the problem with any discussion about literally anything that we might discuss as a “right”. Is everyone entitled to anything other than the minimal amount of convenience/experience necessary to obtain the best outcome at an affordable cost?

If we examine food, we find something quite similar. No one among us would say that X Million people should go without food. Indeed, we don’t even really talk about true hunger in the U.S. anymore, we talk about “food insecurity”, the concern that we may become hungry. By the same token, though, no one asserts that everyone is entitled to the same quality of food. Not even a little bit. No, quite the contrary, all that is discussed is cost and convenience (access).

Now, of course, we in the CrossFit world (and to a degree in the medical world) argue that quality is an ineluctable part of nutrition, that one must extend the equation outside of food alone so that an explicit choice is made that prioritizes quality calories over other purchases (cell phone, cable, fancy car, etc.). While this is accurate and proper I believe that we can reasonably quarantine nutrition and keep it separate from other needs, at least for the purpose of our discussion. The universal concept of the interplay between cost, quality, and convenience holds true in nutrition/food on a global, grand policy making level:

You can pick any two, but only two, when you are declaring what is the minimally acceptable level.

My formulaic approach to the coverage of needs has a little wrinkle that should be mentioned: quality cannot be increased ad infinitum. In all examples we might evaluate there is a practical limit to the ability to improve quality or outcomes. The law of diminishing returns arrives in the form of the asymptote as quality rises. On the other hand, cost and convenience are unbound and can rise almost infinitely. It is the alcohol in a drink that confers the health benefit; the same outcome occurs no matter what you drink. One person’s jug wine from Costco is another person’s Chateau Lafite served in the Gulfstream V. You get the picture.

What will become of our conversations about issues such as healthcare? Will we arrive at a similar juncture to the one we have now in food, clothing, and shelter? Where quality (outcomes) and cost issues are addressed and everyone is left to make their own call on convenience/experience? Beth can’t see how it can be any other way. Me? I’m much less optimistic. That old “want vs. need” thing just keeps popping up. Confusion arises when a truly generous people confuse what people want with what they need. Need is measurable and therefore finite, whereas want is neither. We can, and should, all work to pick up the check for the needs of each. “Want”, on the other hand, is the proverbial “free lunch”, and we as a society will need to agree on that before we can even begin to discuss begin to talk about the mechanics of paying the bill.

TANSTAAFL. Heinlein was right.