Random Thoughts from a Restless Mind

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.

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.

It’s really quite flattering, all the attention. The cynic would say that it’s all really just an attempt to keep my business, and I’m sure there’s a bit of that going on. After all, even though my surgical volume is down since my I left my original practice to start SkyVision, I still do a rather high volume of surgery at a very low cost/case. Still, the sheer number of folks, not to mention who they are, who have gone out of their way to try to make my CPOE transition go smoothly is impossible to ignore. Folks really do seem to be sincerely concerned about me as a person, someone they know and have come to like enough over many years, not just a surgeon bringing business. If only it wasn’t all so…so…useless.

I know, I know, I sound a bit petulant, but I’ve watched this movie before. I know how it ends. It may sound somewhat ungrateful, what with the head of physician training, Chief of Surgery, and Head of Outpatient Surgery and local administrator among those taking an open interest in my journey. It’s just that the story only ends one way, with a great big time suck that undoes a decade and a half of ever increasing efficiency (and with it patient satisfaction) and the associated assault on my emotional well-being.

All these people walking around with lipstick thinking…hoping…maybe just one more coat and he’ll smile when the pig kisses him.

“I suppose I’m sorry I missed my appointment on Thursday. So, anyway, here are the ground rules for how this phone call is going to go and how you’re going to give me the appointment I want.”

“I know it’s been two years and the doctor said my son would need glasses for school and that it’s really busy during back to school time. Yah Yah…I get it. I don’t care that everyone with after school appointments called weeks ago. School has started and he needs an appointment RIGHT NOW. I demand to talk to the doctor.”

“What do you MEAN the doctor’s 5:00PM appointments are all filled? I told you she wants new contact lenses RIGHT NOW! 10 AM tomorrow is totally unacceptable. You tell the doctor I’ll be coming in with her in 2 weeks and you can be SURE I’m going to tell the doctor how unacceptable this is.” CLICK

Seriously, who talks to people like this? These are all near exact quotes from established patients calling to make appointments for routine, non-emergent visits. All three had received explicit instructions at the conclusion of their previous visits, and all had been sent recall reminders that it was time to make their next appointment. Remember, we are a very busy eyecare practice with 3 doctors that sees emergency patients on a same-day basis, including nights and weekends. We are not averse to working hard or seeing extra patients, and we counsel our patients that we will sometimes run a bit behind because of this ER visit policy. Philosophically it doesn’t seem right to over-book our schedule, making the conscientious have to wait longer in the office during their visit, in order to accommodate those who make little or no effort to respond to our instructions and reminders.

Let alone those who talk to my staff like these three. Sheesh. Trust me, the tone in their voices was exactly as you’d imagine it as you read it, equal parts incredulous and offended that anyone could possibly not understand how much more important THEY are than everyone else on the schedule. It got me to thinking, though. What would it be like if people talked like this in other walks of life?

For instance, you are the Registrar at, oh, how about Harvard. You pick up the phone and somebody’s Daddy is calling about Econ 101 taught by N. Gregory Mankiw. The class is full. Actually, it’s oversubscribed and there’s a waiting list with 125 kids already on it. The registration deadline was 2 weeks ago, a deadline that the young scholar just blew off and a deadline that Daddy doesn’t even acknowledge. ” You’re not listening to me. I told you that my son will be in that class. He has a spot waiting for him at Goldman Sachs and no one is going to  keep him from getting what he deserves. I demand to speak with Mankiw.” How do you think that turns out for Sonny?

Or how about this? The flight to Chicago is full, and since it’s about an hour before takeoff no more folks are coming off the standby list. Standing at the United desk is a very well-dressed professional addressing the agent. “I suppose I’m sorry that I didn’t make it to the earlier flight I was booked on. Here are the ground rules for how this discussion is going to go, and how you are going to escort me onto this flight.” I can definitely see some sort of escort coming, can’t you?

Imagine what it would be like if you could listen to a call coming to a judge’s bailiff from someone who talked to everyone like my three patients. “Really? I said I needed to get this ticket taken care of right away but I’m only available late in the afternoon. 2 weeks from now is too long to wait. 10 AM tomorrow for court? That’s just unacceptable. Why aren’t there more times at the end of the day? I will be there at 5:00 in two weeks and you can be SURE I will tell the judge what I think of this.” What would you give to see that one play out?

When I hear the way people talk to folks who work in health care it makes me wonder how far they take it. Does it go so far as to extend to Church? “Listen Father, it’s football season. The Buckeyes on Saturday and the Browns on Sunday, ya know? This whole Saturday and Sunday mass schedule doesn’t line up with the season at all. I can’t believe you don’t get that! Why can’t we just move mass to Monday until after the Bowl Games and the Super Bowl. Tell you what…just forget about it. I’ll be here on Sunday and I’m going right to God on this one. You just make sure he’s in Church this weekend so I can tell him directly.” Well, we know that God is always in Church, and that He does, indeed, hear every petition a member of His flock makes. Like Danny Meyer, the great restauranteur in NYC who holds that the customer is NOT always right, but does have a right to be heard. Actually, this example gives me some comfort, some direction in how we might deal with patients who talk to our staff in such a brassy, entitled manner. We are definitely not God, or even the least bit God-like, but like Danny Meyer and God, we can always listen, as we know they do, and we will always politely offer them an answer.

Sometimes, the answer is “no”.

Every couple or three years comes a slew of articles on friendship, specifically friendships in adults. Thus it is that I find myself returning to the topic for the first time in awhile, having been bombarded of late with articles, books, and movies on the subject (“Of Mice and Men” is being staged on Broadway, for example). That, and my brother’s rather humorous story of having bumped into a fellow Eph with whom I was friendly in college (more on that in a bit). Much has been written on the subject, almost all of it a re-hash except one little gem, a tiny bit of research that suggests that friendship in mid-life is the strongest predictor of longevity of all.

Weird, huh? And not too positive a finding either, what with my oft-told and hard-earned experiences with how difficult it is for men to create new friendships after the age of 30. The magic number is 3. Three close friends predicts a longer life, especially for men. Sadly this usually does NOT include your wife; the overwhelming percentage of wives drifted AWAY from the men in favor of younger women, usually daughters, as they moved through adulthood. As an aside I’m now desperately hoping that Beth will have some room left over from “Lovely Daughter” Megan. (Actually, getting Beth hooked on CrossFit might be my ace in the hole)

Interesting, huh? Three close friends and you live longer. Very few folks had more than 4 or 5, an incredibly tight range when you think about it.

It’s become a kind of psychological dogma that men and women make friends in very different ways. Women, it is said, make friends through the sharing of feelings. In person two women who are friends are said to be most often facing one another, talking. Maintaining this kind of friendship is structurally rather easy in our modern age of communication. Feelings can be shared in any number of ways that do not require the friends to actually be in the same room together. Phone, text, Facebook and Twitter are but a few of the tactical and mechanical advantages to a friendship built on an exchange of feelings, and the currency required for the ongoing investment is simply time.

Men on the other hand make friendship a much more arduous affair. Many women would opine that this could actually describe many, if not most things that men do, but that’s a topic for a different Sunday. The picture most often used to illustrate men in the company of friends has them standing shoulder to shoulder, in the act of sharing an experience but not necessarily sharing any internal reaction to that experience. It makes me chuckle to think that a video of the same scene would probably also look like a portrait, nothing moving, certainly not their lips. For men the basis of friendship is the experience and the fact that both were physically present for it. Whether sitting at a Bulls game in Row J seats 11 and 12 , or working up a sweat at the Loyola Prep gym playing pick-up hoops, the friendship blooms only from the seed of the experience which is fertilized by proximity. At some point the memories of those experiences, stories re-told dozens, hundreds of times, fail to prompt growth in the friendship without the Miracle-Gro of presence. Eventually even shared “experiences by proxy”, raising similar aged children for example, fails to prevent slack from growing in those friendship ties if you aren’t physically there to tighten them.

In my mind the universe is divided into a very few groups of varying sizes. Think of your life as kind of like a bulls-eye floating through a vast space. The center of that bulls-eye comprises that small group of true friends, men and women who would drop everything should you have need, and for whom you would do the same. Friends are people you miss if you haven’t had contact for a matter of days, people whose company you actively seek. These are people you go out of your way to see and never try to avoid. Man or woman, they know how you feel. Again, an aside, happy is the couple who have overlap in this innermost circle of the bulls-eye.

The next circle is filled with friendly acquaintances, people who make you smile. When you have an opportunity to be with them in person or in spirit it makes you happy. There’s no limit on these, and a reasonably friendly character could have dozens of friendly acquaintances scattered throughout a life. This is the group from which most friends are created, and if you are fortunate someone who is no longer really in that bulls-eye drifts no further out from center than this inner ring. Just outside the circle of friendly acquaintances is the ring containing acquaintances, people you’ve met and remember but either don’t ever really spend time with or never have the chance to explore a move toward the center. My brother met a someone who has always been here, the humor in wistful remembrance notwithstanding. Your circles of friends and acquaintances drifts through a vast space filled with folks yet unmet, a (hopefully) few enemies orbiting in there somewhere as well.

We float through the universe in our circles, people drifting in toward the center (perhaps my Brother’s encounter will drive my acquaintance inward) and sadly on occasion out and away. In CrossFit we know both a definition of fitness and a way to measure it. Indeed, Coach Glassman has opined that not only is fitness the most important part of health, but in his opinion it is a precise measurement of the same. He and I disagree around the margins of that position, at least in part because of friendship and what it does for us. We may not be able to define friendship in quite as absolute terms as those we use for fitness, but I’m reasonably sure we all know what it means to be and to have a real friend. Read or watch “Of Mice and Men” if you are unsure. It’s likely that friendship itself, unlike fitness, does not have a precise metric, a measurement of volume or degree. No “friendship across broad time and modal domains” if you will. Though I continue to hold this truth, that you can never have enough friends, there is apparently a number that does have some significance. Three. Three friends, real friends, lead to a longer life. Side by side or face to face, the tipping point is 3.

No amount of time spent or distance traveled is too much for them.

In 2011 I wrote an essay in response to an article I read in the WSJ on the coming physician shortage. In short I agreed with a letter that pointed out the effect of physicians working fewer hours than they had traditionally worked. In that letter the effect of the changing demographics in medicine (more women physicians, generational shifts) was pointed out. My essay agreed with the points in the letter. My thesis is that you can’t “have it all”, in medicine or anywhere. Someone, somehow, always pays.

While reading about “Equal Pay Day”, the day on which the “average female wage earner” achieves the same amount of pay as the “average male wage earner” acquired in the previous 12 months, a couple of things strike me. First, the general thesis of my essay continues to be accurate, at least in medicine. Income is determined by the choice of specialty, as always, but beyond that it is driven much more so by the number of hours a physician works and how productive that physician is during those work hours. Work more hours, get paid more money. Perform more of your doctorly duties in each one of those hours, get paid more money. There are fewer and fewer physician jobs in which seniority on its own drives income, thereby negating any lack of seniority which may be caused by a career “pause” to have or care for children. Physician income is largely gender-blind. As an aside, the dirty little secret of physician pay is that production-based compensation is the norm everywhere, even at those institutions that claim otherwise.

The second thing that strikes me is the malignantly erosive effect of ineffectual, unnecessary external regulation on the practice of all medicine on effective physician work hours. In 2014, whether you are a man or a woman, the bureaucratic load associated with practicing medicine is oppressive, and hours that just 5 years ago may have been spent caring for patients is now spent caring for charts, bills, and other paperwork. These hours generate no real health benefits for patients, and do not produce any revenue that pays the doctors for working them. In a particularly cruel example of Murphy’s Law, or at least the Law of Unintended Consequences, the specialties that are hardest hit by this relentless onslaught of the unnecessary are those that tend to pay physicians the least. Fields like Family Practice and Pediatrics. On “Equal Pay Day”  it is particularly ironic to note that those hardest hit specialties tend to be staffed by the highest percentage of female doctors.

A final note as I read this post 3+ years after the initial writing: the choice of “Mommy-Track” to describe those women who graduate from medical school and work fewer hours than their male peers because of their choice to prioritize their families seems needlessly pejorative and provocative. I’ve left it in for this Epilogue because to edit it today seems dishonest in a way. Besides, I’m a little bit better at writing in 2014 than I was in 2011. I can be plenty provocative now without resorting to the pejorative.

It’s really incredible what’s been said about our CrossFit on the information highways this week. The amount of opinion masquerading as fact-based advice is off the charts. Anyone’s who’s been here for more than 2 years will realize that it’s just that part of the cycle, that time when CrossFit has reached another Tipping Point size-wise and has therefore come to the attention of another outwardly spiraling circle of “experts.” Trust me, it’s Groundhog Day in the gym, so to speak.

This is a wonderful opportunity to take a moment to reflect upon what CrossFit actually is, what it is not, and for whom CrossFit is appropriate. Let’s start with the last and work forward. CrossFit is appropriate for almost everyone. The group for whom it may not be really the best option is actually counter-intuitive: elite single sport athletes in highly skilled endeavors. Waaaiiiit at minute here, you might be saying. The highest-skilled elite athletes may NOT be the best CrossFit candidates, but the great unwashed masses of the obese, unfit, and unhealthy ARE?! You bet, Bucky. That’s exactly what I’m saying. The .01% probably need to spend 100% of their time on their specialty.

CrossFit is for the other 99.9%.

Why? How can that be? Well, that runs into what CrossFit is not, namely a dangerous, hyper-intense program that has a high injury rate, something too over-the-top for “regular” folks. Uh, uh. The real “dirty little secret” of CrossFit (if I may crib a rather recently famous phrase) is that scaling the stimulus and subbing in favor of more approachable movements is decidedly the norm in almost every setting where CrossFit is done. Technique. Then consistency. Then, and only then, intensity. Says so everywhere. Are there small pockets of CrossFit or CrossFitters who jump the gun and go straight to intensity? Sure. But that is hardly an indictment of the program, especially since the program and the company incessantly beat the drum: technique, then consistency, and only then intensity.

Which brings me to what it is that CrossFit can actually be said to be: the solution to the adverse effects of overabundance. A viable answer to the problems created by an unhealthy population. While the CrossFit Games have been an incredibly effective PR vehicle for the CrossFit Affiliates (which is also true, paradoxically, of all this silliness on the web right now!), they have confused a vocal segment of the opinionators about CrossFit and CrossFitters. Peek through the door of any CF Box and guess at who’s inside. Here’s a tip: it ain’t Jason Khalipa and Miranda Oldroyd! It is, however, everyone else. What do you think they will be caught doing? Again, likely not what Jason and Miranda are doing that day! They will rather be doing approximately an hour’s worth of work, some of it skill-based, some of it directed toward some hole in their fitness, and almost certainly culminating in something that we would all recognize as a WOD. Look very closely, though, because if you do you will also see that there will be many subtle variations of that particular WOD going on, maybe as many subtle variations as there are CrossFitters in the gym.

CrossFit is a highly customizable system built on the core principles elucidated in the Classic CrossFit Journal Issue no.2, “What is Fitness”, for which there is a link on the left side of the Main Page of CrossFit.com. A prescription for not only fitness but also health that includes a universally scalable program of exercise in combination with an easily followed guideline for nutrition, all geared to produce incremental and sustainable gains in 10 very specific physical domains. All of this results in health, and when we combine this individual health with the wonders of the communities that have grown out of gatherings of CrossFitters we end up with something that could be called Wellness.

None of this is new. Nothing I’ve said here is unique or original. It does bear repeating, though, because you might be relatively new, and this latest round of “CrossFit is dangerous” or “CrossFit is only for people like Jason and Miranda” might actually be your first rodeo. It’s OK. Relax. It’s still technique, then consistency, and only then intensity. It’s still eat to support performance in the gym but not production of fat. Still learn and play new games. It’s still CrossFit.

CrossFit is still the answer.

It’s really incredible what’s been said about our CrossFit on the information highways this week. The amount of opinion masquerading as fact-based advice is off the charts. Anyone’s who’s been around CrossFit for more than 2 years will realize that it’s just that part of the cycle, that time when CrossFit has reached another Tipping Point size-wise and has therefore come to the attention of another outwardly spiraling circle of “experts.” Trust me, it’s Groundhog Day in the gym, so to speak.

This is a wonderful opportunity to take a moment to reflect upon what CrossFit actually is, what it is not, and for whom CrossFit is appropriate. Let’s start with the last and work forward. CrossFit is appropriate for almost everyone. The group for whom it may not be really the best option is actually counter-intuitive: elite single sport athletes in highly skilled endeavors. Waaaiiiit at minute here, you might be saying. The highest-skilled elite athletes may NOT be the best CrossFit candidates, but the great unwashed masses of the obese, unfit,  and unhealthy ARE?! You bet, Bucky. That’s exactly what I’m saying. The .01% probably need to spend 100% of their time on their specialty, SPP or Specialty Physical Preparedness; CrossFit is GPP, General Physical Preparedness.

CrossFit is for the other 99.9%.

Why? How can that be? Well, that runs into what CrossFit is not, namely a dangerous, hyper-intense program that has a high injury rate, something too over-the-top for “regular” folks. Uh, uh. The real “dirty little secret” of CrossFit (if I may crib a rather recently famous phrase) is that scaling the stimulus and subbing in favor of more approachable movements is decidedly the norm in almost every setting where CrossFit is done. Technique. Then consistency. Then, and only then, intensity. Says so everywhere. Are there small pockets of CrossFit or CrossFitters who jump the gun and go straight to intensity? Sure. But that is hardly an indictment of the program, especially since the program and the company incessantly beat the drum: technique, then consistency, and only then intensity. The injury rate in CrossFit, if anyone cared to ask, is actually quite low, especially when you compare it with, say, running, where something ridiculous like 90% of runners suffer a running-related injury every year.

Which brings me to what it is that CrossFit can actually be said to be: the solution to the adverse effects of overabundance. A viable answer to the problems created by an unhealthy population. While the CrossFit Games have been an incredibly effective PR vehicle for the CrossFit Affiliates (which is also true, paradoxically, of all this silliness on the web right now!), they have confused a vocal segment of the opinionators about CrossFit and CrossFitters. Peek through the door of any CF Box and guess at who’s inside. Here’s a tip: it ain’t Jason and Miranda! It is, however, everyone else. What do you think they will be caught doing? Again, likely not what Jason and Miranda are doing that day! They will rather be doing approximately an hour’s worth of work, some of it skill-based, some of it directed toward some hole in their fitness, and almost certainly culminating in something that we would all recognize as a WOD. Look very closely, though, because if you do you will also see that there will be many subtle variations of that particular WOD going on, maybe as many subtle scalings as there are CrossFitters in the gym.

CrossFit is a highly customizable system built on the core principles elucidated in the Classic CrossFit Journal Issue no.2, “What is Fitness”, for which there is a link on the left side of the Main Page of CrossFit.com. A prescription for not only fitness but also health that includes a universally scalable program of exercise (with scaling options also offered under the “Start Here” tab on CrossFit.com) in combination with an easily followed guideline for nutrition, all geared to produce incremental and sustainable gains in 10 very specific physical domains. Following this “prescription” results in health, and when we combine this individual health with the wonders of the communities that have grown out of gatherings of CrossFitters we end up with something that could be called Wellness.

None of this is new. Nothing I’ve said here is unique or original. It does bear repeating, though, because you might be relatively new, and this latest round of “CrossFit is dangerous” or “CrossFit is only for people like Jason and Miranda” might actually be your first rodeo. It’s OK. Relax. It’s still technique, then consistency, and only then intensity. It’s still eat to support performance in the gym but not production of fat. Still learn and play new games. It’s still CrossFit.

CrossFit is still the answer.

The announcement came in the mail, by email, and proclamation at a dinner. My good friend (and personal physician) would be retiring from the practice of medicine at age 55 to take a position as a very senior hospital administrator. This news was delivered by another physician friend, a 55 year old orthopedic surgeon who put my wife back together after a Humpty Dumpty fall off a horse, during a dinner at which he described his intent to drastically reduce his call schedule and ER coverage. That morning in the OR I was chatting with an industry rep who was telling the story of an extraordinarily talented 45ish year old cataract surgeon who has limited his daily volume to 6 cases (that’s what he’s contracted for with Kaiser) despite the fact that he is able to complete this schedule by 9:30 AM. I thought of all of this while I, a 52 year old eye surgeon somewhat famous for my ability to handle a crushing workload without sacrificing either outcomes or a pleasant patient experience, was mapping out my 2014 office and OR schedule with a reduced work week and additional vacation days.

Have you noticed? There are fewer of us out there doing our jobs. Fewer doctors, that is. We’re slipping away, young and old. The last vestiges of the physicians who lived through the Golden Age of medicine are hanging up their spurs, taking down their shingles, and riding off into the sunset. They are being replaced by an almost equal number of youngsters just out of training, young bucks saddling up yearlings and slowly joining the rodeo. Those of us in the middle, mid-career docs of all sorts, we’re still there. Sorta.

The stands are full. All sorts of spectators and commentators are there to see the healthcare rodeo. The reporters and the pundits, the bloggers, those who dwell in the halls of academe and the basements of the bureaucracy fill the bleachers, prepared for much back-slapping and self-congratulation as the fruits of their intellectual labors, the young buck docs, take over for the much-maligned Marcus Welby generation. The kids’ll be OK, better than OK, because the audience has successfully changed everything about how doctors are trained and made it the way they, the audience, think it SHOULD be. No need to worry about the newbies and all of the non-doctor “healthcare providers” and how slow they are in general, or how they work fewer hours, or take more time to handle a visit–those docs in the “sweet-spot” in mid-career are there to take up the slack until the audience’s brilliance is born out. Sorta.

Everything seems to be a bit chaotic at the healthcare rodeo. There are so many more things that need to get done. It’s not enough to rope and tie that diabetic, there seem to be too many diabetics now. Those young docs spend an awful lot of time just outside the ring doing non-doctor stuff. Where are the grooms, the seconds, the helpers? Why aren’t they doing all that stuff outside the ring so the doctors can get in there and ride? It looks like there are a bunch of those mid-career guys and gals over there outside the ring too, doing non-doctor stuff. It sure seems to take a lot of time. The young bucks seem to take that all in stride. Maybe a stray shrug of a shoulder, but not much more. It’s all they’ve ever known. The mid-career docs seem to be making do. Sorta.

Something’s just not quite right, though. The numbers just aren’t quite working. Matching the number of docs retiring with the number of newly-trained docs seems to be coming up short. All of those newly empowered other “healthcare providers” don’t seem to be making much of a difference, either. There seem to be too many patients, too many people who need both sick and well-care, and too few doctors to provide it. The pundits and the professors say the solution is not more doctors but more other “healthcare providers” and new technology. Help is on the way they say. Preparing the path to this end seems to involve a PR campaign that not only minimizes the contribution of doctors in general, it denigrates the efforts of the one group of docs that is keeping it all afloat: the mid-career physicians who are neither old enough to retire nor young enough to not know any better.

The whole house of cards depends on these men and women going to work and doing just what they’ve been doing for 20+ years. Seeing lots of patients in any given time slot. Performing lots of surgeries efficiently and well. Showing up in the ER for a consult or answering the phone at 3 AM. All for lower pay and less respect. The whole thing rests upon the presumption that they will continue to do this regardless of the non-medical impositions of the new “way it should be”, regardless of the continual battering of their self-worth. Thus far that’s how it’s playing out. Sorta.

There’s something afoot, though. Quietly and without much fanfare, the mid-career doc is slipping away. She’s sliding out the side door and taking a job in administration. He’s slipping in a 4-day weekend every month, on top of the 4-day week he started working a couple years ago. While nobody noticed she started to limit the number of surgeries she would do in a day, ducking out at noon on OR day instead of 2 or 3, the backlog of cases now building up to months rather than weeks. Oh sure, they are still counted as a full-time doc on everyone’s ledger, it’s just that they aren’t as full-time as they used to be, as full time as the system is counting on them to be. The net effect is that with the same number of doctors counted we actually have FEWER docs available to see more patients.

You see, the mid-career physician is also listening to what the editorialists and the bloggers and the academics and the bureaucratic minions are saying, about the “way it should be” and how they really feel about worth of doctor work, and in response they are slip sliding away.

Told to do more for less some of those mid-career warhorses are just doing less. All those men and women who are the equivalent of “innings eaters” on a Major League pitching staff are no longer as available, effectively reducing the number of physicians available to take care of patients. If the new “way it should be” is correct this should pose no problem, right? Just have all those folks who used to be seen by a physician seen by a “healthcare provider.” Got a sore throat? CVS or Walmart is just around the corner and they do the same quicky Strep test your doctor would have done. Surely the AP nurse will notice that tender spleen, or that especially swollen tonsil encroaching on the midline like your 55 year old doc with 25 years of experience would have. No worries. You can follow up with that nice new doctor in the big clinic, that ACO thing you’ve read about. There’s an opening in 12 weeks. Your old doctor who would have stayed late in the office to see you in follow-up in a day or two is no longer available.

He started a new career selling veterinary supplements at rodeos. Slip sliding away…

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

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

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

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