Sunday musings…

1) Jobs. Need more. ‘Nuff said.

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

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

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

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

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

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

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

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

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

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

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

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

I’ll see you next week…

“Constantly varied…” So, routine is the enemy, right? Well, yes and no. Routine is one of those multi-layered words that applies in many ways in many situations.

Routine is the enemy when we train, and I think this is true for almost all athletes, almost everyone who trains. We risk acclimation to the stimulus if we have a strict routine in the gym, if our workouts are substantially the same day after day. We further risk the numbing effects of boredom, a slow ebbing of our enthusiasm and our resolve. Routine is the major building block, the cornerstone in the brick wall that often stands between athlete/trainee and training.

Routine is our ally when “routine” is synonymous with “consistency”. Remember “Form, then consistency, and only then intensity.” The establishment of a routine, a schedule, a commitment of time and spirit to the quest for fitness, health, and athletic achievement is the first paving stone on the highway of living.

Routine, the yin and yang, push and pull, up and down, enemy and ally.

It’s really hard to make something look easy. Think about it. The best knee surgeon takes 1/2 the time and gets twice the good results of the average surgeon. It barely looks likes he’s working at all. The very best LASIK surgeon makes the most difficult case look like a piece of cake, just like the easiest and most straight forward cases done by the average surgeon.

None of this happens without an enormous amount of hard work, practice, study, and yes, a little bit of natural ability doesnt’ hurt either.

Think about double-unders, jumping rope with two passes of the rope under your feet for each jump. A CrossFit legend named Chris Spealer did a Tabata Double-Under set (20 seconds of exercise followed by 10 seconds of rest, repeated 8 times) and got a lowest score of 40, or something crazy like that. Looked like a snap, too.  My best is 10. TEN! If you are a CrossFitter and you’ve struggled with Double-Unders (and who hasn’t, eh Jeff Martin?) you watch and you say it’s easy for him. You gotta know, though, after watching all of the Speal videos, that there were countless hours of work behind that. He just makes it look easy. It’s not.

Samuel Beckett had a run of some 10 years or so where everything he published was nothing short of brilliant, and there was a ton of it. If you are a writer and you have stared at a blank piece of paper or a blinking empty screen (and who hasn’t, eh Daigle?), you might think that Beckett was simply gifted, that the words simply poured out onto the page fully formed and prepped for posterity. Reading Beckett’s letters, though, tells a different tale entirely, one of anguish and toil, brutal hard work. He just made it look easy. It wasn’t.

We tend to discount the hard work behind any skill-based endeavor when we only see the “game film”, so to speak. The untrained eye is often unable to discern the subtleties in some performance or job that the best of the best just blow through, making it look like an everyday, ho-hum whatever. In most circumstances we just don’t have an adequate frame of reference that allows us to see how an average or “regular” surgeon, or athlete, or debater struggles with the curveball, the surprise. We don’t even get a chance to compare how the true superstar handles a truly mundane “game” in comparison with the middle-of-the-Bell Curve guy, at least outside the realm of sports.

This lack of perspective, along with a lack of awareness of how hard the best of the best have worked to get there, leads us to minimize the excellence before us. The average cataract surgeon in the United States takes more than 20:00 to complete the surgical aspects of a case. The very best among my peers take 5 or 6:00 to do the same thing. No movement is wasted, and each tiny step is literally a microscopic ballet. The complication rates for average eye surgeons are 5-10X greater than that of the top surgeons, and the best surgeons routinely achieve better outcomes by all measures.

The best surgeons make it look too easy. Our response as a nation to this is criticism that eye surgeons are overpaid for such a “quick and simple” procedure; there is a palpable, barely hidden contempt for the highest achieving physicians among healthcare policy makers. This is just wrong.

It’s really hard to make it look easy, almost everywhere and in almost every endeavor. We should be MORE amazed and have MORE respect when we see something and think: WOW…she really made that look easy!

The most dangerous man in American health care is Greg Glassman. That’s right, the man who will make the biggest difference in making our country healthier, and thereby reducing the cost of providing health care, is a fitness trainer from Santa Cruz California. And you have no idea who he is.

That’s okay, though; you’re in good company. There are lots of really important, really influential people in American healthcare who have never heard of Greg Glassman. Donald Berwick, head of the Centers for Medicare and Medicaid Services? Not a clue. Toby Cosgrove, CEO of the vaunted Cleveland clinic foundation? Nope, never heard of him. So it goes, as well, for the presidents and executive vice presidents of all the various and sundry medical “letter” organizations like the AMA, the American Association of ophthalmology, and the like. The man who might hold the key to economic healthcare salvation is not even a blip on the margins of the healthcare establishment’s radar screens.

So what’s the big deal? Why is Greg Glassman the most dangerous man in American healthcare? There are two reasons, actually. First, he is right. Glassman has identified not only the most fundamental and foundational problem with the health of Americans, but he has also discovered, defined, and implemented the solution. Americans are not fit. There is an appalling lack of physical fitness in the populace. Fat and slow, or skinny–fat and weak, we are a nation of the unfit. What Science Daily calls “frailty” in an article linking a lack of fitness to poor health outcomes (ScienceDaily.com/releases/2011/04/110426122948.htm), Glassman calls decrepitude. Skinny or fat, how healthy can you be if you can’t get yourself out of a chair without assistance?

Somewhere around 2001 Greg Glassman co–founded a fitness system which he dubbed “Crossfit”(http://www.crossfit.com). He offered  the first actionable definition of fitness ever created: work capacity across broad time and modal domains. How much stuff can you move, how far, how quickly. It’s not enough to be strong, you must also be able to travel long distances. By the same token, it’s not enough to be able to travel long distances if you are not strong enough to lift your own body. This definition led to a measurement of fitness, power output or work.

To achieve this level of fitness Crossett offers the equivalent of a prescription. Exercise should consist of “constantly varied, high intensity, functional movements.” Intensity is the key. Fitness gains are not only magnified but are achieved in the most efficient manner when the exercise is performed at relatively high intensity. Functional movements include fitness standards like running, swimming and biking, but also weight training using major lifts like the deadlift, the clean, and the squat. Crossfit has returned those staples of gym classes in the 60’s, pull-ups, push-ups, and squats, to a prominence not seen since the days of Kennedy’s Presidential Council on Fitness.

Caloric intake matters; you can’t out train a bad diet or a bad lifestyle. Crossfit’s dietary prescription is quite simple: “eat meats and vegetables, nuts and seeds, some fruit, little starch and no sugar. Keep intake to levels that will support exercise but NOT BODY FAT.” Crossfit preaches the merits of both quantity and quality when if comes to food. Carbohydrates with a low glycemic index, protein containing all essential amino acids, AND FAT are all essential to producing physical fitness. Food should be seen as fuel and should be measured as such. Even the highest quality foods consumed in the most balanced proportions will produce increased body fat and decreased fitness if taken in too high volume

A funny thing happened on the way to revolutionizing the fitness industry. In addition to increased strength, increased endurance, and decreased body fat, which translated into a dramatically fewer inches and lower dress sizes, it seemed as if everyone who did Crossfit became healthier. Lower cholesterol. Lower resting heart rates. Decreased blood pressure. Elevated moods. It looked like a move away from decrepitude and frailty was actually a move TOWARD health. Toward WELLNESS.  A scientist at heart, Glassman digested this information and in 2008 made the following statement: fitness is a proxy for health. Indeed, Glassman declared that fitness EQUALS health. In this, Greg Glassman is right, or at least more right than not. At a minimum, fitness is the foundation upon which health is built. A healthy nation is one that need not expend countless $Billions on curing diseases that could be prevented by becoming fit. This is the first reason why he is the most dangerous man in American health care.

The second reason is that he doesn’t care.

Greg Glassman is like the little boy standing at the side of the road watching the naked emperor parade by who declares “the Emperor has no clothes!” He is standing there watching a parade of the fat and the weak and he is saying “hey look…they can’t get their butt off the throne!” It’s uncomfortable to hear someone say that, but he doesn’t care; it needs to be said. The standard dietary dogma of high carbohydrate, low-fat diets with little or no meat? A straight ticket to decrepitude! He doesn’t care that statements like that make all of the Oz’s and Pritiken’s sputter and squirm. When asked once upon a time how to gain weight for a movie role Glassman famously responded: “ easy…non–fat frozen yogurt.” It’s no different with exercise. Walking and other low-intensity exercises? Better than nothing, but only almost. Cue the howls of the Jillians and the Jakes, and every glossy, muscly, fitnessy magazine editor in the English speaking world. Glassman is right, and he doesn’t care.

Greg Glassman has looked at what is wrong with the health of Americans and he is willing to say what that is and say it out loud. He is willing to say that we as a people are unfit, and that this is the primary cause underlying our lack of health, and our accelerating need to spend money to cure disease. He is willing to say that the vast majority of the advice that we have received to fix this is flat out wrong, whether it comes from the government or the cover of Fitness Magazine. He is willing to say the the road to economic salvation in American Healthcare leads through the gym, the grocery store, and the kitchen, not to or through something as meaningless as an “Accountable Healthcare Organization” (whatever that may be). Although he is convinced that he is right he is presently spending gobs of his own money studying the effects of the Crossfit prescription on the health of regular people.

Yup, Greg Glassman is right, and he doesn’t care that all of the so–called experts in healthcare don’t know who he is yet, or that they wouldn’t agree with him if they did. Judging by what’s going on in the physical fitness world right now as Crossfit grows 30% PER MONTH, I’d say that makes Greg Glassman the most dangerous man in American healthcare.

Better learn how to spell his name.

What follows is the draft of an article that Kathy Weesner and I submitted to the Crossfit Journal in the Spring of 2010. Consider it a preview, a “sneak peak” of a series of articles that I plan to post on Health.

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Two Crossfitting MD’s Look at Health

We figured it out! Coach gave his Crossfit definition of health about a year and a half ago and it’s taken us this long to figure it out. We thought we had it after a dinner at the 2009 Crossfit Games,  but something still didn’t quite fit. There was something about “Fitness Over Time” that seemed incomplete. Health to a couple of doctors seemed as if it had to include something else, something other than just fitness as Crossfit defines it and a calendar.

Crossfit defines fitness as “Work Capacity Across Broad Time and Modal Domains”.  With precision and accuracy we can chart or graph our fitness by looking at our power output in multiple domains against time; we can then compute our work capacity, the area under the curve.

[Insert classic CF Graph work capacity age 20 CF training guide]

Coach has declared that his ultimate mission is nothing less than to revolutionize healthcare, to produce healthier individuals who can lead more productive lives and live longer while doing so. Consistent with that goal, and certainly consistent with his development of Crossfit, Coach first had to come up with a definition of “health’. The Crossfit 3-D definition of health is “fitness over time; fitness over a lifetime”.

A little background is probably in order. We are two practicing doctors who happen to be relatively experienced Crossfitters. Kathy is a pediatric anesthesiologist, so she’s the smart one of this pair! Darrell is an ophthalmologist or eye surgeon. We did a little experiment after Coach started to talk about health. What, exactly, do physicians think is the definition of health? What does it mean to be healthy?

When we started to ask our colleagues this question we were almost universally disappointed in their responses. We surveyed newly minted physicians right out of training as well as those who have been practicing for over thirty years.  Believe it or not, the most frequent answer we received when we asked doctors “what is your definition of health” was: “gee…I dunno…I never really thought about it.” Nuts, huh? Not so surprisingly, especially with an audience of American doctors, was the answer “health is simply the absence of disease.” All Crossfitters have heard Coach talk about the 95 year old man with absolutely no diseases on not one single medicine who can’t lift his ass off the toilet without help.  No disease, but healthy?

The flip side of that is where we as doctors struggle with simply defining health as “fitness over a lifetime.” How about the 36 year old man with a 500 Lb. deadlift, a 5:00 mile, 50 pull-ups and a 2:30 “Fran” who drops dead from pancreatic cancer 3 months after posting all of those numbers? Was he “healthy” then? He surely was fit, at least using our Crossfit definition of fitness, but it’s hard to say that he was “healthy” because the volume under his life curve abruptly stopped increasing.

The beginning of the solution to our quandary did come from one of our surveyed doctors.  Darrell was speaking in Florida and, as always, he asked the audience of physicians to define health. One of the docs at that meeting replied “unlimited potential, or life performance without any limits or potential limits.” BINGO! That’s the missing link–PROSPECITVE fitness, the potential to express fitness in the future.

The Crossfit 3-D definition of health is a LOOK-BACK, a retrospective evaluation of how healthy we have been. As such it is missing one of the key aspects of what health is more generally thought to include, the ability to make predictions about future life–in our case as Crossfitters about future levels of fitness. To truly invoke a three dimensional definition we need to include two more dimensions, two additional variables that affect our potential performance.

Interestingly, Crossfit already talks about one of these dimensions when Crossfit instructors discuss “wellness” at Level 1 Certifications. Wellness includes such widely discussed objective, observable, and measurable variables as blood pressure, cholesterol, %body weight fat, waist circumference and chest/weight ratios. Although we can agree that society as a whole is TOO focused on these variables, they do have some value in predicting future levels of fitness.  We are confident that we can identify a validated “wellness scale” that scores this category based on these established markers.

[Insert Illness-Wellness-Fitness Arc pg 16 CF training guide]

The last variable, the third dimension of a comprehensive Crossfit definition of health is “well-being”– emotional and mental health. Although it is virtually impossible to establish a universally agreed upon definition, let’s call this the “happiness” metric. It’s impossible to maximize your fitness if you have some mental or emotional problem that becomes a barrier. We can certainly understand how named problems like depression, bipolar disease or severe pathologic anxiety can affect our fitness. In the same way our ability, or relative inability to handle both the chronic stress of everyday life and the acute episodes of stress we face can affect our fitness.

How do we measure something as amorphous as “well-being” or happiness? We could certainly use something like the inverse of the VAS or Visual Analogue Scale that anesthesiologists use with all of their patients to evaluate pain control in the post-op period. A better option would be something along the lines of the Quality of Life Indicator (http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg511 ). This independently validated proprietary test fulfills our measurable, observable and repeatable Crossfit mandate.

We would like to propose a slight variation on the Crossfit 3-D definition of health by specifically naming two additional dimensions: traditional Wellness, and let’s call it “Well-Being”. We would further like to expand on Coach’s contention that increased fitness will drive all of our wellness measurements in a positive direction by saying that fitness, wellness, and happiness form a bi-directional “virtuous circle” that leads to health; any increase in each of the three elements will drive the others in a positive fashion leading to greater health.

In the end we think Coach has it more right than anyone else when he says that health is work capacity over time. By explicitly adding the pre-existing Crossfit definition and concept of Wellness to this definition, and then by going further and adding the concept of Well-Being we complete the full 3-D Crossfit Definition of Health. Health at any one point can be depicted by a sphere whose volume is determined by the interaction between Fitness, Wellness, and Well-Being.

Our conjecture (hypothesis?) is that the volume of the “Health Sphere”, perhaps combined with the volume trends over time, is a more accurate predictor of prospective fitness or work capacity in the future.

If this is indeed the case we will have further cemented the primacy of Crossfit’s definition of physical fitness. By combining our measurement for fitness with similar metrics for medical wellness and happiness Crossfit will have created the first truly measurable, observable, repeatable, and ACTIONABLE comprehensive definition of health.

So, time to begin our Crossfit conquest of healthcare!

(NB: Graphs and figures to be added)

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I will address all three categories and then expand on the unified definition of health in upcoming posts.