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.

Former Budget Director Peter Orszag wrote an Op-Ed piece in the New York Times titled “Health Care’s Lost Weekend” in which he offers several reasons why healthcare in general, and doctors in particular, should be open for business 7 days a week. “Doctors, like most people, don’t love to work on the weekends…” is his first shot across the bow. He cites a study in the New England Journal of Medicine (the only medical journal to which God subscribes) which is actually a pretty darned good study, one that shows an increase in cardiac mortality of 0.9% (decimal point is correct) for people admitted to the hospital with a heart attack on the weekend in comparison with those admitted during the week.

I’m willing to buy this conjecture, even willing to say that Mr. Orszag’s conclusion, that medical services should be available 7 days a week with expanded hours of business to boot, is a desirable and necessary goal for American Healthcare. The difference between the two of us is that I will openly state what it will take to make such a thing happen, whereas Mr. Orszag has taken the cowardly politician’s route but simply saying “this isn’t right…this isn’t fair…this must be changed,” without offering anything about how.

Someone, or some someones, will pay something somewhere to make this happen. There, I said it.

There are actually a couple of really good examples of this phenomenon right now in my community,  Cleveland. The vaunted Cleveland Clinic is downgrading the trauma service at one of its hospitals, ostensibly because the city of Cleveland is “oversupplied” with trauma centers,  and because it is becoming increasingly difficult to find trauma surgeons to staff these emergency rooms. All true, but in reality it’s because the Cleveland Clinic has decided that the operating loss associated with keeping this trauma center open is more charity than the institution wishes to give to the city, especially in light of a palpable lack of civic gratitude. Similarly, all of the emergency rooms in town are finding it difficult to provide specialty coverage as specialists are declining to make themselves available. Insufficient compensation for the inconvenience associated with that availability, as well as the significant exposure to a litigious patient population are the culprits.

The funny thing is, once upon a time we actually had the equivalent of a 24/7 medical service economy. Back in the day, when Mr. Orszag and I were children, physicians were held in high esteem because they put their patients and their medical practice first, in front of every other aspect of their lives, 24/7.  They were incentivized to do this in two very specific ways: they were paid, and paid very well to perform their services, and they were afforded out–sized doses of respect, occupying a place of honor in every community. In return for this combination of handsome concrete and social compensation medical care was provided when medical care was needed, 7 days a week.

My first real job was caddying for wealthy golfers at the local country club. Not surprisingly, a significant percentage of the country club members were local physicians. Mind you, this was back in the day when only doctors carried beepers. I can’t begin to count the number of times I had a fantastic loop toting the bag for a doctor in the middle of a career round only to see some easy shot go careening into the woods when his beeper went off at the top of his backswing. I vividly remember seeing the assistant pro speeding down the fairway coming directly toward us in a golf cart to retrieve a doctor who was needed at the hospital. Saturday afternoon, Sunday morning, Wednesday evening… no matter.

What was the cost? Well, certainly the doctors didn’t do this for free. They asked for, and received, handsome compensation for this 24/7 availability. Society readily made this investment, in part because the best technology available was actually the technology available only between the ears of the physician. This is somewhat different today given all of our fantastic technological innovations and advancements, but not so different, really, because the stuff between the doctors ears is still what drives all that new technology.

There were hidden costs back then, too. Hidden costs are the ones that are actually the most expensive when we really drill down to see what the ramifications would be if Mr. Orszag had his way. Countless physician families were roadkill, collateral damage to the single-minded emphasis doctors placed on practicing medicine. Troubled children, troubled marriages, broken marriages, broken people all littered the landscape of the medical community, silent testimony to the cost of 24/7 availability. So, too, the nurses and technicians and orderlies who worked the swing shift and the graveyard shift. The social and physical pathologies of shift work are now quite well known. How does Mr. Orszag intend to handle THIS cost? Surely he’s not willing to ignore the well–documented evidence of the social and psychological harm that befalls workers and their families when they are forced to to work weekends and nights?

Behavioral economics is based on the simple concept that people will act in a manner consistent with rational self–interest. Most of the time this is EXACTLY how people behave. Over the course of the last several decades, as physician incomes have declined and as the doctors’ societal esteem has plummeted, physicians have been notably less willing to put their families in jeopardy by putting their profession first and foremost. By the same token, the vast majority of non-–physician workers in healthcare are loath to do the same, hence the difficulty filling nighttime and weekend shifts in hospitals, clinics, and the like. No one likes to work on the weekend when their family is home, when their friends are not working.

So, a  24 seven medical service economy? Sure. Who wouldn’t want THAT? Even without the data from that NEJM study it would be very convenient to have that colonoscopy I’ve been putting off on a Saturday instead of a workday, maybe even a Sunday with Saturday for the prep (prep…yuck). Heck, I found it pretty inconvenient that I couldn’t get a sandwich at one o’clock in the morning at a big convention hotel in Chicago last weekend. I was even willing to pay a premium, not only for my sandwich, but also to the person who made that sandwich appear. I would have given effusive thanks as well.

Therein lies the beginning of the solution. If you wish to have high technology medical care available seven days a week you must provide a significant incentive to those people who provide the care. Simple. I will offer as well that it probably doesn’t make a whole lot of sense to bash those very same people you are trying to convince to put aside some part of their self-interest (or the interest of their families) to work weekends; who is going to do something nice for someone when their reward is to have that same someone turn around and show nothing but disdain for not only the service provided, but also for the provider of the service?

So Mr. Herzog if you want me and my colleagues to be available on Sunday afternoon to take care of people exactly the same way we might on a Tuesday morning you  have to be willing to do two things which thus far you and others of your ilk have demonstrated no inclination to do: you must pay us what those services are worth, and you must be thankful that we are willing to provide them. It’s not enough to declare the “what”, you also have to declare the “how”. Isn’t that what REAL economist do, Mr. Orszag?

Heinlein was right. It doesn’t matter what time you serve it, There Ain’t No Such Thing As A Free Lunch.

Uncle. I give up. Full surrender. Total capitulation. I cannot beat the takers.

It’s funny because my first three drafts of this missive started out “stop the madness”, but I can’t. It won’t stop. The “Do-Gooders” and “We Shoulders” who make the decisions because “they think” or “we feel” have beaten me. Beaten everyone like me. The white flag is up. Turns out the windmill is really a dragon, and contrary to what it says in all the fairy tales the dragon always wins.

You see I, Dr. Quixote as it turns out, thought that being right made a difference. I thought that data, precedent, FACTS would rule the day. Silly me. Silly, sorry sad little me. I thought it was about patients, patient outcomes, statistics, but all along it’s been about the system and protecting the system, protecting it from the very possibility of theoretic risk, protecting it from…patients.

Here I was looking at yet another cost being added to the experience of my surgical patients and asking why a change was being made. Why were we opening a new bottle of $13.00 eye drops for each laser patient, when each bottle held enough medicine for 100 patients? Why were we using a new vial of antibiotic to be injected into the infusion bottle of each case, when each vial held enough medicine for 5 cases? Why, indeed, when there had never…not once…been a reported case of acquired infection, ever, from using one bottle or one vial. Ever. When eye doctors in their offices use and have used, bottles of eyedrops until they can’t squeeze our a single extra molecule. Why?

I blanched at the waste. Plastic baggies of bottles full of drops carted to the trash. Vials of man’s best antibiotics less the microliters used for one surgery crowding the sharps buckets. It was unconscionable, an insult to Puritan and non-adherent alike. The amount of waste nothing short of vulgar.Did no one else see this? I mean, here we are in the supposed throes of a healthcare crisis born of excess and waste, and yet I, Dr. Quixote, flailed alone?

Data…surely data would prevail. Look at the cost, I cried. Never mind the insult to the Puritan ethic, simply look at the cost! You can’t bill the patient, though Lord knows you’ve “mistakenly” done so innumerable times. It’s a cost. It decreases “revenue in excess of expenses” (you’re a non-profit…I get it…we can’t call it profit). I even understand why you’ve spurned my entreaties about Pre-Admission Testing even though there was an article in the New England Journal of Medicine that said PAT is unnecessary. The NEJM is the only medical journal that God reads, and even SHE knew I wouldn’t win THAT one because you can get PAID for PAT. I get that one.

You’ve beaten me. Today I see it. You sent in the REAL decision maker, one of the people who make the decisions in this new age of medicine. I was still under the illusion that maybe I, a doctor, was a decision maker. That I, a doctor who looked at and liked real data, had a vote, some skin in the game. No, today you sent in The One From Pharmacy. I have seen the One With Power and now I know that I am beaten.

The One From Pharmacy has all the words. He has all the weapons. “It’s only fair that each patient receive the same freshly opened bottle/vial.” “What if we have an infection and we re-used a bottle? How could we ever face that patient?” “Here’s an article by a pharmacist that says you could possible have contamination of an open bottle.” “Should we ignore this article that discusses the theoretic possibility of infection?” I also know from prior conversations with The Hospital Administrator that The One From Pharmacy cannot abide not knowing the destination of each drop, cannot abide not having the option of charging each individual patient (if only he could) for each medicine, and that a new bottle must be opened and assigned to each patient for this purpose. This I know.

Oh, I tried. I really did. I tried to point out that each of the articles the The One From Pharmacy shared with me were nothing more than opinion pieces, essays that were little more than editorials sharing one author’s thoughts. His or her feelings. “I think,” therefore it must be. But…but…but…there’s no DATA. No evidence. Nothing to refute decades of experience in the operating room. No results or reviews showing that the status quo is dangerous, only some somebody who managed to get what “they think” into some non-peer reviewed journal.

“Doctor, are you saying that we should just IGNORE these articles? You would have us simply continue with business as usual? The governing bodies ALL say this COULD happen. Are you saying that we should ignore what they THINK?” I confess, I had no answer. I was paralyzed, caught between my horror at the thought that decades of success, as well as common sense so obvious it made stomach hurt, were to be tossed aside because of some someone’s feelings, and my fascination at the sheer revulsion registering on the face of The One From Pharmacy. Funny, he wasn’t anything at all like what I thought the dragon would look like.

I stood there for a moment, bleeding, as the realization slowly came to me that I was defeated. Vanquished. It’s a shame, really, because doctors of my generation are the last, best hope for all of us. We bridge the divide between the ancients who lived through the Golden Age of Medicine–the Giants who cured polio, discovered antibiotics, replaced joints–and the moderns, the nextgen who will live through the silicon age of medicine–Dwarfs who will serve a system, cure the economics, replace care.

I felt small, diminished, inconsequential, a failure, a disappointment. It was hard, frankly, to haul my carcass to the operating room to begin my work day. Yet that’s exactly what I did. I mounted my steed and raised my lance; slowly, ever so slowly, we rode alone to the operating theater.

A white flag, attached to my lance, waving in the breeze.