Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘musings’

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.

 

Sunday Protests

One of my all-time, never fails thrills is a pre-game flyover. I get serious chills and a full coat of goosebumps every single time. Doesn’t matter what event follows, or why I’m watching. Unexpected, surprise fly-overs are an even more special treat, that “oh, you’re kidding…I get to see this even AND I get a fly-over?” It’s like getting dessert first at a Michelin starred restaurant. Never having served in any of the branches of our military I have no special call to feel this way. Yet goosebumps arrive on cue whenever a particularly moving rendition of our National Anthem is played, or if I hear Kate Smith or Ray Charles singing one of our other patriotic anthems.

It should come as no surprise, then, that I am quite completely conflicted about the recent protesting of professional athletes done during these tiny interludes of observing our shared nation. I do get, as should all thinking individuals, that the protests themselves are not directed at either the anthem or the flag, and certainly not toward the men and women who have served in the defense of the historical values that these symbols represent. I truly love these tiny moments of patriotic sentimentality. They are, for me, similar to saying “Grace” before our evening meal: a tiny vestige of a once much larger experience.

Sporting events of all kinds used to be a much bigger presence in my life than they are today. Whether playing or watching, it was weird to not have some sort of game front and center. Once I hung up my various sporting implements, and even when I moved away both literally and figuratively from the teams of my youth, I could usually find some sort of sporting event to have on as background noise on a given day. The fact that I watch fewer games, and almost no football, at a time of unprecedented activism on the field is therefore purely coincidental.

Still, I do think about sports, and major sporting events are still a rallying point (or at least a conversation starter) in most walks of my life. To say that this next statement has me conflicted doesn’t really measure up to the truth: the on the field activism of athletes makes me avoid the discussion of sports entirely. It’s not that I feel the athletes have no place expressing their opinions, nor that I necessarily disagree with the opinions they are expressing. The heartfelt conviction that a particular group has been singled out for mistreatment is a righteous cause to which very public individuals could lend their support. By choosing the venue of a sporting event they have removed my ability to choose whether or when I will engage the topic.

By choosing to do it in the manner that they have chosen prevents me from experiencing a tiny thrill that used to at least feel like it was free.

So what? Isn’t that the point of protest, to make the safe and the secure a little bit uncomfortable? Sure, I get that. I really do. It makes little difference to those protesting to learn that people like me really do set aside time to consider the merits of their grievance; creating discomfort is part of the point. Having twice scrubbed my own workplace of all political activity, making it clear that our team is to avoid the creation of similar discomfort in our clients, I sort of feel like my patronage is being abused I guess. Kind of like that old joke “I went to a fight and a hockey game broke out”, except it’s a political expression upending my expectation. Certain jobs just don’t mesh with political action in the workplace. Who wants to see their local police officers in uniform and protesting anything at all? Can you imagine listening to your surgeon expound on some controversial topic just as you slip under anesthesia?

You could very well read this and say that my bleating is nothing but one more example of “White privilege” (funny, given my name), the smug mutterings of someone safe and secure and as close to immune from the dangers being discussed. I would understand your position. I would disagree, but I would understand, and more than that I would inherently realize that no amount of discussion on our mutual parts would change your mind. All good. I’m uncomfortable, and a little bit unhappy, and maybe that was always the point.

The risk is that my discomfort may make me stop listening. That’s probably not what the protesters are aiming for.

Contentment, Complacency, and My Fitness Tracker

Where does being content end and being complacent begin? As an older athlete this question is just dogging me. The parallel question might be where is the line between being content and capitulating? These are both, of course, extensions of some of my recent thoughts on balancing the effects of relatively high intensity workouts with the countervailing effects on recovery, plus or minus injury.

There might be a more scientific answer to these, at least in so far as fitness is concerned, and it would come from of all places the fitness tracker world. As it turns out my latest tracker(s) have the ability to measure the beat-to-beat variation in heart rate (HRV). This measurement is a proxy for autonomic nervous system activity. A lower HRV means autonomic stress. If correlated with the previous day’s workout that would argue for either a lower intensity session or rest.

Is HRV ready for prime time? Well, world class endurance athletes and many professional athletes in other sports certainly think so. How about for us, the regular folks hoping to improve our fitness and along with that our health? Dunno. I’m impressed and frankly a little depressed to find that my HRV responded so classically to what was for me an intense WOD yesterday. For this to work one must have the discipline to dial it back if your HRV is low on a particular day (be content with your work), but also the discipline to ramp it up when your HRV is high (fight complacency and go to work).

In a busy life it is likely the second part that will prove the more difficult.

Careless Joy

Quiet house. Quiet lake. Quiet mind? Not so much.

When you are riding high, hitting all of your numbers, looking out over a quiet lake as far as the eye can see and embarking on another stretch of smooth sailing, are you the type that rides the crest of that wave with the carefree joy it deserves? Or are you rather the sort that cannot shake the awareness that below your tranquil waters there lies a hidden reef that portends despair should you happen upon it? The question is more than just the old “are you an optimist or a pessimist” saw, I think. At its core lies one of the keys to happiness: can you live in a happy moment without simultaneously giving space to another darker, sadder moment?

During the dance are you always on edge waiting for the other shoe to drop?

None among us lives a life filled with only joy and happiness. Indeed, there are those whose lives are a proverbial slog from one tragic moment to another. Blessedly, in our developed world, these “treadmills of tragedy” are actually quite rare. Likely as rare as the Unicorn lives filled with nothing but rainbows and Skittles. No, for most of us it’s simply a question of degree leavened by, I dunno, attitude I guess. Do we approach the smorgasbord of our lives as ones of “quiet desperation” as so many novelists propose, or do we rather travel in a state of “careless joy”?

Beth and I are hosted friends this weekend at Casa Blanco, the invitation having come spontaneously months prior and quite amazingly accepted and consummated. The one, a classmate from college, I’ve known for 40 years. The other is my classmate’s relatively new love. How they’ve arrived together at Casa Blanco is quite fascinating. One has lived a life which from the outside seems to have been charmed beyond belief, while the other has struggled mightily to overcome significant childhood traumas. One looks back and muses on choices made and how things might have turned out if present day insights might have been available when earlier crossroads were encountered, while the other has doggedly worked through each treacherous road into and out of those crossroads.

What they have in common, at least this weekend, is the apparent ability to live fully within the joy of whatever moment they are experiencing right now, without allowing the intrusion of the “other shoe”. I am quite sure that each has some something that weighs on the balance toward the negative side of the ledger, but for the life of me I haven’t seen it. Pollyanna or a gift? I’m going with “gift” and furthermore I’m going with being able to watch this couple give themselves completely to each moment we’ve shared as one of the most meaningful “hostess” gifts Beth and I have ever received.

Those couple of things in my life (or yours, or my friends’) that are sitting there ruining your winning streak? That other shoe you just know will drop at an inopportune moment? Meh, they aren’t going away regardless of how you decide to engage with the joyful steps in your life, on your journey. Right now there’s a workout to plan and a lake to jump into. Bacon’s on the griddle while I watch the chickadees eat breakfast. Tapping or shuffling, the sound of the shoes is that of happy dancing, and I am taking my cue from our guests and simply listening.

That other shoe will drop whenever but I’ll likely not notice.  I’ll be too busy dancing to worry about it.

Of Tradewinds and Science

“A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die.” –Max Planck

So very much of what we encounter as we seek any kind of guiding truth is not science at all, but strongly held opinion forcefully presented. Think about it for a moment. Think about a few of the really big issues orbiting the intellectuosphere. Climate change. Health. Fitness. The search for the cure for cancer. Heck, the decision on what to have for lunch. So many opinions…so much money…so little true science.

Even more than that, scientific truth is continually bludgeoned by the one-two punch of politics and commerce. True science has always been held hostage by those who have vested interests in what constitutes the prevailing truth at any given time. How many promising avenues of inquiry have been blocked, and how much time has been lost because of the failure to pursue additional lines of inquiry that ran counter to “consensus”? One need only think of inflammation in vascular disease or alternatives to “fat in the diet is unhealthy”, both squelched along with the careers and reputations of their proponents while the single consensus theory was pursued. Why? Alternate theories or parallel theories would siphon the spoils from those who fed at the consensus trough.

It’s quite tempting to hold that this is all relatively new, that it is a function of our highly developed Western societies. Tempting, but ultimately false. Has there ever been a time in recorded history when a new scientific truth has upended orthodoxy and there has NOT been an attempt by the entrenched to not only stop an new line of inquiry but also destroy those inquiring? Think Galileo. From where I sit it seems as if a substantial majority of truly disruptive new scientific truth has arisen from the ranks of those who stood aside the prevailing winds and charted their own course.

What does this mean for each of us as we sit in our own little boats and sail along? The trade winds of consensus are strong, and it seems the weaker the science behind them the stronger they blow. It’s fine to allow these to fill your sails, of course, for the majority of them do in fact propel us along a true course. The best course, however, may lie in the breezes that cross the trade winds. Those tiny little gusts that represent the true essence of real science–skepticism accompanied by inquiry, followed by proof–will ultimately propel us to the proper destination despite the power of the commerce attached to the trade winds.

Every now and again the Newport to Bermuda race is won by a rebel who went off alone and discovered a new truth about sailing. We should be open to the possibility of a new scientific truth in all parts of our lives, lest we find ourselves far behind, capsized in its wake.

Or worse yet gone, as Planck suggests, long before we ever had a chance to benefit.

Evaluating Risk in the Mature Athlete

“Achieving a risk level of 0.00000% is costlier than 0.0%.” –Saurabh Jha (on Twitter)

Think about that for a minute. It was written in the context of medicine and medical care, but we should think about risk in the context of our CrossFit or fitness practice, too. Beth and I had a really nice conversation with my sister-in-law Amy (of Champlain Valley CrossFit, home of Games champion Matt Fraser) about CrossFit for the masses. The specific topic was how many CrossFit WODs should regular folks, especially–ahem–more mature regular folks be doing each week and what sort. In a way it was a discussion about managing risk.

As I’ve gotten older my ability to challenge my body without incurring minor injuries has declined. At the same time, my ability to recover from those injuries has declined apace. A far more mundane, but equally actionable observation is that I do not recover from the intensity of the WOD as quickly as I did 5 or 8 or 10 years ago. In other words, there is some risk in continuing to do CrossFit in the same way that I did in years past.

There is a flip side to this, of course. Prior to embarking on my Crossfit odyssey I would be incapacitated with back pain 2 or 3 times each year. Since January 2006 that has occurred precisely once, and that was because I deviated from standard-issue CrossFit to join a friend in his Oly workout while visiting. I am struggling to create a regular workout schedule since CrossFit Bingo/Comet CrossFit closed. Without question I am not as healthy as I was at this time last year.

Each of us is a study group of one, each with a personal risk/benefit ratio that can only be discovered by at the very least coming right up to the edge of “too much”. The more experience you have the more confidence you probably have in your own ability to determine where that is. Others can, and should, put the responsibility for charting that course in the hands of their CrossFit or other trainer. Once identified, though, it makes little sense to flirt with the flame of “too much” when there is so much to be gained from “enough”.

For me what that means is continuing to pursue at least the maintenance of my functional strength by continuing to follow the latest version of CFSB from The Brand X Method(R). I find that 2 high intensity WODs, 3 at the most, is what I can handle each week. As much as I hate to admit it, long brisk walks are becoming a staple of my fitness and health plan. I should probably ask Abbie the Wonder Dog to join me on those.

Nothing is completely safe; seeking yet another zero after zero after the decimal point before starting treatment means never starting. Once effective dosing is established, in medicine or in CrossFit, one must judiciously minimize risk, but not to the extent that the benefit cannot be achieved.

Better Understanding Conflict of Interest By Studying Bias

So much strum und drang in the air. So many panties in a bunch. The offensitive are on the warpath about, well, everything. We seem to have a surfeit of ethicists among us, proclaiming in nearly real time where anything and everything fits on some mythical ethics grid. To them I offer my own filter, the question I ask before I expend an iota of energy of any kind on the type of “news” that has them all so agitated:

Is what I am viewing unethical, or simply unseemly?

Ethics is a synonym for morals. As such it should be universal and timeless. Ethics should bear nothing in common with fashion.

Speaking of which, it is fashionable in pretty much any field in which expertise can be obtained and the label “expert” attained to lay waste to those so acclaimed by accusing them of having a “conflict of interest”. Traditionally this meant that one might enjoy some sort of tangible gain by trafficking in one’s area of expertise, thereby rendering the expert’s stated opinions somehow tainted. Of late it means that being employed by someone with whom your critic has a beef means your standing to hold an opinion at all is nullified.

Nonsense.

We would be a wiser society if we instead made an effort to sort through the biases held by experts in any field. To demand that one not express any opinion that would support your employ should disqualify the individual who holds such a position, not the expert. To look at the bias that may be present in any expert opinion allows the audience to better evaluate both the veracity of the opinion, as well as its relevance to their own situation. For example, in my day job I have a strong bias to treat any condition that produces meaningful symptoms in my patients.

In truth, in many of the general categories that I cover my remuneration is identical whether or not I treat. Those who bleat on about conflict of interest would seek to nullify all of my thoughts simply because I make my living in the arena on which I opine. Again, this is silly. It is far more useful to read my professional writing through the prism of my pro-treatment bias. In so doing it is far easier to compare and contrast my public opinions with others in my space who may differ. Do they differ on substance, or do they differ because or a countervailing bias?

This is not to say that conflicts of interest do not exist, or that if they do exist that they are never a problem. If you have invented a medical device and choose to use your own device rather than a competitor’s you have a COI. Disclosure of your COI should be mandatory (I disclose all consulting contracts around prescription drugs, for example). If they are of equal quality (equal safety, equivalent outcomes), the COI is mooted. If your device is much more expensive (thereby generating much more income to you), your conflict of interest is unseemly but not necessarily unethical. It should be obvious on its face that using your invention if it is less effective (or Heaven forbid, unsafe) is unethical.

Expertise exists everywhere. Here, on CrossFit.com in the fitness world. Would you disqualify Greg Glassman because CrossFit has been a successful business? How about Jeff and Mikki Martin who have launched a business in the same space? Is their competition a conflict that nullifies their contributions to youth fitness? Among the bureaucrats at the EPA in the care of the environment. Do they not have a contribution to make despite their tax-supported position? Is their (presumed) anti-business bias a reason to dismiss all federal policy? Among the various and sundry talking heads on all of the financial offerings on cable news channels. Don’t you really want them to be rich and successful, especially if you are going to follow their advice?

If we seek to understand the biases that exist underneath the opinions of experts we can better evaluate the conflicts of interest that they inevitably carry along with those opinions. From there is is an easier task to evaluate the character of those conflicts, and better decide whether or not we accept their guidance.

Getting paid to be an expert and to share your expertise is only a meaningful conflict of interest if it is unseemly or unethical, not just unfashionable.

 

Essential Tech? Really?

The author of an article in last week’s Sunday Times asserted that Google and Facebook are “essential tools.” Jonathan Taplin states that everyone has “no choice but to use them.”

Facebook as an essential tool. He really said that, presumably with a straight face and no irony intended.

The reality of the developed world is that search is indeed essential at some point in most lives. Google owns 90% of search traffic, but there are at least 3 other search engines that are adequate at worst, and likely comparable in terms of information acquisition (if not ad awareness) with Google. Facebook, on the other hand, is little more than a toy in the hands of its users, and likely a dangerous one at that. The nameless, faceless scientists behind the curtain in Oz…er, Facebook…want to get you there, keep you there, and control what you do there. Facebook (and its kissing cousin Instagram) is purposely addictive, and face it, the super-majority of what you may do there is far, far from essential.

It’s very helpful to be able to call up information at the touch of the finger (a sales guy answered a complex, archaic golf question for me yesterday in about 27 seconds). Quite frankly I’m at a loss to think of a single essential aspect of FB in daily life.

My dentist still puts out magazines to help me kill time in the office.

 

Difference of Opinion Now Equals Enemy?*

When did a difference of opinion become a de facto conflict? When did the evaluation of another come down to whether or not they hue to a fine line of agreement on a single, or a few, or G0d forbid every issue? When did this phenomenon then morph into one in which a difference of opinion then becomes the basis for labeling another ‘good’ or bad’?

Am I the only one who’s noticed this?

I’m not talking about a difference of opinion which is then followed by a concerted attack, one that forces you to identify the holder of the other opinion as ‘bad’, and enemy. There’s nothing new to see there. One only has so many cheeks to turn. Eventually you need to fight or flee an attack, but that’s not what I’m talking about.

On a personal, local, and national level we could once identify broad stroke issues on which we could generally base a level of agreement or disagreement, very few of which would be a ‘deal-breaker’ when it came to civil discourse. The first part of this, the existence of broad stroke issues, remains true. What is fundamentally different in my mind is how un-moveable many of us have become on ever more minute details as we drill down from the 30,000 foot view. All well and good, I suppose, to seek fidelity to an ever more granular level of agreement on whatever issue is at hand, especially in this age when we have ever greater ways in which to find and connect with people of a like mind.

What I don’t get is the subsequent labeling of any and all others as “bad”. Unworthy. Lesser in some way because they do not agree at every level with a particular–very particular–point of view. As I remember it the “80-20″ Rule pretty much applied to belief systems as well as business: if you shared 80% of your beliefs with another that was plenty good enough to allow a friendship, and certainly enough to inoculate against a conflict. Now? Seems like something more like the “980-20″ rule: only the smallest amount of the most trivial difference of opinion is permissible. Anything more than nuance between people and they’re going to the mattresses. Anything more than nuance and we’ve identified something other, something lesser, something to destroy.

What’s up with that?

You could say that anything other than full devotion to a cause or a concept or a worldview is not pragmatism but something more akin to weakness. An inferiority of spirit, perhaps. You could say that nothing other than full devotion to some grand theme or concept is acceptable and brook no deviation from a one, true path. I would say that the world is infinitely too complex to approach life in this manner. I would further say that to do so needlessly isolates you from people who might very well bring infinite joy to your life despite differential nuance or even a fundamental disagreement on one issue. Living and letting live rather than identifying a different opinion as identifying the other as an enemy might just mean a more pleasant life filled with more people who might be better described as friends, or at least friendly.

At the very least perhaps we could just agree to disagree and be on our way.

 

*Lest one think this is a reaction to the news of the day, originally written in April 2014.

“Chaos and Calm”: Father’s Day Sunday musings…

Sunday musings…

Chaos and calm. As far as I can see, and for as long as I’ve known, these are the only two states of being for a father.

To be sure, not all states of chaos are unpleasant, and there are innumerable degrees of calm. At the moment I am luxuriating in the calm of quiet, accompanied by only Tiny Tim and Abbie the Wonder Dog (both of whom have re-racked). A social creature, these moments of calm were once painfully lonely for me. Having rediscovered my “pen” they are now cherished little gifts, times during which I alternately “sits and thinks” and even “just sits”.

Father’s Day brings soft and warm memories of the other type of calm. Those times when I was with one or several of my children or my “extras” (thanks for the new vocabulary Dillie!). Memories of late summer 1988, coming home to “The Heir” in his infancy just in time to fall asleep with him swaddled and resting on my chest. Or tiny Barbie tea parties with “Lovely Daughter” in her “Megan-Loo Who” stage (from which she eventually acquired the nickname “Goobs”). There’s no yelling at a tea party, right? Lil’bingo and I would work on “construction projects” with his Tonka trucks that could last for hours. The best type of calm for a Dad isn’t lonely at all.

Chaos is just as much a double-edged sword. Man, why couldn’t there be a family frequent flyer program at the ER or the orthopedic surgeons’ office? Even chaos, though, is a net positive as a Dad. I find myself smiling as I remember all of the events we just barely got to on time, the “fire drill” leading up to our arrivals notwithstanding. The chaos of a house filled with toddlers, pre-teens, teens or young adults is filled with enough energy to light up a small city for a weekend. My sides are aching from the memories of the laughter.

Chaos and calm.

Father’s Day for me this year will be like every other Father’s Day since we welcomed “The Heir” so long ago. Unlike so many who use the day to do something like play golf or climb a mountain or some such, I will try to spend as many of my waking moments in the active pursuit of doing Dad stuff. Firing up the griddle this morning and making the bacon is so much more fun than breakfast in bed, the chaos of the Man Cub and the dogs and the timing of the delivery of our new grill (presents!) notwithstanding. I have always spent so, so much time away from my kids (and still so much away from my grandchildren) just doing the things that a breadwinner must do; on Father’s Day what I want more than anything is to be allowed to do Dad stuff as much I can. To be able to just be a Dad today is always my goal, always the best gift possible.

Chaos and calm. Happy Father’s Day to each of you lucky enough to enjoy both.

I’ll see you next week…

–bingo