Random Thoughts from a Restless Mind

It was the smile Ms. DMV Lady. No question, the smile told me that you chose to ruin my day when you had a lay-up chance to make my whole weekend, that you did it on purpose, and that it made you incredibly happy. In any other circumstances I’m sure I would have smiled back at you; that’s what other human beings tend to do when they see such unbridled joy on someone else’s face.

That trip back was my third one to the DMV, but there was no way for you to know that. You did see me on the second one, though, and you clearly remembered me. I forgot my license at home so I couldn’t do what I needed to do to transfer the title for my tiny little beater of a boat. Not only that, but there was nothing you could do to help me at that point, and I totally understood that. It was my fault entirely, so I didn’t ask anything of you on that visit because I knew that there was no way that you could help me, no matter how much you might have wanted to on that particular visit. I was really frustrated for sure, but I didn’t direct any of that at you, or anyone in the DMV.

Nope, it was the return visit where you could have made my day. My wife and I hurried home, got my ID and then hustled back. Did you notice that? Did you notice that we were both there? It’s really hard to free up two people who work full-time during your hours of operation. Definitely not your fault, that. We’d already tried to pull this off the week before and been thwarted, and here we were back for a second time with you, third time total. Now was your chance. We approached the desk with obvious relief on our faces. If we were successful this time we would still have to visit the DMV one more time (you only do titles; another location would do the license), but at least only one of us would need to take off work. You took the title transfer again–you looked at it in detail the first time and couldn’t possibly have missed this–and told us that the previous owner had filled it out incorrectly. He signed it in his name alone, instead of his name as “trustee”. That’s it; he forgot to put “trustee”.  You could have tipped us off before we went home for the license. You could have just noted it and let it pass. Nope. You said that we would have to bring it to him to fix before you could transfer the title.

We were equal parts dumbfounded and devastated, and it showed clearly on our faces. Here it was again, your chance to make our day. There was nothing nefarious about the prior owner’s mistake; it was a simple oversight in how he described the ownership. God, it was such an easy fix. It was right there, right in front of you for the taking. I held out my hands and pleaded softly and quietly for mercy. No disrespect toward you or your staff or your department, and no sense of entitlement or demand for action. A very simple request and a very quiet plea that we had acted in good faith. Your response? “You forgot your ID the first time, Sir.” I simply held out my ID and very softly said “but I went home and got it without saying anything, and here I am. Please, we’re really trying hard here and really could’t know.”

It’s a legal document was all you said. You had a duty to protect the State of Ohio, you said. It was then that I responded, still quite quietly mind you. I shared that the couple you had just chosen not to help were a doctor and a nurse. That we routinely put our family second as we care for patients in need. Nights, weekends…no matter. I asked if I could fill out your customer service survey, either on paper or online, explaining that I am evaluated on the care I provide and the experience that my patients have under my care. Oh my…the look on your face was priceless. Utter shock. Not once in your life, it seemed, had it ever occurred to you that it would be possible that you would be accountable to your customers. “We don’t have anything like that, Sir.”

Then came the smile.

Seldom have I witnessed such a pure, unadulterated expression of joy. You had chosen to ruin my day, and having succeeded you were not just pleased, you were infused with a visceral joy. It started in your eyes as realization crept in, and then it spread to every muscle in your face. Like I said above, it was the kind of smile that is almost always returned by another human being; we are wired to share such joy, after all. Alas, ’twas not to be for you and me. It was all I could do not to vomit on your threshold when you somehow found the strength to break through the grip of your ecstasy to wish me a nice day.

You will see me again, Ms. DMV Lady. Three times we’ve tried to get our little 1971 boat licensed, and it looks like we will need to make two more stops to accomplish that. It most certainly won’t be at your particular DMV location, though. Just thinking about that makes me nauseous all over again. No, you will see me again on my turf, as a patient. Karma, if nothing else, is imbued with a keen understanding of irony, a truly wicked sense of humor. In all likelihood it won’t really be me, personally. Even karma would find that too outlandish, an irony simply too delicious to believe. In reality you will need someone who does what I do, and you will need them in a manner and a sense that is identical to how I needed you.

I noticed that you are very nearsighted, and you have an inflammatory disease of your eyelids called blepharitis that often causes an acute type of particularly unsightly pinkeye (you are not my patient; this is not a HIPPA violation). Perhaps your son is getting married this weekend like mine. You didn’t know that, did you?  No, of course not. You broke your 3 year old glasses. Your prescription is out of date and you can’t just walk in to Lenscrafters and get a new pair, and your vision insurance only covers me. It would be a shame to have to wear broken glasses to enjoy this wonderful day. Or maybe that ugly, uncomfortable pinkeye bubbled up and there you are all red and gooey, two days before the whole fam damly shows up for the wedding. Nether one is truly an emergency, and failing to take care of either one right away will not cause you any harm whatsoever.

Let’s make it even more realistic. You know, like my return trip to your office. Let’s say it’s just before closing time, and the only way to get your glasses or your medicine is if a doctor gives the OK to see you right away. No matter what you see on the billboard, you won’t get an appointment at the Cleveland Clinic or UH. No, it will be a private doc like me. We always try to help. The Doc will know your story. How? Well, through our staff we always know the story because it always makes a difference. Would it have mattered to you that the reason I so desperately wanted that boat licensed was so that my son–the one getting married–could take his cousins and his friends out on his wedding weekend? We’ll never know; you didn’t ask.

There you will sit with your non-emergent problem that is only barely even urgent except for how much it means to you personally. Do you have any idea how easily the doctor and staff can slow-roll this even now, after you are in the office? They can follow protocols to the letter, check every preferred practice pattern box and follow every single insurance billing protocol, your chart and super bill as clean and proper as the illustration of a perfect boat title as you wait for your insurance to authorize your vision care visit, or pre-approve your expensive branded medication, and ruin your weekend.

In short, they could be you, ignoring the very real person with the very real need who stands before them asking for help. Or they can see you, hear you, and so easily choose to help you. Which, of course, is exactly what they would do. They will call the insurance company to get your Rx authorized, or they will give you samples of the medicine to carry you until you get pre-approval. Because you see, Ms. DMV Lady, that’s what every single one of us is supposed to do when we are on the other side of the desk from someone who needs our help and we are truly, safely, and easily in the position to choose to help them. It’s the decent thing that decent people do for others. When they can either make your day or ruin your day, it never crosses their mind that they even have a choice. It’s funny, when they know a little more about how meaningful it is to you that they helped, they really feel good about that.

Which is why after you have been helped, after you get what not only what you need but what you really want, you will be surrounded by people with the huge smiles of joy that come from doing the right thing. You’ll undoubtedly smile back.

Will you know why?

Any measurement of health must provide some sort of predictive value with regard to the likelihood that one will remain healthy. While the entire idea of screening tests is fraught with controversy–both false positives and false negatives bring with them real risks–there are still a number of health measurements in the realm of traditional medical care that have a proven value when trying to predict downstream adverse health events. The trick, of course, is to decide which ones matter, filter that group to come up with tests that are as close to universally available as possible, and then decide how much weight each particular test in the group of survivors should receive in the single cumulative metric that is then created. This measurement, call it “M”, will be one of the variables in our calculated health measurement.

Let’s start with the simplest of all medical inquiries, a medical history. More specifically, let’s include a brief family history in our calculation of M. While it is becoming increasingly easy to obtain a very accurate genetic profile that identifies very specific health risks, these genetic tests are both controversial and expensive. Until the very real societal issues of knowing your exact genome and the risks it includes have been worked out by both ethicists and elected government, we should take a simpler and more narrow approach and ask two very simple questions: Has anyone in your family died from heart disease? Has anyone in your family died from cancer? Equally simple follow-up questions (How young were they? What kind of cancer) would allow us to add risk (reduce M) or ignore the historical note since the disease is not hereditary.

From here we move to an equally spartan individual medical history. Again, just two questions in this part: Do you smoke? Do you drink alcohol? The negative effect of smoking on an individual’s health, both in the present and future tense, must be accounted for in any measurement of health. It weighs so heavily on what we know about future risks that we will see it as a negative integer in M. Too many studies to count exist pointing out the deleterious effect of excess alcohol consumption to count. One compelling study, The Eight Americas Study in PloS One, found alcoholism to be the single most powerful lifestyle variant after smoking when predicting the life expectancy of groups studied. A recently published study of Harvard men found that alcoholism was the greatest second greatest influence on the happiness of the men studied, just behind the presence of loving friendships. Unlike smoking, however, there is a volume component to alcohol consumption. Indeed, a modest intake actually INCREASES longevity, while no intake DECREASES longevity. So M will see a small bump from moderated alcohol intake, an equally small decrease for teetotalers, and a dramatic negative effect from heavy alcohol intake.

So far we’ve managed to obtain some variables underlying M through the use of simple inquiry, costing only the time it takes a subject to fill out a questionnaire. At least two other variables are as accessible and inexpensive: blood pressure (BP) and a measurement of body habits. Once upon a time you had to visit a doctor or hospital to get your blood pressure checked. Now? Heck, for $20 you can buy a reasonable accurate BP monitor and take your BP at home! Minute Clinics in pharmacies, health clinics in the workplace, and coin-operated machines in the local Mall now make it easy to get a BP without visiting a doctor. While there is ongoing controversy in the medical world about what constitutes Hypertension it is safe to say that health risks are higher with a systolic pressure >140 and a diastolic >90. Above or below these levels is our toggle for M, positive or more healthy for lower and the opposite for higher BP.

Using body habitus is controversial, mostly because the measurement that is routinely utilized is so inadequate. The Body Mass Index, or BMI, is wildly inaccurate when it is applied to the fit. 4-time winner of the CrossFit Games Rich Froning, arguably the fittest man on the planet, would be deemed obese at 5′ 10″ and roughly 195 pounds with a % body weight fat of around 4%. Ridiculous, huh? The temptation, of course, is to use % BW fat as the preferred method of measuring body composition risk, but measurements that are accurate enough to be useful tend to be very expensive and difficult to access. On the other hand, all you need to determine the waist/hip ratio is an 89 cent paper tape measure and a calculator. A waist/hip ratio of >1.0 is associated with an increased risk to health from myriad metabolic illnesses including diabetes and heart disease, especially in men. Greater health in M for measurements under 1.0, and progressively less as that number increases.

It is impossible to utilize all that modern medicine has to offer when it comes to measuring health without spending a little bit of money. Several simple blood tests can be obtained with or without the input of a physician. The presence or control of diabetes can be ascertained with a HbA1c and a fasting glucose level. In the presence of a normal HbA1c an elevated fasting glucose may indicate a problem with insulin sensitivity, so it is important to include both. While it is far from settled whether or not it is cholesterol itself which is responsible for heart disease there is simply too much evidence that serum lipids can help predict cardiac events to leave them out of any health measurement. Our basic health index should therefore include the basic measurement of total cholesterol, HDL, LDL, and triglycerides, and M should reflect the negative effect of elevated Total Cholesterol, LDL and triglycerides and the positive effect of a high HDL.

How should we put all of these together to come up with our traditional health variable, M? This one is fairly simple; there are a number of “risk factor” measurements online that are good models. I envision a rather simple form on which one would add up weighted values for the measurements above, arriving at a straight forward mathematical sum. The final formula is being developed with the assistance of cardiologists at my medical school alma mater, the University of Vermont.

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.

We are starting to see some turnover among the OG CrossFit Affiliate owners. Some, like Skip, were in literally on the ground floor, and a successful Box rode them into the sunset (enjoy your retirement!). Others, like Steve and Kelly, have nearly 10 years into ownership as they approach both mid-career and mid-life. They turn over a highly successful business and take on the role of “Founder” (can’t wait to see what’s next for you!). Some owners have left the CrossFit fold and changed the name and structure of their gyms. There have certainly been some closings, typically folks who either didn’t really know what it was they were getting in to, or found that being the owner of a job is more than they bargained for.

As such, the successful CrossFit Affiliate is much like every other small business where the owner is also operator. My day job is like that: if I don’t show up for work no revenue is generated. A huge percentage of small businesses run just like this. What you own is not so much a business as it is owning your own job.

With all of the talk of exercise as medicine lately, it’s interesting to compare and contrast the megatrends at work in the fitness industry and medicine when it comes to practitioners. In medicine we are in the midst of what is nothing short of a diaspora with physicians leaving the private practice of medicine for employment in ever-larger organizations. It should be noted that this phenomenon is in direct response to government action. Men and women who once owned their job, with all of the responsibilities (payroll, rent, etc.) and freedoms (hours of operation, client experience, etc) now work is settings where process and protocol is dictated to them, and fidelity to the organization has primacy.

Thanks to CrossFit and the CrossFit Affiliate model, the megatrend in fitness is exactly the opposite. Trainers have been unleashed from the corporate environment where salesmanship is the most highly regarded skill, and put in charge of a job where outcomes drive the business. Affiliate owners are the new private practitioners of fitness, in charge of everything from programming to toilet paper.

A certain tension has always existed between large medical organizations and smaller private practices. It should come as no surprise that similar tensions exist between CrossFit and its Affiliates and large fitness businesses and their partners. Large organizations crave control and abhor independent competition. Indeed, for those behemoths the only thing worse than independent competitors is being shown up by them. You know, like getting better surgical outcomes or having clients who look like the crowd at the Games. Large organizations often turn to government to suppress this type of competition and make the megatrends flow their way.

There are several important points to be made from this comparison. First, of course, is that every Affiliate owner and every member at every Box should fight alongside HQ is this battle. Trainers get better with more experience, not with more certificates.
Trainers who own their jobs also own not only their outcomes but everything about the experience of their clients. Just like a private physician. I’m biased, of course, but this is well worth fighting for.

For those fortunate enough to train people for a living the reality is that you don’t, and likely never will, own a business. There are very few large CrossFit businesses. For every CrossFit NYC or CrossFit Eado there are 3 or 4 hundred boxes run primarily by the owner. What you own is your own job. You’ll need initiative, passion, and resilience. A thick skin is helpful, too, because you’ll get plenty of feedback on that job. With a little luck you, too, may one day leave behind something significant enough that there is someone there to carry on when you leave.

There’s some turnover in Affiliates. At the moment nothing like a trend exists. Owning your own job is not for the faint of heart, and some will find it not their cup of tea. Others, like the OG’s above, will leave for that next thing on the horizon. What mattered is that they had the opportunity to own a job and took it, creating something that will live after they have gone.

The best boss is the client (or patient) who chooses you. The chance to work for them is worth fighting for.

I’ll see you next week…

Sometimes someone says something so profound and says it so profoundly well it’s best to simply share what they said and get out of the way. This is one of those times. This gem appeared in the WSJ letters to the editor 7/10/15:

“The philosophic underpinning of the conflict-of-interest mania in medicine is the assumption that every physician is a spineless, deceitful, money-grubbing felon-to-be. The conflict-of-interest mafia stifles innovation and restricts creative thinking.

The New England Journal of Medicine would never have published the Hippocratic Oath if it ever found out that Mel, the local herb salesman on the Island of Kos, once bought Hippocrates a flagon of wine on a hot summer day.” –Leo A. Gordon M.D. Los Angeles

That, friends and colleagues, is brilliant.

It was the missed workouts that finally got me. That, and the fact that I was not getting to the gym after surgery because I had to RE-DO orders I’d already entered. That caused me to crack. Why I was missing workouts.

Computer Physician Order Entry went live in December at one of the surgery centers where I operate. As is my lifelong pattern, once I decided that I would remain “in the game” at that particular center I simply viewed CPOE as a new set of rules to learn, a new challenge to conquer (however involuntarily), a new game to win. Maybe it’s my first-born status, or perhaps just the result of an upbringing where everything was a contest to be won, but I learned the ins and outs of the system in less than a month. My office staff, the surgery center staff, and I then went about the task of generating a process that would minimize the depth of the “time sink” into which CPOE had tossed me. On days when I was only operating out of one OR I was only down about 2:00 for every laser done and pretty much dormie on the rest of the cases because I could enter orders during pre-existing “dead air” time.

A funny thing happened on the way to happily ever after: patients we knew were scheduled were failing to show up on the OR schedule in time for me to enter their orders, and orders I’d entered started to turn up missing. That’s right…I had sucked it up, learned the system and taken my paddling like a good plebe, and the system insisted on inflicting this random form of unearned pain. The first time it happened I just re-did the orders. The second time I went off. My “Doc Whisperer” watched me put in every order for this coming week, documenting my status as a quick and accurate little Dr. Lemming. Patient lists and screen shots document my every order. All of this is to no avail. Once again, orders I placed for cases to be done tomorrow do not exist in any part of the Epic wasteland that is the EMR at World Class Hospital.

Is anybody paying attention to this? Does anybody care?!

Not only have I been forced to take time out of my day to do something I did not need to do previously, to perform acts of documentation that once took me a fraction of the time it now takes electronically, but these impositions are now compounded by the fact that work I’ve done is nowhere to be found. Lost in the ether, in a world that no longer even uses ether. This is maddening. Is there even a “Happy enough, ever after” with EMR?

Sadly, I’m afraid this is to be continued…

With the launch of SkyVision Centers 10 years ago I entered the era of EMR. Our group was certainly an early adopter, but since we had chosen this path so early we were able to make our own determinations about what we valued in the technology, and what we would not be willing to give up or compromise in order to have EMR. Our choice of platforms was one that expressly sought to enhance the efficiency of a busy specialist, while at the same time allowing us to hold on to a very personal approach to the doctor/patient interaction. That experience has informed my reaction to all subsequent encounters I have had with other EMR’s, government regulations, and the like. The launch of  Epic CPOE at my World Class Hospital ASC was just the latest example.

A tip of the hat and heartfelt thanks to the folks at the ASC who took such a personal interest in my experience. To my surprise and near delight, the CPOE intrusion in the OR during cataract surgery (in a single room) was negligible. There’s a lesson here for implementing EMR changes: do your homework. The reason my day went so smoothly in the OR is that the people who were thinking about me spent the time necessary to head off problems BEFORE I showed up that day. Two sessions with me, both of which occurred AFTER examining my pre-CPOE processes and paperwork, helped to head off predictable and preventable frustrations.

Having said that, a pox on the houses of all who created the tragedy that is the post 2008 EMR. That means both the government “know-betters” who shower all of us in the trenches with dictums on how it’s supposed to be, as well as the EMR software engineers and execs. Never mind that not a one of them could possibly have ever manned a bedpan, let alone a needle-driver, the arrogance of simply declaring what should be without looking at what is continues to be appalling. To a person every single one of my patients complained about being ignored by the ASC staff on CPOE Day One. Heck, there was literally no way for me to position my Pig, “Babe”, so that I could have eye contact with my patients when they entered the laser room; I was just like every other physician lemming with his eyes glued to a screen when they walked in. I at least have 10 years of goodwill built up with my patients so that I might be forgiven for the insult delivered by Epic.

While I’m at it, can we talk about the arrogance of the programming…ahem…experts, the Cave Dwellers at World Class Hospital? Do they work for Epic, World Class Hospital, or some outside agency? I asked for an order set for a particular type of procedure, one that would more exactly represent what and how we do it at our ASC. I was told in no uncertain terms that the Cave Dwellers had already declared that they had done more than enough for me and us, and that I should feel very lucky that they did as much as they had. Seriously. Never mind that my request would have saved me time, saved the staff time, and made for a better experience for the patient. The Cave Dwellers had spoken. These people have as much power to inflict unnecessary pain on productive folks like doctors and nurses as the pharmacists at World Class Hospital (remember a brand new bottle of eyedrops for every patient for every laser to avoid infections that had never happened in the history of laser surgery?). Here’s hoping one of the Cave Dwellers doesn’t recognize some very important name and drops that same load of attitude on that Very Important Person. Kinda makes a lie of the whole “support” part of “tech support”. This is fixable, by the way, if anyone’s listening, especially if they work for World Class Hospital.

In the end there remain two very critical problems with CPOE in general, and EMRs of the Epic ilk in particular. The first and most problematic is that at their heart they are not medical records at all, they are billing and compliance systems. The primary customer is not the physician or the patient but an accountant, and the outcome that is maximized is not a medical outcome but a financial one. These systems will always be a time suck for both doctor and patient (and nurse, and receptionist, and…), and with that will come an inevitable happiness suck. I had a full hour stolen from my day; this isn’t going to get any better. Every one of my patients had an unsatisfactory experience as ASC staff paid more attention to their Pigs than to my patients; this isn’t going to get any better, either.

The second issue reflects the end of my first day with “Babe” and it is the only issue that could possibly get better: computers and software of any sort are only as good as the people using them. Despite all of our planning, all of the preparation that happened before I arrived at the ASC, everything came to a screeching halt when I tried to plug in my orders for next week. The poor woman whose job it was to enter the patients into the system was simply overwhelmed with work. On top of her regular job and her regular duties she was now not only responsible for the additional task of putting patients into the Pig Pen, but she also had a very hard deadline to beat. At the moment of truth it was her failure, but just as it isn’t the waitress who is at fault when she delivers the overcooked steak, neither was it the poor clerk’s fault that I sat and stewed while she completed her task under the baleful glare of her boss. Just as it is the chef who is at fault for the burnt steak, so too is it the fault of management upstream for failing to give a frontline worker the time necessary to feed the Pigs.

Here, at last, is hope. Faint hope, but hope nonetheless. Someone, somewhere in the chain of command at World Class Hospital may realize that they can make this whole CPOE mess a little bit better for at least some of the folks who are affected by it. It won’t be me, or anyone like me; it’s clear that physicians are just interchangeable cogs in this machine–the noisy ones will be replaced. It surely won’t be patients; that ship left port way before Epic arrived, no matter how many ads World Class Hospital takes out declaring fealty to “patient-centered care”. My hope, and my new crusade, is that the non-physicians on the front line who are taking a beating from this will be acknowledged and given the resources necessary to NOT be the fly in the oink-ment (couldn’t resist). They don’t deserve to end up in the crosshairs of a doc looking for a place to put his unhappiness.

Now, the Cave Dwellers on the other hand…

It’s my own fault, really. I admit that I had allowed myself to believe that the uneasy peace I’d made with Epic, the EMR utilized at World Class Hospital, would be a lasting one. A peace for all time. I would interact with the beast on a quarterly basis, signing verbal orders that kindly nurses had accepted and op notes for surgeries that deviated just enough from the routine that they needed to be dictated fresh. In return I would be allowed to simply sign orders, op notes, and other sundry paperwork as I had been doing for the last 24 years. Simple. Everyone wins. My OR days run efficiently saving me, my patients, and the institution countless hours of wasted time, and I continue to bring the majority of my cases to one of the outpatient surgery centers owned by World Class Hospital. (It should be noted that I am the lowest cost eye surgeon in the entire system, thereby generating the greatest per/case profit for WCH). I truly believed that I would still find sanctuary in the OR from the thousands of chickens pecking away at my professional satisfaction and by extension my general degree of happiness.

BzzzzzzPfffffTttttt…sorry Doc, that’s the wrong answer. Johnny, tell our contestant about his lovely parting gifts.

For the first 16 or so years of my post-residency career literally every process change in which I’ve been involved has had a direct, positive effect on outcomes or safety, patient experience, or my efficiency. About 8 years ago tiny little negative things started to creep in, some of which chipped away at that efficiency. A few more forms to sign. More pre-op checkpoints for my patients to pass on their way to the OR. Along with this came the madness that arises when a huge organization plays defense against an unregulated regulator like CMS (medicare) or JCHO (the hospital regulator). Not one, not two, but three personal checks by the surgeon to confirm the surgical site. A pharmacy either running scared or run amok that demanded a brand new bottle of eye drops for every laser patient despite an industry-wide infection rate on lasers of 0.00000001%. It was mostly piddly-diddly stuff, and the OR staff did their very best to run interference and preserve our efficiency.

Now? Oh man. The introduction of the Epic EMR into the OR has turned our 2-nurse room into a 2.5-3 nurse set-up. There is so much dropping down and clicking necessary to fulfill the beast’s demands (man, would this analogy be perfect if they still let us call them Computers On Wheels?! Feed the COW!). Previously, one circulator could do all of the paperwork, prep the patient, and have time to spare to facilitate room turnover. Admittedly I move pretty quickly as I do cataract surgery, but it’s impossible for just one person to do all of these tasks now that Epic must be served, without all of the rest of us sitting on our hands and waiting. The local administration and the staff have rallied around me and my patients and for most cases an extra pair of hands is there to keep things moving. Heck, I do my part as well by taking the trash out of the room and bringing the used instruments back to the sterilization room.

With the introduction and implementation of CPOE (Computerized Physician Order Entry) all of our efforts to improve efficiency, with all of the wonderful things efficiency brings, will be for naught.

How can I possibly know this before experiencing it even once? People talk, and doctors are people. I’ve chatted with a score of surgeons about how long it takes for them to do what Epic and World Class Hospital requires of them, and I’ve got a bit of experience just signing stuff after the fact. It just simply takes a lot of time. Add to that an institutional indifference to the psychological effect of hoovering  time out of a surgeon’s day and you’ve created the world’s biggest, most frightening chicken peck.

Tell you what, let me share a few numbers with you before we make the switch, memorializing them here, dated, before the transition, so that there’s no possibility that I made stuff up after the fact. The baseline numbers I am about to share admittedly are rosy in part because everything that can be done to/with the paperwork by someone NOT me happens as part of well-established routine. Details such as start/stop times, IOL serial numbers, etc. are filled in by support staff; there is little to no chance that this will be the case when everything moves from paper to screen judging by other surgeon’s experiences.

95+% of my cases are either cataract surgeries, post-cataract lasers, or lasers to treat dangerously narrow anterior chamber angles. Through a combination of fortunate genetics and hard work I have become very good, and very fast, at all of these procedures. My team and I achieve enviable outcomes and microscopic complication rates despite the fact that we move very, very quickly. A patient having cataract surgery spends approximately 15 minutes in the OR. For comparison sake, a study from a prestigious eye hospital recently posted an average time in room of ~33 minutes for its top three cataract surgeons. Turn-over time (patient out/next patient in) is 6-7 minutes. On average it takes me 26 seconds to complete ALL of the paperwork that must be done in the OR. It takes another 9 seconds to sign the op note when it is returned from transcription; this is important because Epic will require either finding, editing, and signing an op note in the OR, or dictating one on the spot.

Our team of nurses and doctor has achieved an even more enviable efficiency when doing lasers. The average time it takes for a patient to have the entire laser experience–enter the laserium, be seated at the laser, have the laser successfully performed, and leave the room–is 3 minutes. That is not a typo. The average set-up in the United States is closer to 15 minutes or more for this procedure. At the conclusion of the laser it takes me on average of 17 seconds to complete all of the paperwork that is required, and again 9 seconds on average to sign the op note when it becomes available.

You’re probably thinking why this is a big deal, aren’t you? That I should stop whining and just get on with it. Here’s the rub: I do lots of these procedures each time I go to the OR. Any additional clerical time must be multiplied by the number of cases done that day, and all of that time will be stolen from my day. When I finish in the OR I then do other stuff that’s pretty important. Sometimes I go back to the office and see patients, patients who may have had to wait a long time for their appointment. On really good days I get to go to my beloved CrossFit gym to get a workout in. An even better day is one on which I get my WOD in and then sit down in front of the computer to write. These latter things, especially, make me happy. They make it worthwhile to work as hard as I do. Every extra minute it takes me to do something I already have to do not only brings frustration in the OR itself but also keeps me from parts of my life that bring me happiness. A happier doctor is generally a more effective doctor.

We are establishing a baseline today, and that baseline includes a certain degree of happiness. What do you think the chances are that CPOE will increase my happiness? Stay tuned for Part II.

“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”.