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Dr. Darrell White's Personal Blog

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Posts Tagged ‘wsj’

Optimization vs. Diminishing Returns

Some time ago I wrote about the Minimum Effective Dose (MED), the concept in which we seek to optimize our results with the smallest amount of whatever it is that we are using to achieve that outcome. The quest to find the MED is one that crosses quite easily between my day job (medical) and my own quest for health (CrossFit). A quick mention of Eva T in Outside magazine and the program she uses with her clients made me think a bit more on the MED. The Everyday Math column in the WSJ provided an enhanced vocabulary for the journey.

Sometimes the MED really is a “something” you take. Here one thinks of medicine or food, for example. More often is the case that we are looking at a dose of time or effort. Or perhaps both. In this case we are seeking to optimize the effort as it relates to the outcome, to make the value of outcome divided by effort as large as possible. The rate limiting factor here is the Law of Diminishing Returns, of course: at some point additional effort produces such a small incremental increase in the outcome that it becomes not worth making. This applies to everything from WODs/week (or day) to decorating a birthday cake. At a certain point you just have to feel you’ve succeeded.

How, then, to know when you have reached this optimal level? Eugenia Cheng, the mathematician who wrote the WSJ piece, offers the concept of the “minimal acceptable standard”. Once she has reached this outcome the additional effects garnered from more effort have moved beyond the point where Diminishing Returns kicks in and she simply accepts the outcome. We would call these “minimal standards” goals, but the concept is essentially the same. We want an outcome; setting a target or a goal is step one in optimization.

Cheng then goes on to refine optimization with a discussion about boundaries. One is your goal, of course. In real life others also exist, things like a 24 hour day and a 7 day week and the need to make a living. The dose you choose, both qualitatively (what it is) and quantitatively (how much you get) is unavoidably affected by boundary conditions over which you have less control.In the end no outcome worth getting happens without effort. Health, friendship, or the unraveling of a gnarly math problem–you’re going to put effort in to get your results out.

Maximizing your outcome-to-effort ratio is just another way to say you are seeking your Minimum Effective Dose, in CrossFit and elsewhere.

Is There an Optimal Age?

Last week I got a bit sidetracked with the main focus of Sunday musings. Nuclear attacks will do that to a body. I’d run across an article on WSJ.com in which a fascinating hypothetical was proposed: If you could stop the aging process at a particular point in time, at what age would you do that? At what age do you feel that you are close enough to your physical peak that you are comfortable balancing that against your intellectual capacities and maturity? Great question, that.

My physical fitness has been slipping for at least several years. Despite this I remain generally stronger than I was at any time other than my years as a college football player. When did I peak? At what time was my overall physical fitness, when my capabilities across the 10 general characteristics of fitness at its highest level? Although I didn’t know it at the time I probably peaked somewhere in medical school. My buddies and I managed to cram in marathon hoops sessions, round robin squash fests, and an admittedly conflict of interest laden exploration of 1980′s aerobics classes (most of my friends were single) while we finished up school. I supplemented this with pretty standard issue weight training (Mrs. bingo like lifting, even back then). Make that peak age 25 or 26.

Believe it or not, from there the slow age and career inflicted decline began in earnest. Had it not been for that Men’s Journal article in December 2005 I’d likely be a typical 58 year old desk jockey, broken by my job and the various and sundry weekend warrior injuries I would have doubtless suffered. Ah, but this CrossFit thing not only saved me from that but also gave me another peak somewhere around age 48. To be truthful I’m back on the descent now, but at least summited another (slightly lower) peak before starting the slide.

How about the other half of the equation? The part where you have a certain amount of intelligence, experience, and maturity? Well, for sure I was whip smart at 26. Every doctor is simply brilliant on med school graduation day; we have no idea what we don’t know, and no idea how to actually be a doctor, but hey, we just crammed for 4 straight years and our brains are busting at the seems with, you know, smart stuff. You know where this part is going, of course. At 26 I’d yet to acquire the maturity and experience that is necessary to create what I’d like to call “actionable intellect”. Such a thing could also be called “judgment”, and in short the ingredients you add to the mix are mileage and the accumulated humility that one acquires “on the road”. Like every other 26 year old I was pretty sure I knew it all already, but we all know how much longer the story is at that point, don’t we.

So it must be age 48 then. Another physical peak achieved. lost of miles under my belt including the humility of a struggling business and the grounding effect of nearly losing a child. Must be 48, right? Well, to be quite honest, I would really love to return to age 48 in a physical sense. My 58 year old bones are more than weary, and I’ll admit right now that I’m slow-rolling writing this because I’m dreading the WOD that’s gonna happen right after I hit “comment”. A funny thing happened on the way to my “final answer” though: I realized that my non-physical growth over the last 10 years has been extraordinary.

It’s not that you have to forgo all of the wonderful things in life at your chosen “stop age”, but the proposal in the exercise is to choose an intersection where the combined peaks were some kind of best. The truth is that my non-physical fitness has continued to grow at a rate which is far, far greater than the rate at which my physical prowess has declined. I have learned, and become so much better at things like empathy, acceptance, caring and the like that there are times that I wonder how anyone ever put up with my younger version. 10 more years of loving and being loved by Mrs. bingo. Of learning how to continue to love other people in my life despite their (or my) faults.

And joy. Oh my, learning that there is joy to be had out there if you can spend just a moment and let it come to you. My little Man Cub has taught me that. At 48 I really had no idea just how much joy there could be. No, for me at least I don’t think I’ve hit that magical intersection of mental growth and physical decline at which I can say I’m at the optimal point. So it’s off to the gym for me so that I can stave off decrepitude just a little bit longer, to give myself a chance to enjoy whatever non-physical growth I have in me yet.

The Man Cub is bringing his family over to play later on and I’ve gotta be ready.


When We Will Exclaim a Person of Substance

My life is centered around, and centered by, the myriad women with whom I share airspace. There are certainly men there, too, and I am certainly fortunate in that my immediate world does not include anything like what other folks would consider a boss. While most of the women in my daily professional life are either employed by me directly, or employed by someone who has in some way contracted to assist me, the reality of my daily existence is that I have a symbiotic relationship with teammates who happen to be women, and we depend on one another every waking moment.

Because of this I have become alert to all kinds of slights leveled at women in general, and women who work in healthcare in particular. Frankly my worldview is really pretty restricted when it comes to the workplace, especially since the family Box closed a couple of years ago. In healthcare the hierarchy/patriarchy has historical sheltered bad behavior directed at women from both view and recourse. Is it changing in this volatile world that has emerged these last few weeks? That’s not really for me to say, of course; all I can do is whatever is in my means to provide an environment that respects a gender-neutral environment and chain of command whenever I have the privilege of setting the tone.

What is very interesting to me, and what I find to be a very positive (if tardy) side effect of the recent “outing” of men in power who have abused that power, is the celebration of thoughtful women whose thoughtfulness might not have been quite as well-known before. Again, it goes without saying that this should not be something that is remarkable in the least, but for the sake of this particular musing perhaps we can simply acknowledge and agree upon that, and spend our time thinking about what it is that these women are saying.

Reese Witherspoon comes instantly to mind, of course. Ms. Witherspoon has forcefully said that SOP in Hollywood is no longer even a little bit OK when it comes to opportunity to control the spoils of the industry. Not content to simply raise the issue she has literally put her money on the line along with that of like-minded individuals and begun to create those opportunities. Ms. Witherspoon has much to say that is worth hearing. One could do worse than the recent WSJ Magazine cover article as a jumping off point to begin your listen.

It’s highly unlikely that there is any woman in the world about whom more electrons have been circulating of late than the actress Meghan Markle. There’s not a rock big enough for you to have crawled under in the developed world for you to be unaware that she has recently been betrothed to an heir to the British throne. While Ms. Markle and her beau are, indeed, impossibly cute together, it’s more than a bit of a shame that it has taken her very public romance for the non-People reading public to discover her, her story, and her intellect. This is a person of substance.

Hopefully Ms. Markle will forgive me for I will certainly get some of details wrong (as usual I am writing without notes). She is the daughter of a caucasian father and an African-American mother, and she has been on the receiving end of various forms of discrimination from a very young age because of that. She tells a story of being forced to declare in school that she is one or the other, Black or White. To check a box because, well, that’s what is done. She declined. Maybe she was 12. She opted not to opt. I don’t know how long it’s been since you’ve been in school, or had a child in school, but that’s a rather gutsy move.

She went home and asked her Dad why. Why should she have to choose? His response informs her message today: draw your own box. Man or woman, if the choices that are presented to you do not include the right choice, draw your own box to check. Ms. Markle tells the story so much better than I, but I am happy to pass it on with a further encouragement that you should go look for her telling this story, and while you are at it there is a wonderful clip of her accepting an award for her advocacy on behalf of empowering women. She is universally described by anyone who has listened to her as a woman of substance.

My hope, and my goal in writing this today, is that the term “woman of substance” will one day be replaced (as I did above) for both men and women with “person of substance”. Substantive ideas matter, and they ought to matter irrespective of whatever labeling might be applied to the holder of those ideas. While they may not have the name recognition of Ms. Witherspoon or Ms. Markle, I am surrounded by women of substance whose ideas bear our listening. My wife and my daughter, my sisters and my mother, my daughters- and sisters-in-law, as well as the extraordinary women with whom I’ve worked in healthcare and met through CrossFit, give me confidence that this can be.

Not today, not yet, not soon enough but soon, for the benefit and betterment of all.


Sunday musings 11/26/17, Rigged in Your Favor

Sunday musings…

1) Capulet. Juliet’s last name. No reason; just seems like a cool thing to know.

2) Apokalypsis. Ancient Greek for uncovering or unveiling. I’m not exactly sure why, but this particular derivation of “apocalypse” seems all too appropriate for the last couple of months, eh?

3) Lifetime. After a bit of time I recently tried to access an online place to which I’d once been given a lifetime subscription. It’s one that I used to look at very frequently;my user name and password never changed. I discovered a different sign-in format, one that did not even accept the form of sign-in I’d been accustomed to. “Lifetime” in this case had nothing to do with my longevity, but rather the employment lifetime of the gifter, or the lifetime of institutional awareness of my being.

It leaves one to ponder: how many lifetimes do we have, and what is it that brings any particular lifetime to an end?

4) Babar. I have a thing for watching the end of a series. TV, movies, a particular character in an author’s books. I seem drawn to them even if I had little to no engagement with them over the course of their long or short lifetimes. Just the tiniest bit of introspection leads me to M*A*S*H, a beloved television series that I actually did watch quite religiously. I’m pretty sure that the final episode of M*A*S*H was the first finale I consciously watched as such (thanks again for hosting us all Evan Tabor!).

What’s funny is that I have gone out of my way to put the series finale of shows that I pretty much never watched on my calendar with the same amount of “gotta see it” as those few that I never missed. “St. Elsewhere” was just as much of a must-see as “Hill Street Blues”, for example. Even more interesting–maybe sillier is a better word–I find myself with the same type of nostalgic yearning at the loss for both. Weird.

So it is as I discover that the beloved children’s character “Babar” has made his swan song. With the publication of “Babar’s Guide to Paris” author and artist Laurent de Brunhoff signs off and Babar takes a final bow. There is no heir, and the character is not meant to have any further adventures. After finishing the WSJ interview I know that I will read this book despite the fact that I have read (or been read to) only the original story (written by Laurent’s father Jean) and not a single intervening edition. As avid collectors of children’s books and enthusiastic readers to our children and now grandchildren, this is even more striking.

Why this book, and why now? Well, I have to admit that I’m a sucker for sentiment, and this quote makes it a slam dunk: “I never really think of children when I do my books. Babar was my friend and I invented stories with him, but not with kids in the corner of my mind. I write for myself.”

Who wouldn’t want to spend a few pages with a 92 year old and his friend of some 70 years as they explore the City of Lights together one last time.

5) Rigged. “Live life as if everything is rigged in your favor.” –The Persian poet Rumi (as told by Neda Shamie)

Have you ever heard a more lovely description of optimism? What a smashing way to approach life! In the past I’ve written that one should assume that each endeavor will be a success, that this simple assumption does, indeed, increase the odds that it will happen. So often we hear from people that the game is rigged. Heck, I’m gonna go out on a limb and say that every single one of us has felt this at least once in our lifetimes. We all know people who have simply given up on all but sustenance, so completely do they believe that any effort at advancement will be thwarted in a game that is rigged.

But it isn’t.

At least it isn’t if what we aspire to is simply taking that next step up. Sure, if your only definition of “winning the game” is to have Gates/Soros/Koch kind of money, the game is surely not set up for you to succeed. In reality, success (see “Gratitude = Success”) and happiness do not require such an outsized outcome. Therein lies the brilliance of Rumi’s insight. If everything is “rigged in your favor”, if all of your “ducks are in a line” and the deck is stacked for you, why NOT take that opportunity and turn it into your next success? You could certainly accuse me of being a pollyanna here, but heck, doesn’t it feel better to look forward with hope than otherwise?

The game of life is here, today, just waiting for you and me to play a winning hand.

I’ll see you next week…


“Lift”, Fitness, and the CrossFit Games

Here we are, a couple of weeks away from the CrossFit Games. Getting pretty exciting, huh? Sadly, once again, due to an illness in my extended family, I will not be able to attend the Games in person this year. Last year turned out to be our last with my Dad. This year we are spending as much time as we can with Beth’s Dad. No need to feel sorry for me, though. I think I’ve made it to 8 of the Games, each time as a guest of Greg Glassman who is a most gracious host. I’ll  surf over to the Games site and check out all the different ways to watch our annual extravaganza from home. Maybe this is the event that finally pushes me to get that new, “big ass” TV I’ve been planning to buy for…oh…3 years now.

Tuesday’s Wall Street Journal has a book review on “Lift” by Daniel Kunitz, a history of fitness. According to the review, Kunitz is very complimentary of CrossFit and Coach Glassman. Interestingly, the author of the review is a gentleman named Michael Shermer. His personal fitness journey sounds remarkably like that of so many of us in the CrossFit community. Indeed, he even references both “What is Fitness?” and the Ten Essential Characteristics of Fitness. Shermer’s discussion of fitness, sport, and training brought me back to thoughts I have had about fitness as sport.

There is a tension that exists between CrossFit, the strength and conditioning program and CrossFit, the Sport of Fitness.This tension is usually expressed in the guise of criticism of various versions of CrossFit programming. What’s very interesting is the lack of tension on this topic among the truly elite CrossFit athletes. If you look at their programming it looks like they are training to become…wait for it…really good at CrossFit.

Weird, huh?

What does that mean, anyway? Good at CrossFit? Follow Mr. Kunitz’s lead. This is a perfect time for you to both re-read the seminal article “What is Fitness” in CFJ #2 and to recommend it to anyone who is either curious or unsure as to what constitutes CrossFit, and for the sake of this musings, CrossFit programming.

CrossFit is the pursuit of a broad, inclusive general fitness where fitness is defined as work capacity across broad time and modal domains. In the vernacular, CrossFit trains and tests us to move larger loads further over a longer period of time. In order to do this Coach Glassman has identified 10 Essential characteristics of Fitness as so defined and noted in the book review, each of which needs to be equally expressed. Cardiovascular/Respiratory endurance; stamina; strength; flexibility; power; speed; coordination; agility; balance; accuracy.

Fitness as defined by CrossFit and Greg Glassman includes a precisely balanced degree of each of these 10 elements, with no one element being more of less important than any other. The CrossFit Games, and the athletes who take part, are simply an expression of the farthest right side reaches of the fitness Bell Curve. Look carefully and you will see that the events ask for equal competence in all 10 Elements; the athletes are simply better than the rest of us across the board. They get there because they do more work on all of the 10 Essential Elements.

While we here, and most folks in CrossFit Affiliate gyms, can assume agreement on the benefits of seeking Fitness as defined by CrossFit, this is not to say that either our definition of fitness or our particular way of seeking it (expressed through our CrossFit programming) is appropriate for every individual. Some people just like to run really long distances, while others are happiest when they lift really heavy stuff. Still others are interested only in the appearance of their body, and their entire fitness program is geared toward achieving a particular vision or visual. There is nothing inherently wrong with any of these desires, nor anything inherently wrong with the programming necessary to achieve these outcomes.

It just may not be CrossFit.

Because of this, the issue of programming is always on the table, especially during the Crossfit Games season that starts with the CrossFit Open and culminates in the spectacle in Carson, CA. Is there an optimal version of CrossFit programming? People take turns at supporting and denigrating the programming on the Main Page and in various CrossFit Affiliate gyms. Countless efforts are made to “improve” on the model you see on what we call “.com”. Some of these alternatives make sense, while others IMO are not really alternative CrossFit programming but alternatives to CrossFit itself. Most of these, indeed most of the conversations in general, have to do with strength and strength training. Are you (is anyone) strong enough? Will CrossFit.com or another version of CrossFit make you strong enough?

The 10 Essential Elements found in CFJ #2, “What is Fitness”, are also posted on Workout  030530 ( ironically on a day when heavy Deadlifts were prescribed). Pretty much all of the conversations noted about programming revolve around the premise that strength is somehow more important than other elements of fitness. Reasonable people can disagree on this point, but as a premise in discussing CrossFit the notion that strength is a, or the, primary element of fitness has no standing. There are 10 elements of Fitness, each no more and no less important than any other if we are seeking a broad, inclusive general physical preparedness that we call “fitness”. Full stop.

Whoa, wait a minute there pal, aren’t you the guy who co-wrote an article called “Strong Medicine” introducing a programming alternative called “CrossFit Strength Bias”? Hasn’t your home gym programming had supplemental strength training per CFSB principals since it opened? Isn’t that statement there just a bit, oh, duplicitous? Forked-typing?

Nope. Not at all. You see, if you read the original article you will see that CFSB is one way to address a DEFICIT in strength relative to the other 9 Essential Elements, not a program meant to gain strength at the EXPENSE of the other 9. As such it, like some others, is a program for the masses, a CrossFitter who perceives a hole in his/her fitness that needs to be addressed, not at all unlike a CrossFitter who does supplemental work on balance or flexibility. Additional Element-specific work, be it strength or agility or whatnot, that drives continued balance and improvement in all 10 Elements is very much CrossFit. All versions of CFSB (I am now using v3.2) are designed to be one way to address this imbalance. There are others that you may enjoy more (Wendler, Westside, Conjugate, etc.), and just like having personal goals, there is nothing inherently wrong with another supplemental strength program as long as it works without the need to sacrifice other competencies.

Whether you are looking at members of a CrossFit Box or competitors at the CrossFit Games, CrossFit is outcome based. The outcome desired is a broad-based fitness comprised of equal quantities of each of the 10 Essential Elements. What goes into the left side of the hypothetical Black Box should produce Work Capacity Across Broad Time and Modal Domains if the Black Box is a CrossFit athlete of any type. An increase in your Deadlift brought about by concentrating on strength training at the expense of cardiovascular/respiratory endurance will be accompanied by a decrease in your 5K run time and vice versa. This may be precisely in line with your goals, but it is not CrossFit as defined by Coach Glassman and expressed at its limits by Games athletes.

Programming for CrossFit should be aimed first and foremost at CrossFit outcomes. For most people, ever increasing fitness as described and defined by CrossFit results in increased health. What you find on CrossFit.com, and what you should probably expect to find as the primary goal in a CrossFit Affiliate gym, is programming that seeks to balance all 10 of the Essential Elements of Fitness, doing extra work in a lagging domain, and increasing all of them in an effort to produce increased work capacity across broad time and modal domains.

A demonstration of CrossFit programming will be available in a couple of weeks online and on ESPN. We call it the CrossFit Games. While I won’t be able to accept my invitation to visit my CrossFit friends and see it in person, rest assured that I will be glued to my (hopefully big ass) TV and watching nonetheless.



Sunday musings 8/9/15

Sunday musings…

1) Iron. The iron is always hot. Be ever ready to strike.

2) Walker. “I’m a guy with a wife and two kids and a Harley. One could call me aggressively normal.”

I like that, but I’m also struggling with it a bit. I mean, do you have to have a Harley to be normal? And what about that two kids thing?

3) Navy. Rum, as you probably know, was the traditional spirit onboard ocean going vessels for at least a couple hundred years. Rum that is particularly strong, say 57% alcohol strong, is said to be “navy strength”. If you spill it on your gunpowder, the gunpowder will still ignite.

I like everything about that.

4) Grit. In a post on last week’s “musings” that nobody saw (it was caught in the filter TWICE) I ruminated a bit on opportunity in America in response to a link on FB offered by my CrossFit friend JT, and an op-ed in the Sunday NYT. For the second week in a row a commentator is taking up space on the first page of the Review section bleating about an indelibly institutionalized LACK of opportunity the U.S.


For whatever it’s worth, I’m not going to go back to that well here today (though I will in Random Thoughts for both of you who care) except to say that you can show pretty much anything you care to simply by cherry-picking your cohort. Instead, let’s take a look at the singular ingredient necessary to seize and take advantage of opportunity when it arises: grit.

What is it that produces vastly different work products, outcomes, from similarly situated and talented individuals? Why do two equally gifted athletes similar in every way achieve at different levels? How best to explain widely disparate test scores in math, for example, from the “best and brightest” students? There is something within those who succeed at the higher level that is somehow missing in the others, or at least missing the same degree of expression. It’s likely that there are a number of words or expressions that capture this quality, but I kinda like “grit”.

Grit begins with a belief in self, a sense of self-worth, of being worthy of success. Without this first step it’s rather easy to see how anyone might just give up before ever starting. Here, as my cousin Rick has pointed out, might be a true variable when discussing opportunity: those of us who grow up in a demanding family characterized by firm boundaries, unfailing support, and high expectations may actually have an unfair advantage. People with this type of upbringing truly do believe that the iron is always hot and that they are worthy and capable of striking. Without this foundation of belief in self it’s easy to see how one might look at the same iron and think only of how not to get burned.

By the way, this is why neither poverty nor wealth is a valid predictor for success. Think of people who grew up in dismal poverty and climbed to literally dizzying heights in life, or the opposite, scions of wealth who grew up to be self-loathing under-achievers. A look in the window of the former would find an atmosphere like the one Rick describes, one in which that deep belief in yourself is instilled. The wealthy family from which opportunity is squandered is more likely one in which little or no support is offered to a child, one in which the child is continually found wanting and told as much.

To have grit one takes this core belief and puts it into action. Angela Duckworth, professor at Penn, calls passion and perseverance the two actionable components of grit. You have to want it, whatever it might be, and you have to work at making it happen; the fact remains that the overwhelming majority of people looked upon as lucky actually worked their asses off to get that way. Perseverance might very well be defined as ongoing maximal effort. One who has grit might not necessarily get the best outcome, but it’s not likely to be due to being out-worked at that thing called “it”.

An important sub-category of perseverance is resilience, and this is the final core attribute to grit. Resilience is the ability to bounce back from defeat with faith intact to resume the quest for “it”. Think about what comes to your mind when you hear someone described as “gritty”. It’s someone who has a passion, a commitment and a willingness to work toward an achievement. More than that, someone you think of as gritty has faced adversity or moved on after defeat. No one has a straight line to success; the gritty move on, secure in the knowledge that they are willing and able to do the work needed to succeed.

Grit is passion and perseverance bookended by a sense of worthiness on the front side, and the resilience to overcome setbacks on the back.  Opportunity is wasted without it.


I’ll see you next week…


Conflict of Interest Mania

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.




Epilogue to “Mommy-Track” post on “Equal Pay Day”

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

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

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

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

TANSTAAFL And “Mommy-Track” Docs

Uh oh. Now they’ve gone and done it. Someone has gone and rained the facts down on what is generally considered a feel–good story in American medicine, the dramatic increase in female doctors in America. In response to Dr. Herbert Parde’s “The Coming Doctor Shortage” article in the Wall Street Journal, Dr. Curtis Markel pointed out that there is a difference between the raw, gross number of physicians in America, and the EFFECTIVE number of practicing physicians.  Not only that, but he had the audacity to point out that roughly 50% of newly–minted American trained physicians are women, and that many of them do not practice full-time.

The NERVE of that guy. I mean, how dare he bring facts into a discussion of physician manpower? Wait a minute… maby that’s it right there… MANPOWER. This must be just another incidence of the male–dominated world of medicine cracking down on those female party-crashers. Except for the fact that…no… this really isn’t a case of that at all. Just an illumination of a significant part of a more general trend. When we look at the economics of physician resources the more important statistic is NOT the number of physicians working, but the number of physician–HOURS that are worked. Physicians newly minted in the United States in the last 20 years work fewer hours per week and annually than their predecessors, and “mommy–track” docs work even less.

That, my friends, is a fact–based reality of healthcare economics in the United States. The fact remains that Heinlein was right: there ain’t no such thing as a free lunch. The facts do not care what you think. They do not they do not care how you feel about them. They do not go away and they do not change if you try to change the topic or bury them with obfuscation. Torn between self–righteousness (I’m staying home for my children) and righteous indignation (I work HARD), the mommy-track docs have fired back.

Unfortunately, their return fire has been little but emotion-loaded pellets, rather than fact–filled ordinance. An ER physician talks about choosing to work fewer shifts in order to tend to her family, or an ailing parent, or even to avoid “burnout”, and conflates the effects of these personal choices with her feelings about the effects of inequities between the compensation for so–called cognitive versus procedural specialties. Another talks about wanting to work part time with the thought that this will make her a more effective doctor. Still others try to shift the conversation from the “mommy–track” to general lifestyle considerations: I wish to “paint, or cycle, or just read.” All well and good, of course, but all also well beside the point. The fact remains that women physicians tend to work fewer hours than their male colleagues, those who have children take long stretches of time away from practicing medicine to do so, and both men and women recently trained tend to work measurably fewer hours than their predecessors did and do.

Sorry. You CAN’T have it all. Thinking that you can is a fantasy; it’s just not consistent with a fact–based reality. There ain’t no such thing as a free lunch. In medicine or anywhere else.

Please don’t get me wrong. I personally find absolutely nothing inherently wrong with working fewer hours or taking time out to have children. Back in the day there was often a terrible price to be paid because of the traditional work ethic of the American (mostly male) physician. The landscape is littered with the carcasses of medical marriages that didn’t survive this “profession first” rule. Substance abuse was rampant among these physicians, and the physician suicide rate was (and is) a multiple of the general population’s. Younger physicians, mommy–track and otherwise, are certainly onto something. The life balance that is so important to them is healthier in almost all respects, at least as far as the physicians themselves go. But in terms of our health care system as a whole? Nope. The facts say we either need more doctors, or doctors need to work more hours. To say that you, the physician, are making these choices for anything other than lifestyle reasons, to blame some reimbursement inequity or other external factor is disingenuous at best.  My mother used to call it “the consequences of your decisions”, but I prefer Heinlein. TAANSTAFL.

While there are some medical specialties that are very lucrative (neurosurgery, gastroenterology), the income that physicians take-home is generally reflective of how hard they work. How many hours per week they to spend doing clinical work. How much they actually do in each of those hours. General surgeons tend to make more money then family practitioners,  not so much because they get paid all that very much for any individual thing they do, but because they tend to work lots of hours, and they tend to do lots of work in each one of those hours. Nights, weekends, dinnertime, and long after Conan has called it a night, general surgeons are at work because the work needs to be done. The vast majority of primary care physicians work 40 hour weeks, hours that look more like the proverbial banker’s day than the surgeon’s. Nothing wrong with that, and neither is this always the case. I have a friend who is a very successful, family practitioner who is blessed and cursed with both ADD and insomnia. I think he works more than anyone I know, doctor or otherwise, and his income is consequently more like that of a general surgeon.

Perhaps an illuminating example would be the decision I made approximately five years ago to totally change the way I practice my specialty. Suffering from a severe case of professional and business dissatisfaction, I left an extremely successful practice (a practice that remains extremely successful in my absence) and started Skyvision, a very different type of eye care practice. (As an aside, when they finally got around to replacing me, it took TWO 30–something year-old physicians to do so.) At Skyvision I see many fewer patients each day, and consequently have a dramatically lower income. When presented with the Zen–like question “do you wish to be wealthy or happy” I chose happy. The decision has made me quite “UN–wealthy”, but I really am quite happy.

That is the fact–based reality of physician economics, my  little micro–economic example to explain the macro–economic effects of physician–hours versus physician numbers. There’s no one to blame. No government conspiracy. No specialty vs. primary care inequity. I am the sole bread–winner in a home with a “mommy–track” Mom. There are more eye doctors where I live because some of the eye doctors who are already here, mommy–track or otherwise, are now working less.

Are mommy–track docs the sole problem why we face a pending physician shortage in the United States? Of course not. We have a decades–long history of new physicians working fewer hours than their predecessors, a relatively static number of new physicians being trained, and an ever–expanding population of patients who need the care of these physicians. No matter how they might FEEL about it, and no matter how they might feel about having it pointed out, the fact remains that, on average, newly–minted doctors work fewer hours than their predecessors, and mommy–track docs, on average, work fewer hours than their peers. Wanna stay home with your kids? Cool. 12 weeks to bond with the new baby? Sure, who WOULDN’T want that. Just “man up” and face the facts–you can’t have it all. Nobody can. Be a grown up and accept the consequences of the choices that you have made, and accept this gracefully when someone else points that out in the Wall Street Journal or elsewhere.

There ain’t no such thing as a free lunch. Somebody, somewhere, always pays.