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Archive for July, 2012

Sunday Musings 7/22/12

Sunday musings…

1) Date. Happy Birthday to the founder of CrossFit. Many more to come.

2) Secular tailwind. Heard on MSNBC. What does that even mean? How can people rag on medical people for using medical terms when BS like this is spoken? At least my stuff means something.

3) Gym sign. “Tired of being Fat and Ugly? Just be Ugly; Come to the Gym.”

That there’s pretty good.

4) Failure. “There are no failures, only feedback.” (Unknown). I like that, pretty much exactly as stated. I’ve written before that in order to learn, to progress, to succeed, it’s probably NECESSARY to fail as long as the failure is examined and parsed for the lessons to be learned. The quote is inaccurate and loses its essential truth if one encounters failure and simply walks away from it, leaves it behind.

Examining a failure in oder to obtain feedback that will prepare you for the next attempt allows you to experience the ultimate way to fail: Fail UP.

5) Practice. I read about a couple of athletes who do the same thing in their training: they practice winning. That’s right, each training session they do something they are good at and make sure they succeed in order to get accustomed to winning, to make winning feel normal. A decathlete, a golfer, and a basketball player I think it was.

Makes sense, I think. Visualize all of the first-time winners you’ve ever watched in any type of event. The biggest opponent they faced as the match wound down was sitting right between their own ears. Doubt, fear, a palpable sense of “what am I doing here” born of being in the foreign territory out front, bourn like a yoke attached to a freight car filled with anxiety.

I’m quite sure there are dozens of ways we can do this in our CrossFit world as we do our WOD, whether we do them simply for the fitness benefit of do them on the fields of competition. I also know that we learn how to win, to defeat our fear, our weakness, our natural tendency to turn away from the difficult and the uncomfortable simply by doing CrossFit.

That, in and of itself, is a little exercise in the practicing of winning that carries over into the game of life.

6) Random. You know where this one’s going. Another random act of heinous, senseless violence just occurred, only not the one you are thinking of. I just got home from several hours at a local hospital ER caring for the victim (1 of 3) of a random beating outside a bar last night in Cleveland. While they will live, this vicious, ugly act will cost this person the use of an eye.

How should we, as individuals and as a society, respond to last night in Cleveland and Friday night in Colorado? The larger societal question is almost certainly bigger than we can handle here, and I’m pretty sure it’s bigger than something a tiny voice like mine might answer. But I think we can tackle the question of how we can or should respond on a personal level, as an individual.

We should live today and tomorrow and the next day just as we lived last week and last month and last year.

For these acts are the doings of madmen, of people who have somehow lost that part of themselves that makes them fully human. We are empathetic creatures on both a micro level (I gaze down upon my patient on the ER gurney) and macro (we shrink in horror at the story on the front page). Those who have committed these acts do not look upon their victims and see the same thing that you and I see; they do not look upon another being with whom they share vastly more then the total of any paltry differences and see a version of themselves, another person. How could they? How could they see another person and still do what they’ve done? By disregarding the humanity of their victims they relinquish their own. We gaze upon them, or we should, with little more than that which we would summon as we looked at any animal that savaged a person.

We react to these random tragedies by going about our daily business, going to work, to a ballgame, to a movie just as we would have done last week. We maintain, and should always maintain, a situational awareness of our surroundings, but we defeat these madmen by not letting them make us afraid. If they change us at all we win by becoming more open, more friendly, more generous. We who remain become serial perpetrators of an entirely different type of random behavior: Random acts of kindness.

And we win.

I’ll see you next week…

Posted by bingo at July 22, 2012 7:49 AM


Sunday musings 7/15/12 From the Games

Sunday musings (from the Games)…

1) Hall Pass. Yup. Got mine. The whole weekend to hang at the CrossFit Games. With “The Heir” and Lil’bingo. Yup.

2) Cyber-gym. Once upon a time in CrossFit land most of the people who did CrossFit congregated here, on the Main Page of CrossFit.com. This cyber-gym has since expanded, kinda like an Affiliate that got so big it needed a bigger space, and now it includes stuff like FB and Twitter. Many of us have forged a very cool kind of friendship or kinship through the shared suffering of CrossFit in this cyber-gym.

It’s especially cool to actually meet these folks in real life. For real…like shake hands and hug kinda real. At the CF Kids Teen Challenge I met the near-OG who once upon a time went by “Cougar” around here along with a half dozen other women who’ve met the same way. Very cool pic floating around FB as proof.

Full frontal hugs had by all.

3) Vetted. Bumped into Kelly Starret. You know, budding author about to be published (do look for his book, out in early 2013). We got to chatting about our community and the word he used to describe it was “vetted”.

“I know everything about you once I know you are a CrossFitter. I know who you are. I know who you hang out with. I know the kinds of choices you make, good choices. I already know we will be friends. You’ve been vetted, simply by telling me you are a CrossFitter.”

I really like that word and all it stands for in this context. There is an assumption of good will extended from all CrossFitters to all CrossFitters. We are not surprised in the least when we meet yet another really nice person with a great story. Astonished yes, but no longer surprised. Like today when an honest-to-goodness real-life American hero spent 20 minutes talking with my boys after just having met them, sharing words of encouragement and inspiration (you and your fiance know who you are–thank you).

Indeed, I like that word and how Kelly used it so much I think I’ll buy him a dinner at a place called “Lola”!

4) Community. I’ve been reading Allison Belger’s book “The Power of Community” in which she dissects the CrossFit Community from the perspective of both a CrossFitter and a psychologist. I’m reading and re-reading parts so I’m not going through it all that quickly–I’m enjoying savoring the gems and jewels I’ve been finding there, and I’m sure that I will share more than several of those once I’ve mined it fully.

Every anecdote so far elicits a knowing nod. I struggled a bit with the question of “why”but I think I’ve figured it out. You know, as in why does CrossFit create such a strong community? Again and again, on a micro (Affiliate gym) and macro (the CrossFit Games gathering) level.

The science is cool: it turns out that we as creatures are probably wired for community, wired to become a part of a community. What it takes for this pre-wired state to become operational is some trigger or stimulus. The most exciting applied neuroscience now extent is in the realm of my day job where the brain part of the vision system can actually be made to change, to get better, if the stimulus that causes maximal activity in a neural pathway is repeatedly applied.

Ah… now we’re getting somewhere. Our stimulus is the willful acceptance of discomfort, and more so the shared experience of that discomfort in an effort to better ourselves. There is obviously something about this particular stimulus that fits right into that pre-wiring for the creation of a community. Dr. Belger’s book not only gave me an expanded vocabulary to describe our community, what our CrossFit community looks like, but it also helped me answer the the question of “why” it happens.

Whether in the cyber-gym or a Box, the stimulus for community lies in the willingness to pay the price to move beyond your perception of what is possible; once having done so one seeks others willing to do the same.

Having found them one always seems to be at home.

I’ll see you next week…

Posted by bingo at July 14, 2012 10:30 PM


Sunday musings 7/8/12

Sunday musings…

1) Wimbledon. Breakfast at Wimbledon. Why thank you, yes, I think I will.

2) ESPY. Kyle Maynard is up for an ESPY. Go find a place to vote for him.


3) Life? Billy Ray (not his real name, of course) turned off his implantable defibrillator (ICD) yesterday. Billy Ray is 44.

In my day job I was asked to evaluate him for a problem in my specialty. I was told he was about to enter hospice care and assumed that he was much, much older and simply out of options. I admit that I was somewhat put out by the request, it being Saturday and the problem already well-controlled. Frankly, I thought it was a waste of my time, Billy Ray’s time, and whoever might read my report’s time, not to mention the unnecessary costs. I had a very pleasant visit with Billy Ray, reassured him that the problem for which I was called was resolving nicely, and left the room to write my report.

44 years old though. What was his fatal illness? What was sending him off to Hospice care? I bumped into his medical doc and couldn’t resist asking. Turns out that Billy Ray has a diseased heart that is on the brink of failing; without the ICD his heart will eventually beat without a rhythm and he will die. A classic indication for a heart transplant–why was Billy Ray not on a transplant list? Why, for Heaven’s sake, did he turn off his ICD?

There is a difference between being alive and having a life. It’s not the same to say that one is alive and that one is living. It turns out that Billy Ray suffered an injury at age 20 and has lived 24 years in unremitting, untreatable pain. Cut off before he even began he never married, has no children. Each day was so filled with the primal effort to stop the pain he had little left over for friendship.

Alive without a life. Alive without living. Billy Ray cried “Uncle”.

I have been haunted by this since I walked out of the hospital. How do you make this decision? Where do you turn? Billy Ray has made clear he has no one. Does a person in this situation become MORE religious or LESS? Rage against an unjust G0d or find comfort in the hope of an afterlife? Charles DeGaulle had a child with Down’s Syndrome. On her death at age 20 he said “now she is just like everyone else.” Is this what Billy Ray is thinking? That in death he will finally be the same as everyone else?

And what does this say about each of us in our lives? What does it say about the problems that we face, the things that might make us rage against some personal injustice? How might we see our various infirmities when cast in the shadow of a man who has lived more than half his life in constant pain, a man alone? The answer, of course, is obvious, eh?

The more subtle message is about people, having people. Having family, friends, people for whom one might choose to live. It’s very easy to understand the heroic efforts others make to survive in spite of the odds, despite the pain. Somewhere deep inside the will to live exists in the drive to live for others. The sadness I felt leaving the hospital and what haunts me is not so much Billy Ray’s decision but my complete and utter understanding of his decision.

Billy Ray gave lie to the heretofore truism that “no man is an island”.

Go out and build your bridges. Build the connections to others that will build your will to live. Live so that you will be alive for your others. Be alive so that your life will be more than something which hinges on nothing more than the switch that can be turned off. Live with and for others so that you, too, can understand not only Billy Ray but also those unnamed people who fight for every minute of a life.

Be more than alive. Live.

I’ll see you next week…

Posted by bingo at July 8, 2012 7:17 AM


Hoisting Another White Flag: Generic Medications

The great Dick Lindstrom recently posted an editorial on the challenges faced by doctors in a world that is focused solely on the cost of medication, one in which pressure is brought to bear on both doctor and patient to use an inexpensive generic at all times. Dr. Lindstrom reaffirms his career-long position that only one factor matters in the complex decision making process that is medicine: what is best for my patient’s health is my sole concern. Indeed, it is important for each physician to fight for this outcome, to fight for the person who sits before us in the exam chair or beneath us on the operating table. When a clinical difference exists between the expensive branded medicine and the cheaper generic we are honor and duty bound to prescribe and support the better medicine.

Sigh. It’s just all so tiresome, this battle. We physicians certainly did not choose this fight, and frankly most of us have no dog in the fight other than the best interests of our patients. I wrote PREVIOUSLY that the notion that pens, penlights, and candlelight dinners prompt doctors to become shills for pharmaceutical companies is farcical and offensive. Come on…I’m gonna look for a reason to prescribe some new eyedrop because someone dropped off a couple of pens? That’s all silly enough, but the battle has escalated with the entry of insurance company and government programs that automatically switch to a less expensive “therapeutically equivalent” medication and then require doctors to personally run the gauntlet necessary to “justify” their clinical decisions.

We are on the receiving end of the same kind of stuff that big companies use to defeat smaller foes in court: we are bombed with paperwork. Not only that but it’s carpet bombing, indiscriminate deluges of time bombs meant to bludgeon doctors into submission. There’s collateral damage, just like in carpet bombing, only the casualties are more subtle. Forcing doctors to be a part of this irreparably damages the doctor-patient relationship, making it more of a commercial interaction as doctor becomes ombudsman for patient.

As Dr. Lindstrom exhorts, I’ve been fighting the good fight. Dr. Lindstrom doesn’t need this fight. He’s a living legend who has earned the right to stand aside from these types of petty issues and to choose to put his considerable gravitas to work on stuff that has to be more fun. Yet he willingly takes on this battle and I’ve followed his lead. Standing my ground and insisting on newer branded meds when they are superior to older, cheaper generics. It’s getting to me, though. I’m tired. My staff is tired.

I surrender. Up goes another white flag.

I’m going to surrender in the battlefield of Glaucoma. Why Glaucoma and not cataract surgery for instance? I’m tired and beaten up, but I’m neither a hero nor a coward, not a sentient nor an idiot;  I don’t need to be a seer, some kind of morbid Karnac the OK, to know the outcome for either cataract or Glaucoma. I’m declaring right up front what is going to happen, how it will affect my patients, my staff, and me, and what the ramifications will be for American healthcare. I’m surrendering in Glaucoma because I can, continuing to fight in cataract surgery because I must.

In my 27 years as a physician only one paperwork/government regulation/billing issue has ever resulted in better care of my patients: the requirement to do an extended Review of Systems for a particular kind of visit resulted in the identification of major side effects from glaucoma eyedrops. Indeed, this was a total surprise and led to a rapid change in the way we took care of Glaucoma patients. Older medications, effective or not, were replaced by newer medications or laser because the newer treatments were both more effective and freer of side effects. What will I find this time?

Timoptic (topical Timolol) was introduced in the early 1980’s. It was a Godsend. Nothing less than a miraculous savior of vision, keeping legions of patients out of the operating room and saving thousands and thousands of people from certain blindness. It’s been off patent for decades but is now no more than a third line treatment. Why? Tons of side effects, some subtle (decreased exercise capacity, erectile dysfunction) and others less so (my friend essentially killed his very first Gaucoma patient in year one of the Timoptic era by prescribing Timoptic and causing 1st degree heart block). It’s really cheap now, but who can write this Rx and look themselves in the mirror, white flag or not?

We know that the Lipid class of Glaucoma eye drops is the most effective group of pressure lowering medications. The original, Xalatan, dethroned Timoptic in less than 2 years. Lower eye pressure and no systemic side effects and a new treatment paradigm was nigh. The worst side effect was a permanent darkening of the iris in 9% of patients, the price to pay to save your vision. Xalatan is now available as a generic (latanaprost). There are 3 newer, stronger, more effective Lipid medications, all of which are branded and all of which are 2-4X the cost of latanaprost. They all reduce eye pressure on average 2-3 points more than latanaprost.

I’ll start here. Starting next week every new glaucoma patient who opts for medical treatment will start on latanaprost. On top of that I will change every patient on a branded lipid to latanaprost if they risk losing insurance coverage for their drop. I will not respond to any insurance company challenge. If pressure reduction is inadequate I will follow my standard protocol and I will offer a second medication or glaucoma laser treatment, both of which are standard of care. If a second medication is chosen I will write for the generic second line Rx, an alpha-agonist. The generic and the brand alpha-agonist have equal efficacy; the generic has a 35-40% unacceptable side effect rate compared with the brand’s 10-12%. The generic cost is ~1/4 of the brand.

My staff and I will take the time necessary to inform my patients of these side effect issues, a time investment that will be a laughably small fraction of the time it takes us to fight the paperwork wars for Brand coverage. I will document this up the wazoo, noting every treatment failure and every last little side effect, jotting down every incidence of patient non-adherence. I will gear up for more glaucoma surgery, both laser and incisional, because I remember how much more of both I did in the days when Timoptic was king, in the days when version 1.0 of today’s medicines was so hard to take due to side effects. I will have this all on hand when we start to read of the new golden age of Glaucoma surgery.

I will be ready to answer the critics who accuse eye doctors of doing too much Glaucoma surgery.

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