Random Thoughts from a Restless Mind

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

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.

Who keeps the score in your life? Come on…none of that “I just live day-to-day” nonsense…we ALL keep score. Money, house size, free time, successes of the progeny, number of followers, all simply proxies for hits, runs and ERA. I guess the better, more actionable question is really “who do you allow to keep score?” Let me explain.

It’s my contention that the score is ALWAYS kept. It’s inescapable. Not only that, but many people keep a running scorecard going on you. Your parents, siblings, children. Co-workers and neighbors. Friends. Everybody is paying attention and everybody is keeping score. It’s not all bad, of course, because many times folks are only counting the goals, runs, and touchdowns and ignoring the flubs and errors. It’s OK to be consciously unconscious of these particular scorekeepers because for the most part these people are engaged in a “non-zero sum” game in which victory for all is the goal, for all. They are probably cheering for you in some way, shape, or form.

It’s the OTHER scorekeepers who use the score as a weapon, who compare the scores, compete to win in a “zero sum” game, who may or may not have your permission to even be IN the game, let alone keep score, who can wreak havoc and render destruction on the playing field. These people insist on a game in which someone must lose in order that someone may win. +1 -1 = 0. They always see the game, every game, in these terms, and they want you to see it that way, too. They insist, demand, that you not only keep score in this manner, but that you also accept them as the scorekeeper.

Here’s where you get to choose, where I think you should exert your right to choose. You may seek, as I do, to convert as many of the games in your life into “non-zero sum” games, ones in which EVERYONE may triumph, as you can. Or, you can decide that this is pollyana-ish folly and view the world always through the “zero-sum” prism. Or some combination of the two. Your call. When you have a choice, though, what I DON’T think is optional is to allow anyone else to wield the pencil that keeps the score on your particular game but you, or maybe a very, very small subset of players intimately close to you. Think about it…how could you ever win, or even tie, if it’s “zero-sum” and someone else is keeping score? Why is that? Because the scorekeeper also makes the rules. Always. Why allow that to be imposed on you if you could choose otherwise?

In many ways letting someone else anoint themselves your scorekeeper is to hand over to them the right to determine what makes you a success or not. Heck, they’ll even chime in on whether or not your “score” should make you happy. Scorekeeper is just another word for “judge”, and scorekeepers seem to love to pass judgement. Should your success, your happiness, be defined by someone who seeks to impose their right to make that call?

I re-learn this lesson, slowly and painfully, again and again, over and over. My advice, offered freely and without condition, is that you should try to be smarter than I am, learn it once, and refuse to give up the pencil. Don’t let someone else decide that they get to choose the rules and keep the score on you.

“Constantly varied…” So, routine is the enemy, right? Well, yes and no. Routine is one of those multi-layered words that applies in many ways in many situations.

Routine is the enemy when we train, and I think this is true for almost all athletes, almost everyone who trains. We risk acclimation to the stimulus if we have a strict routine in the gym, if our workouts are substantially the same day after day. We further risk the numbing effects of boredom, a slow ebbing of our enthusiasm and our resolve. Routine is the major building block, the cornerstone in the brick wall that often stands between athlete/trainee and training.

Routine is our ally when “routine” is synonymous with “consistency”. Remember “Form, then consistency, and only then intensity.” The establishment of a routine, a schedule, a commitment of time and spirit to the quest for fitness, health, and athletic achievement is the first paving stone on the highway of living.

Routine, the yin and yang, push and pull, up and down, enemy and ally.

It’s been 30 years since I left the Purple Valley and Williams College. How fun it was to spend the weekend surrounded by my fellow Ephs.

I learned a little bit about my younger self this weekend and in doing so gained a tiny bit of insight into the maturing adult I am striving to become. I graduated from college 30 years ago along with around 400 classmates. 100 or so of us returned for our Reunion weekend. You would think that in a class that small each of us would at least be on a “hi, how are you” first name basis with everyone who was there, right?

Not even close. There were folks there who I’m quite sure I never even saw in 4 years of college. Never, as in not a single time. Even more than that, there was a measurable number of really nice people with whom I had zero interaction after freshman year. How could that have been? I was a pretty social character in college. You’re shocked, I know. What’s up with that?

At a time and an age where it should be all about expansion, expanding one’s mind, experiences, circles of acquaintances and friends, quite the opposite was happening at Williams when it came to the people part of the equation. And it wasn’t just me, either; this mini-epiphany was shared almost universally at breakfast the last morning by all present.

There seem to be a couple of teachable moments in this experience, only one of which is for the younger version of me. It’s obvious looking through the retrospectometer that one should harvest as many friendships, plant as many of the seeds of friendship when one is young and still living among other young people. Makes a ton of sense, so much so that it seems almost trite. Yet here were 100 reasonably accomplished adults who’d grown up out of reasonably accomplished youngsters who almost universally let this opportunity slide by. At a minimum, we collectively failed to reap or sow as much friendship as we could have.

And for us now? We who are now 10, 20, (gasp) 30 years removed from those fertile school year fields, what is the lesson for us? Much simpler, I think. You can never have enough friends. Whether across the street and there for a wave with the retrieval of the morning paper, or across a continent and only touched when one sends news and a photo of classmates doing their tiny part to make the world a better place, you can never have enough friends.

Even more, as we learned this weekend, it’s never to late to make a new friend.

I have been pretty generous in sharing my thoughts about some of the ills of our American Healthcare system, especially with regard to the barriers erected between physicians and patients. The attempt to “reform” medical care via a top-down, bureaucratic solution to what may or may not ail our system is ridiculous on its face. We are to believe that our Federal Government can handle something as complex as healthcare, a segment of the economy representing ~20% of GDP? A Federal government that has proven so adept at managing other major segments of our economy like, oh, energy policy?

The “baby with the bathwater” approach in the halls of our Capitol and the editorial offices of our leading media outlets (WSJ excepted) is about as wrong-headed as you can get.  What we need is an AMERICAN solution to the challenges that we presently face with the economics of healthcare in the U.S., using our present system as the foundation. We need a solution that emphasizes the strengths of our markets, with government providing oversight to establish a playing field that is as level as possible.

Not surprisingly, I have some thoughts!

1) Malpractice tort reform. See my thoughts in “Tort Reform = Healthcare Reform”. Effective reform will dramatically reduce the scourge of defensive medicine with its attendant costs and risks to patients. We all do it, and we do it when we don’t get paid to do it. Defensive medicine represents 15-25% of all medical costs in the U.S. That’s 15-25% of $2.5 Trillion. Do the math.

2) Tax Reform #1: Remove the tax deduction for employer-offered health insurance. Provide a 100% TAX CREDIT to the lowest 60% of wage earners for the purchase of health insurance. Provide a progressive TAX DEDUCTION for the upper 40% of wage earners. Level the playing field by removing the penalty for not working for a company that can deduct your insurance premiums.

Tax Reform #2: Remove the tax deduction for advertising as a business expense for Hospitals. If we are concerned about unnecessary increased utilization of medical resources why are we allowing advertising by hospitals? Seriously, why are we subsidizing the Ohio State Medical Center when it advertises for business in Cleveland. Ohio State is in Columbus, 2.5 hours away.

For that matter, remove the tax-exempt status of any hospital or  provider that advertises. How is it appropriate to allow a hospital system to advertise to increase revenue, deduct that advertising as an expense, and still be not-for-profit? If it looks like a business, acts like a business, and sounds like a business, tax it like a business.

3) Insurance Reform #1: Reverse all of the for-profit conversions of previously not-for-profit health insurance companies. Who was the genius who thought THIS was a good idea? I don’t remember insurance premium increases that were quite so massive when all of the Blue Cross/Blue Shield plans were not-for-profit, do you? And while there were $Million execs in the non-profits I don’t recall any $10, $20, or $100 Million execs. Removing the need to answer to the stock market will create companies that will compete quite nicely with the for-profit companies without the horror of a government run system. Let the equivalent of NGO’s compete with the United Healthcares of the world.

Insurance Reform #2: Remove state-level coverage mandates and create a minimum federal set of mandates for comprehensive insurance policies. A REAL minimum. REAL medically necessary items. This is the brilliance of Sweden’s system. No Viagra or artificial  insemination coverage. Allow cross-state competition for the business. Real competition always drives prices lower.

Insurance Reform #3: Do whatever it takes to encourage the purchase of  high-deductible catastrophic health insurance for all. Real insurance that covers real medical disasters like car accidents or cancers that strike young adults.

Insurance Reform #4: Allow insurance companies (Medicare and Medicaid included) to discriminate IN FAVOR OF people who make healthy lifestyle choices (eg. no nicotine, no DUI, etc.). We are all so afraid of the stick that we refuse to allow any use of the Carrot.

4) Freedom of Speech/Restraint of Trade Reform #1: Abolish, once again, direct-to-consumer pharmaceutical advertising. There was a quantum leap in the utilization of all sorts of medications immediately following the 1997 rulings that allowed DTC pharmaceutical marketing. If it is so obvious that our ever-increasing levels of spending on medical care is a threat to the very existence of our fair Union, then DTC drug marketing is a version of yelling “FIRE” in a crowded theater.

Freedom of Speech/Restraint of Trade Reform #2: Begin a return to the professionalism of yesterday by prohibiting all forms of advertising by, or for, physicians. The AMA gets a lot of criticism, most of it well-deserved in my opinion, but the court and FTC rulings that prohibited the AMA from censoring physicians who advertised was a seminal event in the de-professionalism of doctoring and medicine. Doctors and other medical advertising was, is, and always will be wrong. While we’re at it, do the same thing for lawyers and the practice of law.

5) Public Health. Finally, and most importantly, go to the true root of whatever “Crisis” we may have here in the United States, be it a “Healthcare Crisis” or a “Healthcare Finance Crisis” or what have you. We as a people are not healthy; certainly not as healthy as we ought to be. We are not healthy because of some wrong-headed previous Public Health decisions (simple-carbohydrate based diets, abolition of school phys-ed programs, tort-fearing closures of playgrounds, etc.). We are not healthy because our ability to treat the diseases that result  from poor lifestyle choices (cigarette smoking, alcohol abuse, preventable accidents, etc.) is SO GOOD that we are able to keep more and  more unhealthy people alive longer and longer, paying ever more to do so along the way.

This is where true leadership can make a difference. Remember JFK and the President’s Council on Fitness? I do. 8 pull-ups in the fifth grade for me. Sweden identified saturated fats from whole-milk products as a significant cause of heart diesease in the 70′s; a full court Public Health press for low-fat dairy brought about a dramatic decrease in cardiac deaths in the 80′s. Polio, measles, smallpox and whooping cough were once the leading killers of children in the U.S. but are now historical footnotes due to Public Health initiatives.

We lead the world in per capita alcohol related accidents and deaths, losing young lives by the thousands each year (is it just me or does it seem we have MORE alcohol-related problems in our youth since raising the drinking age?) We have ever more increasing numbers of truly obese citizens who go on to suffer the diseases caused by that obesity, and we pay ever more for their diabetes, hypertension, strokes and heart attacks. These lifestyle choices are root causes for our increased expenditures on Healthcare, much more so than all of the targets of Beltway demagoguery like insurance company expense ratios and pharmaceutical company profit margins. A solution to this issue, more than all of numbers 1 through 4 combined or any other proposal yet floated, is the true crux of the solution to any “Crisis” we may be facing. Everything else is only there to buy time. Time to get healthy.

It’s a Presidential Election year in the United States. There are no votes to be had in making Americans healthier. Nothing but hard work on every side of the equation. Who will stand up and do the hard work? Who will lead?

Who will have the guts to not only say that the Emperor is naked,  but also drunk and fat and puffing away our economy.