Random Thoughts from a Restless Mind

One of the reasons CrossFit HQ finds itself in the crosshairs of so many folks of such varied persuasions is that the folks speaking on behalf of the company mince no words. Speaking thusly has become so rare that this, in and of itself, has earned CrossFit (and its founder Greg Glassman) the enmity of people all across every spectrum, people in any and all categories. Standards are set and rules enunciated in plain English. Answers to questions or responses to attack are given quickly, directly, and without artifice.

This makes lots of folks uncomfortable.

In the Western world we’ve become inured to the way the majority of the world talks or writes. The standard operating procedure is now to bend words in such a way that they appeal to a belief system rather than reference a collection of facts. Strong, substantive words like “cause” become hostages to this new feelspeak when they are joined with a qualifier such as “may”. So, too, the verb “to be” in all its splendor is slimed by the addition of “might” or “could”. You’ve seen this: “Experts say that CrossFit may cause injuries when it becomes a sport,” or some such nonsense.

The slimy words, the qualifiers and the hedges, remove all need for honesty. They provide cover for agendas unencumbered by  reality. These words speak not for the facts but for the beliefs, the feelings of the speaker. Likewise, they appeal not to the individual who seeks knowledge or understanding but to one who seeks to have his own belief system validated. I feel, therefore I am.

It is in this world that the plain speakers stand out. It’s not necessary to have a large vocabulary, only that a truth be plainly spoken or a position be firmly taken. No hedge. No qualifier. Nothing slimy. No question about where you stand. In “The Deer Hunter” DeNiro’s character didn’t say “this may be this,” did he? Uh uh. “This is this. This ain’t something else. This is this.” Clear, without qualifier, free of slime.

From now on, you’re on your own.

Do you get the feeling that there are folks out there who are quite certain that they have you totally figured out simply by observing you? You know, judging the book by the cover and all. People make all kinds of grand statements, extrapolating from ever smaller glimpses of us, ever tinier aliquots of information or observation. Tall or short? Man or woman? Dark or light?

Sometimes it’s a single person looking at you, or looking at the world you occupy, and leaping to some sweeping conclusion based on that brief view. Can you really discern what makes me tick, or how I truly feel about some global issue about which you might care deeply, by how and when I Tweet for example, or what I “Like” on FB? You watch me in the supermarket as I push my basket, or you follow me at B&N and peek at my keepers and my discards, and from this you make a statement about all white males of a certain age?

A lesson lies here for each of us, whether we sit in the seat of the observer or the observed. The shotgun is more likely to hit its mark if the target is closer to the muzzle.

A recent study looked at survival statistics for colon cancer. While >90% of patients with early stages of colon cancer survive at least 5 years, the 5 year survival rate for advanced cancer is only 12%. One of the conclusions from that study is that the increased survival rate of cancer detected early justifies wider scale screening for this deadly disease. Makes sense, right? Find the cancer early and you live longer. The problem here, of course, is that the incidence of colon cancer in a broadly chosen group of individuals is actually rather small making both the cost of making the diagnosis as well as the “cost” of any complications from the screening test prohibitive. Whether or not to screen is a very complex question. This is a version of “better care” but it is probably not worth the cost unless we can find some way to identify an at-risk population.

Let’s say there’s a brand new test that allows you to identify another, different, important disease years, perhaps decades earlier than is now feasible. It is possible to narrowly define a population of patients at high risk of having the disease. Utilizing this test will provide physicians the opportunity to treat this disease before it causes irreversible destruction of vital organs, destruction which renders present day care of this disease when it is presently diagnosed little more than palliation.  The effects of this disease in later stages cause dramatic negative changes in the lifestyle of affected patients. There appear to be ways to treat the disease in its earliest stages in order to prevent the ravages of its late stages. Do you initiate testing in the at-risk population?

Let’s think about it.

What if the test is relatively easy, relatively painless, but relatively pricey? Remember, you can identify a population for this test that is at risk to have the disease based on patient history and physical exam criteria, making the percentage of people afflicted (incidence of disease) relatively high in the tested group. The weakness of many screening programs (routine colonoscopy for colon cancer for example) as noted above is that the disease is either relatively uncommon, or it is impossible to identify a truly at-risk group. This is not a problem with our hypothetical test. Let’s make the test very accurate, too, say 95% sensitive and 95% specific in any study group; the number of both false positives and false negatives would be very low. This would make it more useful than serum lipids when screening for cardiac risk, for example. While we’re at it, this test is extremely safe with no real risks. It sounds like a pretty strong case to roll it out, right?

Now would be a really good time to go back to one of the earliest things every medical student is (was?) taught about ordering a test: the result of your test should in some way influence your care of the patient. A positive test result should prompt you to do something differently from a negative result. If your course of action would be identical with each/every possible result it is entirely reasonable to ask why you are doing the test in the first place. Our new test meets this threshold. A negative result means continue with “standard operating procedure”, treating a patient with the constellation of symptoms and signs you have identified as you have been. A positive test, on the other hand, obligates you to enlist the assistance of another specialist, and furthermore to insist that your patient receive treatment that is not yet in any way considered standard. Therein lie the problems.

Many, if not most complex medical problems require the engagement of a specialist in order that the patient receive the most up to date and effective  treatment. Contrary to the popular notion that we only have a shortage of Primary Care doctors in the U.S., every family doc will tell you that it is nearly impossible to find a rheumatologist, dermatologist, neurologist, endocrinologist or various other medical specialists to take care of a new, complex patient. Imagine if you have a new test that identifies 1 million or 2 million or MORE new patients whose disease requires one of these specialists to run the show? What if the effective treatment that will be proposed is off-label (FDA approved for something else) and extremely expensive? What now? Remember, failure to identify these patients early and treat them before irreversible damage occurs dooms them to progressive misery as they age. What’s the call?

This would be truly better care. Is it truly worth it? Who should make the call?

In the abstract it’s a different question, and without the context of knowing what disease is involved also makes it somewhat more difficult to analyze this in any meaningful way. Let’s face it, some diseases simply carry more emotional weight than others, and this would likely increase the amount of money that anyone faced with this question would be willing to spend. The question itself is hardly abstract at all, however. Just today I read about tests for Alzheimer’s Disease and Sjögren’s Syndrome that will allow for extremely accurate diagnoses made dramatically earlier than we are now capable. Unaware of the diagnosis physicians and patients have no opportunity to consider treatment; if you can’t take a temperature you can’t find a fever. Without the ability to make an early diagnosis pharmaceutical companies have no incentive to evaluate treatments that will prevent the scourge of late-stage disease. This is the situation on the ground today.

The challenge will come as these tests are put into routine use and we identify large numbers of patients whose eventual course in the absence of treatment is well-known. Who will care for them if we already face a shortage of specialists in these fields? Uncertain of a return on the investment necessary to prove the efficacy of treatments for these diseases, what pharmaceutical company will do the studies that will show the benefit of treatment? With these new treatments likely to be very expensive, will insurance companies and the government pay the costs of the care? In the abstract these tests and the treatments that will follow certainly constitute better care. Will it be worth the cost?

Who makes that call?

There are real wars afoot. Not silly PR wars or Rap Battles or video games, but real, live shooting and killing wars. Admit it, you’ve barely noticed.

As I prepare to launch into a new topic for my next round of “serious” reading (I am slowly working my way through the very heavy science in “Waterlogged”) I stumbled upon a curious historical overlay. My daily newspaper sat on a coffee table under which sat a picture of a paper from the 1940’s. We have been at war in the United States, no matter how you care to characterize that war, for much longer than the entirety of WWII. Yet the tenor of our homeland experience could not be more different.

The books I’ve got cued up are “Billy Lynn’s Long Halftime Walk” by Ben Fountain, and “Redeployment” by Phil Klay, the first discovered in that newspaper above, the other from an interview of the author on the radio while driving to work (note: Evernote is brilliant for remembering that kind of stuff). Thus far I’ve successfully avoided reading a full review of either, having discovered in the first 2 sentences of a NYT review that there’d be more editorializing on the reviewer’s part than reviewing. Your mileage may vary, of course, especially if you agree with the reviewer.

What’s drawn me to these two particular books, indeed what has drawn me to this topic, is the conversational emphasis in both. Each is written from the points of view and in the voices of soldiers and Marines talking about being in a war. Driving to work this week I was struck by the complete absence of these voices in my life. Looking at the front page of a newspaper ca. 2014 beside the image from 1946 it’s clear that my experience is not unique. We have had men and women in a war for some 12 years now, but we are hardly a nation AT war, at least in comparison with our nation ca. 1946.

We barely talk about war, about Iraq, Afghanistan, or Al Qaida at all, while America in the 40’s talked about little else. If my experience is typical there is very, very little conversation that occurs between those who have served and those who have not, even though the length of our present wars has likely generated a similar number of war veterans walking among us then and now. Were the conversations of war only on the front page back then? Was there so little discourse about what it means to have been in a war when the veterans returned in the 40’s, too?

The United States has experienced exactly 3 incidences in which our country has been attacked since the Civil War. All of our wars and conflicts since then have been prosecuted on the soil of other lands. This is no less true now than it was in 1945, no less true following 9/11 than it was after Pearl Harbor. The towering strength of the U.S. economic engine insulates us today from the daily sharing of the war effort as completely as our new information technology makes the wars almost completely available for viewing. Interesting dichotomy, huh? War footage on demand, up to the minute, up close and personal, no war bonds or fuel rationing required.

It’s different now, you say. It’s not the same now as it was then, you add. Is that really true, though? All wars are unjust and all wars are just; which it is depends only on which team you’re on at what time. Did those who hated the wars of yesteryear hate them any less than now? Is the aftermath of being in war any greater or lesser now than then? Never having served, never having been in war, I have no standing to say, but from afar it doesn’t seem any less terrifying to have been detonated by a mortar in a WWI trench or bazooka in a WWII tank or an IED in a Humvee in Fallujah.

And there’s my point. I don’t know. There is no conversation, no opportunity to know. I don’t know why that is. I don’t think we need to re-introduce war bonds or ration nylons (imagine the carnage at Victoria’s Secret) to know we are at war. What I do think is that we will continue to have a disconnect between young people in a war and their country not at war until we engage in those conversations. War always seems to find us, for whatever reason, even when we are mostly minding our own business. We should know more about what it means to be at war.

When you come home from the War I’ll be ready to listen and to learn whenever you are ready to talk.

Once upon a time I came to the “comments” section of CrossFit.com several times each day to check in on my cyber-gym mates. Heady days, those, with >1000 posts on a “Fran” day, for example. The explosive growth of the Affiliate model has drawn most people to a local Box, and what we shared so many years ago is now shared locally and regionally rather than in one central place.

Except during Open Season, that is. This is our soccer World Cup, Olympics, and Mardi Gras, all wrapped up into 5 weeks. More than 200,000 of us are signed up, doing the WODs, posting our results, and Scoreboard Watching, “Leaderboarding”. Who got what? Where do I stand? Did you see that score from Kenya? Even if you, like me, simply use the Open WODs as a check on your own fitness, or even as just another day of training, there is still something just enough different, just special enough to make it seem like a bigger deal even if you won’t even see the middle of the Bell Curve of results.

I think it’s because you’re in. For the price of 3 Mocha Grandes at ChichiBucks you are as in as anyone and everyone else. For 5 weeks the Leaderboard is today’s equivalent of the old Main Page CrossFit.com “comments” section. And if the previous 3 CrossFit Opens are any indication the WODs will allow pretty much everyone who signed up to STAY in, too. I’m sticking with my contention that the Open is a great, big, wide open funnel that not only feeds into the Regionals but also stays open at the top each week so that most of us will stay somewhere on that Leaderboard. Everyone with the CrossFit basics in their quiver can take a shot each week. The folks running this show will see to that. The CrossFit Open is nothing less than the largest single participatory athletic event in the world today.

This is fun. The CrossFit dinner table becomes a banquet hall for 5 weeks, the old CrossFit.com writ large. So pass the Kettlebells and don’t hog the Wall Balls. Yell and cheer as loud as you’d like. Don’t worry a bit about making too much noise. Grandma and Grandpa signed up, too!

Should be a word. Offensitive: adj. One who is easily offended. Highly sensitive to perceived offense.

Have you seen the sculpture at Wellesley College in Massachusetts that’s been causing such a stir? “Sleepwalker” is a lifelike depiction of a rather–OK, very–unappealing male sleepwalking in nothing but a pair of “tighty whities”. The appearance of the sculpture has created a spasm of outrage among the offensitive, those especially prone to being offended. It’s gone as far as a petition demanding the removal of the statue because its very presence is a kind of assault, a violation of the civil rights of the offended.

Think about that for a minute: art that offends, or even art that only provokes a bit of discomfort, is a violation of some sort of civil right.

What have we become when a statue that should be met with ridicule and contempt because it is actually quite banal is rather invoking reactions that imply some sort of assault on the collective population of Wellesley? Is it the topic, the subject, a nearly naked man, skinny fat with a paunch and a frog butt that fails to fill his skivvies? It does make one wonder, what with the venomous attacks on those who were offended some years ago by sculptures of a Crucifix covered with excrement, or years before that by various desecrations of the American flag. Have we succumbed to some sort of spiraling weakness of spirit or character in the ensuing years, a collective fragility driven by the growing population of the offensitive,  or is there some qualitative difference in the “art”, who it offends, and how they are offended that is at issue?

That last part is a question that is probably above my pay grade, the relative effect of art on different audiences. There are a couple of things I do understand, though. Art, in all of its forms, is meant to provoke some sort of response in those who consume it. It’s my considered opinion that BETTER art makes you work a bit harder in its appreciation in order that you arrive at your own response; being bludgeoned by the artist’s intent markedly reduces my appreciation of any particular work. Some art makes some people uncomfortable, sometimes on purpose. I’m quite sure there’s a line beyond which it stops being art and truly does become an assault–free speech, after all, famously does not include the right to yell “FIRE” in a crowded theatre”–but “Sleepwalker” is as benign in this respect as it is banal.

The other question, that of our thin-skinned tendency to declare anything that makes us feel bad as some sort of assault, is something I also understand. We are trending as a society, at least at a certain educato-economic strata, to a level of offensitivity that threatens the fabric of our collective. Not only is there a greater tendency to be offended by ever tinier actions, but there is also a corresponding ratcheting up of the response to any offense. Call it the “offendedness arms race” if you will. Something that produces discomfort or offends is now something so much more. I mean, seriously, “Sleepwalker” violates civil rights laws? Other, even more trivial pieces of art have spawned lawsuits and public condemnation of any who have the audacity to question the fortitude of the offended. It’s all so silly. Have we in Western society so little to contend with in the prosecution of our daily survival that we have both the time and the energy to be offended by “Sleepwalker” and its ilk?

I dunno. Maybe it would have been different if “Sleepwalker” had been a CrossFitter.

The weekend papers introduced me to Charlotte Stockdale this week. I will admit that I’m a bit conflicted about Ms. Stockdale. My first impulse is to view her as inconsequential given her high birth and the subsequent layering of additional wealth garnered solely through genetic entry into the business of “pretty”. However, in an otherwise vacuous interview spent mostly discussing her personal relationship with skin care products, she provided me with the yin for a hanging yang.

You see, Beth and I have been on an adventure cruise, a quest of sorts. We’ve been exploring the wonders of the classic cocktail. Equal parts alchemy and indulgence, our trip has been more exciting (as all adventures are) because of the little bit of risk involved. What if we find one (or two, or…) we really like?

Like many pleasures to drink is to willingly hold the proverbial double-edged sword in your hand; in this case the sword just happens to look like a martini glass. Alcohol as both a substance and a subject is complex and rife with controversy. It’s legal, but only to a point. It’s beneficial, but with a caveat–people who drink just enough live longer than those who drink more or not at all. As a chemical it’s a depressant, and yet in many circumstances it imbues joy in those who imbibe. It all comes down to a fine and delicate balance, not unlike that found in a perfectly aged wine.

The matter of regulation intrudes on the pleasure. Knowing the existence of the second edge and maintaining an awareness of its cut is both necessary and nettlesome. If you find this lurking behind every glass, cannot escape it’s specter, it may rob you of the joy; if you careen from joy to joy you will inevitably suffer the cut and bleed. Temperance, then, is the essential ingredient, the co-pilot who must be ever present on this particular trip.

Ah, but temperance, willful self-control, can feel like a 50 MPH governor on a Ferrari, especially if you make the Indiana Jones-like discoveries we’ve recently made. It might be so difficult and so distasteful, temperance that is, that you decide to roll your dice on the “not at all” line. “Abstinence is as easy to me as temperance would be difficult.” Samuel Johnson. Indeed, temperance seems so often driven by that wraith “guilt”. There’s joy and pleasure to be had, but what if there’s too much? Ah, guilt.

It’s all so complicated, not unlike the math involved in the archaic elixirs we’ve been experiencing. So very hard sometimes to ease off the throttle without the aid of the governor. If the “Gizmo”, the “Sideswiped”, and the “Carro del Lô” be guilty pleasures we might ask my interesting discovery Charlotte Stockdale what she thinks of such things.

“I don’t have a guilty pleasure. I don’t really feel guilty about anything. What’s the point?”

As out of the corner of your eye you see it, the shadow of the double-edged sword, one edge Samuel, the other Stockdale, as the light dances off the blade.

Skyvision Centers has a subsidiary company called the Skyvision Business Lab. We do business process research for pharmaceutical companies, medical device companies, and other medical businesses in the eye care arena. One of the companies we have worked for is a very cool company that produces animated educational videos for  ophthalmologists and optometrists. I had an interesting experience while talking to their chief technology officer. It was interesting because the conversation proved our basic reason for existence at the Business Lab, that it is impossible for any company to develop, sell, and install any kind of product in our world without understanding the ins and outs of every day activities in an eye care practice.

Of course, I always find it extremely interesting when I’m right!

It was a tiny little point, really, but how could you know something as small and seemingly insignificant as our discovery unless you had spent time on the “frontline” of medical practice? The chief technology officer for the video company was frustrated because doctors and their staff were not using this really cool product that they had purchased. Furthermore, because they weren’t using it, they were failing to buy downstream products from the video company. As it turns out the salespeople for this company were telling the doctors that this particular product should be “turned on” by the staff at the front desk of the office. This is exactly the wrong place because the front staff personnel simply have neither the time, nor the understanding, nor any incentive whatsoever to do this. The product actually works beautifully if it is “turned on” by the back-office staff. Bingo! Problem solved.

So what does this have to do with Electronic Medical Records (EMR), and for heaven’s sake what does this have to do with underpants? It’s simple, really. When was the last time you bought a totally new type of underpants, underpants that you had never seen before, and underpants that you had certainly never worn before, without trying them on? Furthermore, what’s the likelihood that you would allow someone else to design, fit, and choose a style  of underpants for you if that someone has not only never met you but has never even seen a picture of you?!  That’s the image I get every time I read an article about EMR.

In theory the concept of an electronic medical record that would allow permanent storage of every bit of medical information, with the ability to share that information between and among doctors and hospitals involved in the patient’s care, is so logical and obvious that debating the point seems silly. If you have ever seen my handwriting, for example, you’d realize that the entire field of EMR was worth developing just to make doctors stop using pens and pencils! Trust me on this… the doctor hasn’t yet been trained who is also a specialist in penmanship.

I actually trained at  two of the pioneering hospitals in the use of electronic medical records, and indeed in the use of computers in medicine in general. Dr. Larry Weed and Dr. Dennis Plante at the University of Vermont were pioneers in the concept of using computing power to make more accurate medical diagnoses. Both the University of Vermont Medical Center and the Maine Medical Center were among the very first institutions to develop and implement digital medical records for the storage and use of clinical data like lab reports and radiology reports. In theory both of these areas make sense, but in practice the storage and display of clinical data is all that’s actually helpful in day-to-day practice.

If this is the case, if the acquisition, storage, and retrieval of critical data is helpful, the next logical step must be to do the same thing with the information obtained in doctor’s offices, right? Well, in theory this makes a ton of sense. The problem is that nearly none of the EMR systems now in place have been designed from the doctor/patient experience outward; they’ve all been designed from the outside in, kind of like someone imagining what kind of underpants you might need or might like to wear, and making a guess about what size would fit you. With a few exceptions, tiny companies that are likely to be steamrolled in the process, every single EMR on the market is the wrong fit for a doctor and a patient.

Why is this? How could this possibly be with all the lip service that is being paid to the doctor /patient relationship and the importance of getting better care to patients? It goes back to that same tiny little problem that the medical video company tripped over: it’s really hard to know how something should work unless you spend some time where the work is going to be done. Electronic medical records in today’s market are responsive to INSTITUTIONS, insurance companies and governments and large hospital systems. System before doctor, doctor before staff, staff before patient. Today’s EMR’s have been designed with two spoken goals in mind: saving money and reducing medical errors. Should be a slamdunk at that, right? But even here the systems bat only .500, producing reams of data that will eventually allow distant institutions to pare medical spending, but neither capturing nor analyzing the correct data to improve both medical outcomes and medical safety. Fail here, too, but that’s another story entirely.

So what’s the solution? Well for me the answer is really pretty easy and pretty obvious. Send the underwear designer into the dressing room! Program design, programs of any type, are one part “knowledge of need” and one part plumbing. How can you know what type of plumbing is necessary unless you go and look at the exact place where the plumbing is needed? How can you know what size and what shape and what style of underwear will fit unless you actually go and look at the person who will be wearing the underwear? It’s so simple and so obvious that it sometimes makes me want to scream. Put the program designers in the offices of doctors who are actually seeing patients. Set them side-by-each. Make them sit next to the patients and experience what it’s like to receive care.

THEN design the program.

I’m available.The  Skyvision Business Lab is available. I have a hunch that the solution will hinge on something as simple and fundamental as my example above — front desk versus back office.  It doesn’t necessarily have to be me, and doesn’t necessarily have to be us, but it absolutely is necessary for it to be doctors and practices like Skyvision Centers, places where doctors and nurses and staff members actually take care of patients. Places where patients go to stay healthy or return to health. Places where it’s patient before staff, staff before doctor, doctor before system.

For whatever it’s worth I’m 5’8″ tall, I weigh 150 pounds, and I’m relatively lean for an old guy. I guess it’s a little embarrassing to admit this… I still wear “TightyWhiteys”, but I’m open-minded. I’m willing to change.

Just take a look at me first before you choose my underpants for me.

The CrossFit Open 2014. Are you in? Of course you are! It’s a few bucks, sure, and you aren’t gonna make it to Regionals, but you’re in anyway. Right?

Of course you are!

The CrossFit Open is the ultimate participatory athletic event. It’s as if the USGA or the Royal and Ancient ran a tournament for every golfer who wanted to take a shot at the U.S. Open or British Open. $20 and you get to play a round on the same golf course as everyone else, even Tiger. Not only that, but in OUR version you get to play 5 times. Who cares if the chances that you will make it to the Big Show are pretty much exactly the same in the CrossFit Open as they are in my hypothetical USGA Open? Like golf (or tennis, or tennis, or Triathlon, etc.) we play the same sport as the pros.

You know, more or less…

How will I approach The Open this year? For people who are new to my bloviations I am at best a middle-of-the-Bell-Curve CrossFitter for my age and I have exactly zero chance of winning local Masters competitions, let alone make it through the Open. At 54 I am in the oldest group of my Masters division, but for the Open I will try the “As Rx’d” WOD each week, try to get a score that I can submit. It’s fun just to be a part of the conversation. You know, the anticipation all day every Thursday. What’s it gonna be this week. Watching the Leader Board is a hoot, even when your name doesn’t show up until page 14 or so (at least for me). Someone should come up with a “Fantasy Football-like” game we could play during the Open!

Or a drinking game. Yeah, THAT’S the ticket! A CrossFit Open drinking game.

Too heavy and too technical is what I expect to see, at least for me, so after my (likely feeble) “As Rx’d” attempt I will then either move to the 55+ group and do that level, or simply scale and do the Open WOD as my Workout Of The Day, my training. Throwing it in there, not knowing what it will be or how it will jive with the day before or the day after, it’s a little like the “Unknown and Unknowable” for which we train, right? In the end that’s the most important thing for me–the training I get from CrossFit.

Got a legit chance to break through and make it to Regionals? Very cool! Good on ya, and good luck! For the rest of us let’s try our best, give it our all, but let’s also remember that we do CrossFit for health, fitness and fun. Keep your wits about you.

As Sarge used to say on Hill Street Blues: let’s be careful out there.