Random Thoughts from a Restless Mind

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.

–bingo

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.

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.