MUSCLE UPS
It is 5:30 in the morning, and my right hand is bleeding again. I rotated a barbell knurl too fast and unhinged the epidermis from a week-old callus that had mushroomed over the base of my fifth metacarpal, and the blood-covered callus is now attached to the knurl. I stare dully at the blood and proceed on my rounds. I have six to go.
Bleeding calluses of the hand are an unusual occurrence for any physician, but especially a shrink. We develop backaches from sitting too much, sore wrists from writing too much, and headaches from hearing too much. We rarely bleed. We rarely have calluses. Our hands are usually used only for handshakes—when we fear our patients, not even for those. Lately, though, my hands have been as rough as unsettled earth, with peeling calluses on the palmar skin at the base of each metacarpal bone. It is my own fault. I joined what some call an exercise cult. I took up CrossFit.
A year into the regimen, my brother-in-law told me a joke.
“How do you know when someone does CrossFit?”
“I don’t know. How?”
“They won’t stop telling you about it.”
CrossFit adherents have earned that reputation. We proselytize. Adherents want to tell you about the Paleo diet that many swear by, which purports to approximate the diet of our Paleolithic forebears, and they shun apostates who eat the forbidden legumes or drink the verboten milk. Some celebrate a season of fasting, the Whole Life Challenge, in which adherents advance by being more abstemious than their peers. They move through a series of constantly shifting positions, like Catholics who kneel, stand, and kneel again during a mass. They have their own language, a blizzard of acronyms and eponyms that indicate how adherents should move their bodies through those positions. They celebrate their own brand of saints’ days, memorializing servicemen and servicewomen killed in combat with specific workouts that bear their names. Holleyman. Murph. Severin. Members meet in sacred spaces—neglected warehouses and service stations emptied of all adornment and furniture except those essential to their rites—which adherents call “boxes.” CrossFit has it own garments, calf-high socks and technical T-shirts printed with aggro slogans and garish skulls and avenging angels that are worn by the engineers, lawyers, and physicians pursuing exercise just rigorous enough that they must purchase a special instrument to file down the calluses which disrupt their once-smooth hands.
. . .
The nurses on the psych ward were the first to tell me about CrossFit. Psych nurses can be salty. They spend their days stationed in a landlocked version of the medieval ship of fools, supervising an unruly collection of people shunned by society. The quarters are tight, because space is monetized in contemporary hospitals, and to the extent the unit resembles a ship, it often feels like a submarine that has been at sea too long. When we have a group of especially agitated or assaultive patients, the air becomes stale and the mood tense. We spend day after day deep in the implacable currents of madness.
Joshua spends more days in the deep than most people. In a good year, he will be admitted only once. In a bad year, quarterly. Lately, he has been stitching bad years together. Each is a variation on the same theme. His meds stop working, or he stops taking his meds. He feels good for a few days, then the pharmacokinetics collapse underneath him. His thoughts begin to race, his words to clang, and he starts adding phrases to songs, as when I heard him shout-singing, “We’re gonna rock down to Electric Avenue, and then Lord Jesus will take us higher!” In the febrile moments of his mania, Joshua preaches constantly for the rapturous return of Jesus. By the time Joshua tears the clothes off his massive frame and struts naked down the Electric Avenue of his mind, he has been kicked out of another group home, and the list of places where he can live has been diminished by one, so he has to spend more days at sea in our unit, waiting to be accepted by another supervised home.
Arriving on the unit one morning, I checked in with the nurses at their station.
“How’s Joshua?”
“Oh he’s good. CrossFit this morning.”
“What’s CrossFit?”
“Oh, you know.”
“No.”
“Doc, he’s wearing himself out by pleasuring himself.”
At that point, “CrossFit” was just a new nursing euphemism to me. There are many, and like the slang of eleven-year-old boys, most relate to bodily functions. I approached Joshua’s room carefully and knocked. No answer. I heard murmuring and carefully opened the door. Joshua was naked on the floor, his backside to me, his lips pressed against the return grill of the ductwork in his room. He was whispering, “Eunuch, eunuch, eunuch for the kingdom. Eunuch, unicorn, unicorn, horn, just born.” I could not see his hands; whether Joshua’s CrossFit session was over or ongoing, this was an occasion where I feared a handshake.
The next time I heard about CrossFit was when the cultural trend crested into my neighborhood. A few years ago, a CrossFit adherent named Neil Allman bought a modest home catty-corner to an empty gas station, its pumps long exhausted and the twin blades of its high-bay fluorescents dim on the light pole out front. He leased the gas station, replaced the fluorescent bulbs, repaired the toilet and sink, and patched a few of the holes in the walls. He removed the automobile repair bays to accommodate steel pull-up rigs and attached ropes to the ceiling so athletes could clamber up them. He covered the oil-stained concrete floor with tiles of interlocking rubber. Neil transformed the wrecked station into a CrossFit box, and within a few months, the sweat of dozens of neighborhood athletes had dripped upon the floor.
I biked by one evening and saw Neil, a blond twenty-something Übermensch, shouting instructions at a group of thirty-somethings who looked as exuberant, if more sweat-stained, as my siblings and I did while climbing over tires in our grandfather’s tire shop. I stopped for a moment to watch. Every minute, a digital clock that looked like an overgrown pager would beep and they would make a rotation, from repeatedly striking a tractor tire with a sledgehammer to flipping those tractor tires across the cracked pavement to carrying weighted plates from one side of the parking lot to other and then back again. I biked past them to the gelato shop down the block, another cultural trend that had arrived in the neighborhood, but one that delivered known pleasures.
The next morning, I woke up before dawn and drove over to the hospital gym, a mirror-paneled room filled with treadmills and Cybex machines facing televisions broadcasting the overnight events from our wars. Several physicians were already strapped into the machines, earbuds in; we nodded hellos. I worked the pedals on the elliptical machine for forty-five minutes while reading medical journal articles. After completing that morning’s physical penance, I shaved, showered, and dressed.
I made rounds at the hospital. I saw patients. I taught residents and students. I used the One-Minute Preceptor to ask patients and students what they believed and why they believed it, and how they could change their beliefs. As I was giving them my feedback, a resident looked shocked that I was criticizing her performance so directly. As I noticed her expression, I recalled seeing Neil outside his box, giving constant, pointed, public feedback. Instead of being discouraged, his athletes had cheered one another on as they flipped tires, swung sledgehammers, and carried weights across the wrecked surface of a parking lot. If I were looking for a way to get somebody to do something he or she would not do without prompting, it occurred to me that Neil might be able to teach me how.
I gave up on the elliptical machines.
. . .
Neil told me to come by the box for a test. When I arrived, the box was quiet. One of Neil’s fellow coaches, a preposterously fit woman named Emily Schromm, was waiting for me. She asked my name and administered the test. CrossFitters call it “Baseline.” Row a half-kilometer (a third of a mile) on a rowing machine, then complete forty squats, thirty sit-ups, twenty push-ups, and ten pull-ups as quickly as you can. The workout is simple but not easy. I started off quickly, before becoming winded on the push-ups and breaking the exercise into smaller sets. I did the last five pull-ups one at a time. The whole cycle took me six minutes, almost forty minutes less time than I was spending on the elliptical machine, but when I finished, I felt far more spent. Ten pull-ups was something I could not do on my own.
As physicians traverse our training, we are encouraged to focus on the activities we can do with the greatest efficiency and effectiveness. If you are a surgeon, you are encouraged to identify those procedures that you perform most successfully and stick to them. If you are an internist, you are encouraged to identify the illnesses that you treat most effectively and specialize in them. You learn the practice guidelines, the billing codes, and the quality metrics for your illnesses and confine your expertise to those areas. After a decade of having every weakness identified and explored in medical training, you find yourself, as an attending physician, playing to your strengths.
As Osler promised, seeing much had taught me what needed to be done in almost every situation that occurred on my floor, and I knew how to teach other people to do the same. After completing the Teaching Scholars Program, I was giving more feedback to students and trainees. I asked for feedback from them, but they rarely spoke as directly as I did. As I pointed out the weaknesses of my students and trainees, I started to feel cruel. I have many weaknesses and failings in need of remediation, but since I have been doing the same job every day for half a decade, they are less visible. I wanted to know again what it felt like to receive direct feedback while learning something that did not come naturally.
. . .
“Hang from the bar. Contract your shoulders. Core tight. Legs together. Pull from the hips. Push from the hips. Pull your chin over the bar.”
It is five in the morning. Neil is teaching me how to perform the ten pull-ups in a row that I could not do during the baseline test. I am one of six or seven adherents awake on a frozen fall morning, and Neil is leading us through a series of exercises. We stretch, work on a skill, and then perform a combination of skills at full speed. As Neil works on the skill with me, the other athletes walk over to a bucket of gym chalk, rub a nugget of magnesium carbonate across their palms, leap to the bar, work through five, ten, fifteen, twenty pull-ups at a time, and then vault off the bar to begin the next movement. Pull-ups are a warm-up for them.
Pull-ups are a painful reminder for me. In my junior-high gym classes, boys were ranked by the number of pull-ups we could perform. I remember hanging inertly from the bar, unable to muster the force sufficient to bring my chin over the bar and thus raise me from the ranks of the athletically inadequate. Gym coaches would yell encouragement at us—“You can do it! Just do it!”—but they never taught us how to do it. Many of those coaches looked as though they had not performed a pull-up in decades. I remember looking at them with a skeptical glance, wanting to say, “I cannot just do this. Neither can you, you sadist.”
It was because I was starting to get those kinds of looks from my own students that I found myself hanging, once again, from the bottom of a pull-up bar. Neil climbed onto the pull-up rig next to me and broke down the movement into steps. With each step, he corrected my posture, reinforced what I was doing right, and corrected my failures. When my chin did not reach over the bar, he yelled “No rep,” but then taught me how to generate the extra bit of force necessary for my chin to crest the bar.
It took him two months, but I learned how to perform pull-ups. Over the next year, Neil taught me to climb a rope, to clean and jerk a loaded weightlifting bar, and to snatch kettlebells overhead—an array of movements I had believed myself incapable of. My growing ability increased my devotion. I woke up before the alarm went off, eager for that morning’s challenge. As I dressed for the box, I could see how the rituals were changing my body. My clavicles were bruised from cleans, my shins were scraped from snatches, and my thighs were expanded from squats.
Physicians had specifically advised me against squatting. In high school, I ran cross-country and loved long-distance running, especially runs where we explored new terrain, but my knees did not share my enthusiasm. As we increased the distance and frequency of our runs, my knees talked back more and more pointedly. I spent half of my senior season running laps in the pool. I visited physicians and physical therapists who eventually advised me to give up running and take up the elliptical machine, where no terrain was explored, as an alternative. They told me to build up the muscles around my complaining knees, but never to lift weights and never to squat. The treatment was economical, but it taught me no new skills. I learned how to use the elliptical machine on the first day, then spent a decade on elliptical machines, going nowhere.
Neil told me the opposite: learn to squat, and then squat often, with escalating weights. He taught me to air squat without weights, then to back squat with a weighted bar balanced on my shoulders, then to front squat with the bar pressing against my clavicles, and to overhead squat with the bar held above my head. I learned to pistol, squatting on one leg while holding the other in the air before me. Of all the weightlifting movements we performed in the box, I was best at squatting, the very activity physicians had told me to avoid. After six months of squatting, my decade and a half of knee pain was over, and I resumed long-distance running. I ran my first half-marathon at a faster pace than I had run in high school, the kind of experience that makes a true believer of one.
These experiences raised questions. How many of my patients are similarly stuck in unnecessary, physician-recommended regimens? Should I, as a physician, be more like Neil, more like a kind of coach?
The first question was difficult to answer, but I decided to put the second to the test. With students and trainees, translating Neil’s approach was fairly straightforward. Neil worked with each of his athletes differently, encouraging a fearful athlete to try a more advanced movement and discouraging a reckless athlete from lifting a dangerous weight. For both kinds of athletes, he would break down a movement into its constituent steps, so that they could learn one piece of the movement at a time, instead of being asked to perform the entire movement on the first day. So when students or trainees join our team, we meet on the first day and I ask for a description of a teacher or coach for whom they excelled. Together, we identify what motivates a student or trainee and how he or she learns. Watching Neil led me to break my comments into smaller steps. I take notes as a student or trainee interviews a patient. Afterward, I identify a misstep or two and discuss alternate approaches, rather than simply observing that an interview did or did not go well.
The trouble comes with translating Neil’s approach to patients like Joshua.
The literal translation would be to join my patients in our unit’s daily group exercise class. On occasion, a yoga instructor visits and leads the patients through poses. These sessions are well received, but the most disturbed patients frighten many yoga instructors, so we find that after a few sessions the teachers are less interested. Joshua, in fact, has seriously assaulted a staff member in the past, so lying next to him in corpse pose is a lot to ask of a volunteer yoga teacher.
More commonly, staff members lead the group exercise class. They do a few generic stretches and then insert one of two donated videotapes into what might be North America’s last working combination VHS-TV machine. When the patients are a bit rowdy, the staff plays a Tai Chi videotape, in which the mulleted and mustachioed instructor over-enunciates Chinese phrases and frequently invokes “My Master” while making slow movements through the air. When the patients are more lethargic, the staff plays a Billy Blanks Tae Bo videotape, in which Blanks wears a singlet that stops below his oiled nipples and prances around a studio set thrusting his legs and hands in the air. Whenever I arrive on the unit and find the patients exercising, I always stop to watch. The videos seem to be teaching viewers less about how to make peace with embodiment or to exercise, and more about how to be a narcissist. Look directly into the camera. Speak in catchphrases. Surround yourself with smiling sycophants mimicking your moves. Endorse your own line of workout clothes.
Both videotapes allow the staff—who are, after all, punished or rewarded based on how well they document patient care, rather than on their ability to motivate patients—to catch up on charting from the comparative safety of the nursing station. And some patients love the videotapes and will happily spend a full hour with Mr. Tai Chi or Billy Blanks. But most lose interest after a few moments; like the rest of us, the patients find it harder to complete the workout if they have to supply the motivation. So I sometimes fantasize about leading patients through chest-to-bar pull-ups and double-unders and Turkish get-ups.
Then I realize that this fantasy is one in which I impersonate Neil, in which I give up on medicine in favor of becoming a literal coach, while missing the lesson he taught me about being a physician.
. . .
Among CrossFit initiates, there is a popular saying: “Your physician is a lifeguard, not a swim coach.” The saying comes from a videotaped lecture by Greg Glassman, the founder of CrossFit, which adherents recirculate on social media. In the lecture, Glassman explains that physicians, like lifeguards, watch life’s action from a distance, intervening only when a problem develops. If you tear your ACL, a physician will repair it, but if your knee pain can be controlled by time on the elliptical machine, earbuds in, there is no need for a physician to intervene. In contrast, Glassman claims that CrossFit coaches are like swim coaches who teach you how to move differently before a problem develops. If your knee has pain, Glassman says you need to get off the elliptical machine and learn to move differently. Glassman contrasts the passive nature of most fitness programs with the active challenges of CrossFit.1
Like many of Glassman’s statements, this is an admixture of insight and overstatement. We need a lifeguard sometimes. Still, I take his point that we physicians ought, more often, help people improve their health the way a coach does. Neil certainly helped me.
There are no mirrors in Neil’s gym, no sycophants watching you exercise, and no one charting your movements on the sideline. There is, as in most CrossFit boxes, a dry-erase whiteboard mounted to the wall, where adherents keep track of their own records. When I look at the whiteboard and compare myself to the other athletes, I feel the same sharp fear I used to feel when I looked at hospital whiteboards and saw a list of new patients. Like those lists, where the patients changed daily, no record in the box is permanent, and each athlete is forever seeking a new personal record, the ability to perform a new movement or complete the “WOD,” workout of the day, “Rx,” as prescribed by the coach. The pursuit of mutual betterment through personal records is central to the social structure of the box. Working together, we push one another to complete one more round. I do not want to quit when the person beside me is working her or his way through another round, even when my calluses are bleeding. Persevering side by side builds community. So does the program, which is constantly varied to identify and address individual weaknesses.
My weakness remains muscle ups, a movement that combines speed, strength, and skill. You leap up and grab hold of gymnastic rings positioned just out of standing reach. With your legs together, toes pointed out, you pull yourself up so the rings are level with your sternum, then push down on the rings down so that they are tight against your hips, and you are balancing in the air. On one level, this is just a pull-up followed by a dip, two moves you learn early in CrossFit. The difficulty lies in the skill it takes to get from a pull-up to a dip while maintaining your balance in the air. The muscle up is a movement that is usually perfected by gymnasts, not physicians, and mastering the muscle up distinguishes the skilled adherents of the box from the merely committed.
It was muscle ups that the other members were working on when I started learning pull-ups on my first day. On the day I joined, they did not ask what I did for living—it was months before someone did—but whether I could do a muscle up. When I said no, they offered encouragement rather than condemnation. In the box, what matters are the movements you can perform, the weights you can lift, and the workouts you can survive working alongside each other.
In that respect, the box resembles a religious community. What matters is your participation in the life of the community, not your life outside the box. Neil reinforced this, sending reminders about missed sessions, passing out free vegetables from his backyard garden, and organizing community dinners for holidays and good-bye parties when a member moved out of town. Like communal meals in a religious community, these meals adhered to a specific diet. There were a lot of kale chips and bacon-wrapped dates washed down with tequila shots.
Over the past few decades, there has been a growing interest in translating the work of coaches like Neil into medicine. Most of this interest is, blessedly, less literal than my fantasy of doing rope climbs and kettlebell swings with persons hospitalized with a serious mental illness.
One adaptation is a variation of psychotherapy called health coaching. As in other forms of psychotherapy, the first step is building an alliance with a patient. In most forms of psychotherapy, a patient then identifies a problem. In health coaching, a patient typically identifies an area for improvement. In traditional psychotherapy, we often help a patient discern the relationship between past events and the patient’s own present condition. In health coaching, the therapist typically focuses only on present conditions. I work as a kind of health coach when I engage in motivational interviewing. Motivational interviewing, like the One-Minute Preceptor model, depends on getting someone to commit to a belief, exploring the evidence for the belief, and assessing his or her willingness to make a change.
You can engage even profoundly ill patients, like Joshua, in motivational interviewing.2 Some days we talk about what his medications do for and to him. Some days we talk about his desire to live in an apartment of his own. Some days we talk about whether he will strut unclothed around the unit or get dressed. With motivational interviewing, you can always identify a change that someone, even a patient as visibly ill as Joshua, wants to make. The work is satisfying to me because the interaction is less about telling a patient what to do than about motivating a patient to change. When I act as coach to someone like Joshua, I accept approbation or credit only for the extent to which I am able to motivate a patient to attempt to take action. It feels more honest and bearable than full responsibility.
A growing literature of rigorous evidence, the kind Archie Cochrane feared psychiatry could never achieve, supports the efficacy of health coaching, motivational interviewing, and related techniques like cognitive behavioral therapy. Cognitive behavioral therapy can be as effective as medications for many people with mental illness. Motivational interviewing is an extraordinarily effective way to help a person overcome addiction. Health coaching improves control of chronic diseases like diabetes and hypertension.3
The authors of this literature are enthusiastic about the benefits of health coaching. They write that coaching is focused on health rather than illness and on patients’ needs rather than physicians’ skills. Coaching can be delivered by professionals with far less training than physicians: a diabetic can teach another insulin control, a former alcoholic can coax someone to sobriety, a dynamic certified nursing assistant can help a person quit smoking.
But there are limits. Many kinds of health coaches and patient navigators have, like CrossFit instructors, modest training credentials. Since much of healthcare is routine, modest training is often sufficient. When rare events disrupt the routine, though, modest training can be dangerous. In many respects, the inconsistent training of health coaches, patient navigators, and CrossFit instructors resembles medical training before Flexner’s Report, in that the outcomes depend largely on the character of the coach, navigator, or instructor. Another problem is that for coaching to work, an individual must have some desire to be coached. Those are significant obstacles to adapting the lessons of CrossFit to patients like Joshua. Over the past few years, we have referred him to peer support groups and health coaches. They inevitably dismiss him from their practices, apologetically explaining that he is simply too ill for their services. One told me, “I know he speaks English, but it was honestly like he was speaking a foreign language when he came around.” Sometimes, you need a lifeguard.
. . .
CrossFit has earned its adherents and its critics. Serious weightlifters and gymnasts complain that boxes reduce their training regimens into mere exercise. Concerned physicians and trainers worry that teaching relatively unskilled people to perform demanding weightlifting and gymnastic movements leads to injuries.4 (Full disclosure: I have chipped a tooth and herniated my anterior tibialis muscle, but both injuries fell under the sign of Cochrane’s declaration that “doctors are superfluous” and required no medical attention.) And there are concerns about inadequate training for coaches.
These criticisms have merit, and I recognize that CrossFit is a fad whose time will pass (who still Jazzercises?), but it has taught me something about what to hope for in medicine. I wonder whether it could teach others in medicine as well.
In his lectures, Glassman celebrates the ways CrossFit creates community. Glassman developed the idea of CrossFit, but has no ownership or managerial role in local boxes. Glassman wants owners to focus on their box and its athletes, so he prohibits an affiliate owner from opening multiple boxes. Each box is determinedly local, named after neighborhoods rather than cities or states, so I go to CrossFit Park Hill, not CrossFit Denver. Within the box, the owner decides on the programming, hours, and rules. The creators of CrossFit have figured out how to transform the physical health of millions while allowing someone like Neil to create a community around his box. In contrast, hospitals have been able neither to achieve the health outcomes they desire for their patients nor to maintain local control. We are turning hospitals into factories owned by large corporations, insisting that only its economies of scale can achieve consistent outcomes. The growth of CrossFit suggests that we could still engage millions of people in an activity while allowing significant local control.
Of course, there are limits to how far CrossFit’s principles can be extended. Part of why it is easy for me to see how to be a coach to residents and trainees is that we are on a continuum, occupying different rungs on Osler’s ladder. They began their journey with no assistance from me and are internally motivated. They want to climb the ladder. The same is true at a CrossFit box. You join only after you volunteer for it. Joshua never volunteered for his illness, and he resents his encounters with a medical system that struggles to engage him in conversation. Anyone who knows Joshua will agree that he says remarkable things, but it is difficult to know what they mean. A recent conversation went like this:
“How are you?”
“My heart is indicting a good theme.”
“Why?”
“Roy Orbison is a good singer, but we don’t have to do everything he says.”
Joshua knows the language game of physician and patient better than anyone should. Physicians have seen him at least monthly for the past three decades. He has worked with two generations of psychiatrists and has been prescribed every fad medication around. Sometimes Joshua plays the language game of medicine with his physicians, and sometimes he chooses not to. Sometimes he is simply unable to play patient to the physician. At those times, his thoughts are racing, his ideas flying, and his non-sequiturs might as well belong to a foreign language.
At those times, I become to Joshua what my junior high coaches were to me, a person who demands that he do things he simply cannot do on his own.
Coaches can use techniques like motivational interviewing to kindle and encourage patients and students, but profound illness incapacitates self-motivation. Joshua is neither weak-spirited nor lazy. He is ill. Learning a muscle up—a task I still have not mastered after three years of thrice-weekly sessions—is challenging, but surely overcoming psychosis is a task of a very different order.
Maybe the best way to take advantage of the benefits of CrossFit is to take away the idea not of the coach but of the community of adherents. CrossFit is expensive, but I keep returning to the box, even after Neil moved away and sold the box to a new owner, Michelle Kinney. I still return every week because I am eager to learn new skills in a community that uses some of the techniques of a religious community—a purified diet, a ritualized space, a specialized language, and a communal life in which alliances develop among adherents. Perhaps medicine could use religious techniques to effect change in the lives of patients. That was the hope that first sparked my interest in medicine.