Dr. Anthony Iannarino

Is doing something always the right choice? We see over 5,000 ads a day spurring us to take action. If it’s buying groceries or a new pair of shoes the stakes are low and our knowledge of need and the product is relatively high. However, what happens when the barriers to understanding are hard to hurdle? How do we decide when there is a wall of expertise or perceived complexity blocking your ability to make an informed decision?

Misaligned incentives and knowledge silos are at the center of many offerings. It is the questioning of if you need more than an oil change on the visit to the mechanic. Or if the eloquent high management cost hedge fund portfolios will really outperform simple low cost tactic. It’s wondering if this MRI is really crucial information to aide in your recovery. The consumer is often behind a perceived knowledge wall. And the information is silo’d behind a person with more than enough incentive to do something.  In fact their finances and perceived self importance rely on it. The question we must ask is does this thing actually need done or is this person wrapped up in Do Something Syndrome. 

In his excellent book, Risk Savvy, Gerd Gigerenzer outlines a study on defensive medicine in Spain reported that the majority of doctors choose a different route for treatment for their patients than they would themselves. Additionally, the are most often unaware of the patients preference for treatment. The doctor is incentivized to do something. Gigerenzer refers to this as SIC syndrome. 

1. The decision is highly influenced by the drive to practice defensive medicine (Self Defense)
2. There is a lack of understanding of health statistics (Inumeracy)
3. There is a clear financial incentive to provide a service (Conflict of interest)

This should by no means paint a picture of medical providers as calculated, self serving con artists. Providers despite their most pure intentions to serve the patients best interest are often handcuffed by a fee for service system with a rich history of litigious threats.

The system is rot with misaligned incentives. The antidote? Patient education, advocacy, and information transparency. The paternalistic “whatever you say doc” mindset must shift. The responsibility here must start with the provider. Include the patient in your decisions. Make sure their wishes align with your recommendation. Provide options for care and the data and rationale behind each rather than a directive. Until a system pays the provider for their expertise rather than for a procedural code, Do Something Syndrome will most certainly persist.  

Reference: 
Gigerenzer G. Risk Savvy: How to Make Good Decisions. Illustrated edition. Penguin Books; 2015.

What is optimum and does it exist? 

If so how do we define it?

Is there an “optimum ” answer to a movement problem?

I define optimum as a range of solutions with the lowest cost on the system. The good news is our bodies are pretty good at this. Evolution has solved for efficiency. System really don’t like wasting resources.

Try out my theory. Toss a pen across the room. Ask a roommate or loved one to grab it for you. Did they retrieve the pen by doing cartwheels across the room? Maybe a crab walk or somersaults? 

Nope. 

The human used its bipedal magic to walk across the room to grab the pen. Or they picked an even more efficient route and told you to get your damn pen yourself. But what happens when the difficulty of the task goes up? When the lowest state of energy needed to complete the task is high?

There are many optimal solutions, until there is just one.  Picture a wedge. The thick end is the task at its most simple. Low constraints. The area inside is the possibilities of a correct solution. The narrow end is the task at its most demanding. There are very few correct solutions. 

Picture a bowling lane. There are a number of ways I can get the ball to the pins without landing in the gutter. I can spin the ball, I can throw it straight, I can toss it halfway and let it roll the rest. If I deviate outside a set “optimal” range, then I end up in the gutter. As the relative difficulty of a task increases, say trying to bowl a 300, the number of options that may be “correct”decrease. We move toward the narrow end of the wedge. 

Picture a barbell snatch.  I can get an empty bar over my head in many different ways. But when going for a world record the bar path and the lifters anthropometrics are more or less predetermined by physics. The body will only be able to self organize to a point. We are at the very edge of the wedge. 

Picture the transition from walking to jogging to sprinting. The forces related to walking have the least total cost on the body but you sacrifice speed. We are at the thick end of the wedge. The human can get away with more deviation in walking gait overtime with less risk of negative repercussions. But now try to run a sub 9.58s 100m. Again, we have come the very edge of the wedge.

Arguments over the importance of biomechanics and self organization versus coaching rage on in our profession. But the argument is really pointless without defining the conditions.  Optimum lives on a continuum. This means there are times when I should and shouldn’t care about the minutia. Biomechanics don’t matter AND are the most vital element to performance and managing risk. Context is key. Knowing when is the art. 

-Anthony 

“You do not rise to the level of your goals. You fall to the level of your systems.”

-James Clear

Tired, hungry, busy, frustrated, excited, ambitious, edgy, motivated. The spinning wheel of emotions is a normal day for me. Hell, I can hit 75% of these in an hour sometimes. So what happens to best intentions as my internal states fluctuates? 

I drop the ball. 

If you are anything like me you have 3 versions of yourself. Meet past Anthony, current Anthony, and future Anthony.  Past Anthony has done some cool stuff and has helped us get to current Anthony but he messed up a lot. He set goals and hit some but whiffed on a lot of others. He got tired, lazy, and lost motivation at times. 

Future Anthony is a down right super hero. This guy does not get tired. His will power is the stuff of legends. Tell him what to do and it’s done. On time. Every time. With a smile.

Current Anthony is a wild card. Some days he’s clear, confident, and lucid. Other days the motivation and willpower are as stable as a house of cards. 

Current Anthony loves to punt to future Anthony. Tomorrow will be better because future Anthony is a stud. He will know what to do! But the next day future Anthony never shows up. It’s always current Anthony. And that guy can be the worst. 

So how do we break this cycle? We create systems that allow a C+, hangry, tired current Anthony to succeed. We plan for a rainy day. We allow him to fall to the level of his systems. Motivation and the promise of tomorrow is exciting, but fleeting. A process built for sustainability is boring, but sustainable. Boring sustainable consistency compounds. In the moment these steps feel small but in the long game, they make for incredible levels of change.

Systems make past Anthony the super hero, current Anthony stable, and the story of future Anthony closer to non-fiction than fiction. 

Build a system that allows you to succeed no matter who shows up today.

-Anthony

“If you want to understand irrationality it helps to understand the quirks in your own mental wiring and then you can take appropriate precautions” 

-Charlie Munger 

We are not designed to see the world as it is. We are only privy to bits and pieces. And these fragments are filtered through our species specific glasses.  For instance the way a bat takes in sensory information is far different than how my dog does.  To a bat, the world is a series of sound waves clanging around at different frequencies.  To my dog it is a playground of smells.  This perceptual tool kit is meant to play to our strengths to keep us alive. It is not optimized for us to align with actuality. 

And what protects us to keep us alive can often interfere with our ability to be right. Evolution has incentivized us to think in certain ways. This is our species specific filter.  And as humans, each individual carries some variation of this. The unique way in which they see the world. 

Wouldn’t it be nice to know the tendencies of your own? 

To know whether you are more likely to lean towards optimism or pessimism.

To know whether you are attracted to what is shiny and new or cling too tight to old reliable.

Our life and work is constructed of millions and millions of decisions.  It would be useful to know what’s driving these. Yes we will still be wrong, but at least we can know in which direction. To control for this can make all the difference. 

-Anthony 

2021. The flip of the calendar is always a peculiar time. And this year more than any it feels monumental. From one day to the next not much changes and the weight of this heavy year is certainly not lifted as we enter 2021. But what these transitions provide is a moment to stop and look around. A smack in the face to call our attention to the year that has been and the year that will be. A moment to zoom out of our day to day task lists and simply breathe. 

So as we reflect on this year, be kind to yourself. Celebrate the victories. Mourn the losses. This year has stripped our world down to its bones. Take a moment to appreciate the beauty of what lies under the hood. What is essential.

In a world obsessed with what’s next take a moment to appreciate what is. 

-Anthony

What do we “know”about running injuries: Part II 

In part one we discussed the kinetics or forces at play during running. Here we will discuss the kinematics or joint angles and positions influencing running injury. The beliefs and theories surrounding reduction of running injuries are limitless. Many have reached a sort of religious or tribal status. A lot of these have had their moment in the sun and then faded away. 

Running has many different flavors of “normal”. The flavors of a theoretical optimal are more scant but variation still certainly exists. Among these flavors there are certainly common ingredients. 

Cadence
Strike close to COM
Decreased vertical oscillation

These variables directly influence the way in which we interface with the ground, thus directly affecting the amplitude and magnitude of the forces on the body. Each of these variables has been shown to reduce the loading rate and decrease braking impulse, which as discussed in part I appears to be the most important factor in injury risk. 

Conveniently, manipulating one often has an affect on the other two. For instance, increasing cadence 5-10% will likely shorted your step length which should shift your strike closer to under the center of mass and thus reduce breaking impulse and vertical oscillation. 

As mentioned, there are many flavors of normal. These qualities live on a spectrum with the center being a theoretical biomechanics optimum. Based on a number of constraints (age, weight, anthropometrics) you or your client will not live in the center of the optimal. If performance is plateauing or injuries persistently limit training abilities, perhaps consider increasing one of these ingredients in your recipe for a time. Stir it in and adjust based on taste. Pushing yourself an iteration or two closer to this “optimal” may have compounding effects. 

But of course, it’s not that simple. In part III, we will discuss the risk cycle and complex interplay of factors. 

Remember those old standardized test questions where they would give you 3 paragraphs of information with maybe three relevant bits of information to answer the following questions? There may be no greater trainable skill than the ability to deduce what really matters. We are swimming in information. People are screaming at you every time you open up your phone. Everyone has something to offer or teach you that appears to be essential to your craft. 

But what is essential? 

What are those three sentences that will allow you to answer the questions posed at you? 

We have to consistently seek the signal. Ask: is this relevant? Is this useful for me to solve the problem I am looking to solve?  If the answer is no, then at that moment it is simply noise. And we must have a zero tolerance policy against noise. 

-Anthony

Likely not. 

On his podcast, Akimbo, Seth Godin discussed Alexanders Theorem of Professional Exceptionalism. Simply stated, this postulates that most high barrier to entry professionals perceive themselves to be in the top quartile of ability.

As a potent example of this dissonance, Godin cites a recent study showing that 90% of drivers stated that they are better than average. Additionally, he stated that surgeons perceive themselves to not only be just better than average, but most perceive themselves to be in the top 90% of their field.

So are we as therapists as good as we perceive ourselves to be? Many variables are at play that may be skewing the perceived reality of our skill. I will outline a few

For starters it is a high resistance field to get into. Test scores, financial investment, and time all limit the pool of players. Thus, this limits the perception that anyone could do the job beacuse logistically, they can’t or choose not to. Compared to a creator of logos or a writer, where most are literate and have access to a marker and paper, the competitive market is much smaller and perception of the ability gap is much larger. 

Second, we are shielded by regression to the mean. A statistical phenomenon that pushes outliers back to the middle. Many enter our care as outliers and will naturally slide back to homeostasis with no intervention or a slight nudge. Many will get better and attribute this to our work whereas they would have improved without intervention

Third, our raving fans come back while the critics just simply fade away. That patient that didn’t get better and stopped coming could have been the result of a million different reasons that had nothing to do with our quality of care. While the fans come back and bring their friends. And unless the care is egregious or negligent many will not disparage the medical practitioner on a review as the relationship was personal and the intent was ultimately to help. Additionally, many who have come to you because they may not have liked their last therapist. This can be interpreted as, “I must be better than all of the schmucks down the street.” We do not see those who have left us. In our purview, they typically cease to exist. As therapists, we are most likely living in a echo chamber of fans. 

Creatives live with self doubt. They wade in failure and embrace it by stepping back up to the plate and improving. Many creatives have the opposite problem of seeing themselves as below the mean. So humble therapist, there is no one size fits all blueprint. The person in front of you is primed to like you but their problem is one in need of a creative solution. Be weary of resulting. Be weary of praise. Be weary of perceiving that you are special. Embrace the creative process and work to improve the elements of your practice. 

Judge yourself by the quality of your process not the quantity of your results. And remember, you are likely not as good as you think.

-Anthony

What do we “know” about running injuries? If we reduce the question down to its core elements, it is conversation about managing forces. It’s a conversation about tissues being able to dampen external forces and use them to produce internal forces to act back upon the ground. It’s about them being able to handle these demands with forces at given magnitudes over a certain accumulated volumes both acute and chronic.

So what are these forces at play? Vertical ground reaction forces (vGRF) are the highest magnitude forces at play during running. These forces can be broken down into 2 smaller elements. There is the impact peak, which is the initial “shock” of braking. The body taking the punch from the earth as we return from our brief moment of floating. Many studies show that the rate at which this initial loading occurs may be as important or more important to certain common injuries. ( see work by Willie, Dicharry etc..)

The rate of loading is broken down into instantaneous and average. A lower loading rate is akin to “riding with the punch”. The high forces can be dispersed over a longer time reducing impact peak. When we are watching runners and see a smooth glide versus choppy stomper this is the quantification of that aesthetic visual. The stomper takes the punch by ramming his head into it, while the glider patiently rides the wave. 

Second, there is the active peak. This is moment the rubber band is released. Potential energy being converted into kinetic. Occurring right around mid stance, this is the moment of maximum propulsion. The forces are internal tissue compressing and acting on each other to allow a punch to be delivered to to the ground. 

With force, it’s all in how we manage it. How efficient we can be. The difference between graph one with the choppy peak and graph two with the smooth peak are all in the movement profile of the individual. Central to this is the long debate over striking patterns. Conventional wisdom may tell you that the high impact peak directly relates to the heel striker while the smooth slope is related to the forefoot striker. While these are correlated they are not directly linked.  What factors are more directly linked?

Stay tuned.

As a coach or clinician we are results thirsty. Results are probably why we entered the field.

To help others meet goals.

To be better versions of themselves.

We brandish our marketing with sayings such as “I get you results”. Our professional identity gets hitched to this wagon. And this works if the population is right and the success indicator is fixed enough. It easy to get the 14 year old boy to gain weight. Leave him alone with a dumbbell and a jar of peanut butter and magic will happen. But drawing results from our direct interventions is a slippery slope. 

First, resulting may draw an undue attachment to a method. A this always works for me so this must be THE way. We can see past the blinders of our experience to know that the 14 year old ticking hormone bomb would have gotten bigger with about any training stimulus food combo. Same with a patient with acute back pain. “My patients all get better with X intervention.” Well, the literature shows MOST will get better with MOST things over enough time. In this way,  resulting can lead to myopia, overconfidence, and rigidness in thinking. 

Additionally, resulting can lead to an emotional attachment to results. If I am the person who gets results, what happens when I don’t? “My method works so it can’t be my issue?” We look elsewhere for blame. “The client lacks discipline. No way they are doing what I told them to do.” Or we blame ourselves. “I don’t know enough.” “I should have seen that coming.”

But the reality is outcomes are a bound to infinite variables both within and outside of our control. We are helping increase the probability that the goal is reached, not determining it to be. The best poker players in the world lose hands they should win and win hands they should lose. Manage probability to the best of your ability and understand the ultimately the result is out of your hand. 

The world is complex, be humble. 

The world is complex, be kind to yourself.

-Anthony