Black Swans
In my early thirties, I became interested in the link between exercise, nutrition and orthopedic ailments. After practicing for some time, I noticed that my patients generally fall into two groups. The first group are those who lead active and health-conscious lifestyles. These people are fit and rarely come to the doctor unless they are injured. Minor injuries in this group heal quickly and major injuries that require surgery heal well and I don’t see these patients again until the next time they are injured. The second group is inactive and generally less health conscious. They are the ‘frequent fliers’ who are on many medicines and sometimes even have a couple surgeries a year. After being in practice for 20 years, I know these patients well and many of them are my favorite patients. However, I often wonder if there is anything that could be done so they do not have to see me so much. The answer is yes! All these people need is a little nutrition and exercise.
Exercise and nutrition and their relationship to orthopedics is one of my favorite topics to discuss. I am sure that I sound like a broken record when I turn the discussion to this topic with my patients, colleagues, friends, and family. That said, I have noticed over the years that some people will use the ‘black swan’ as an excuse to avoid exercise and nutrition. It often goes like this. “I know a 53 year old vegan cardiologist that ran marathons who dropped dead last year from a heart attack, so why would I eat grass and seeds? We are all going to die anyway.” My argument is this is an example of a ‘black swan’ or an unpredictable event. The vast majority of vegan, cardiologist runners live to a ripe old age. We may just want to focus on the one in a million and use him as an excuse for our own lack of effort for better health. Maybe if we look closer he is not even a black swan. Maybe he started paying attention to his health in his late forties and the damage was done, or maybe he had a strong family history of cardiac disease and was afraid to get a check up himself and confront his own mortality.
I love to give health advice, but I sometimes am afraid that I could be that ‘black swan’. I do a good job exercising and trying to eat right, but I am well aware there is at least some miniscule chance I could get cancer or drop dead from a heart attack. It worries me that someone would think that I was always preaching about health and nutrition and look where it got me. If I can I would haunt that person and let them know that I lived a healthy 55 years. I will say again: the body can be a cage or a machine that takes us on life's adventures. I have enjoyed hiking, mountain biking, paddleboarding, and many other physically-demanding activities with friends and family. I still enjoy playing in old man lacrosse and basketball games. I can still ski all day and play Thanksgiving football. I could be a ‘black swan’, but I’ve had fun along the way. I am not unusual though. This is normal for the health conscious, middle age population. but foreign to the “it sucks to grow old” gang. I have a senior partner who is almost 15 years older than me. He still plays tennis, pickleball, old man basketball, and skis. He is slower than he once was and a little more careful, but he is still out there having fun.
The “it sucks to grow old” gang can’t do these things. They slowly lose the activities and hobbies they once enjoyed and they wouldn’t dare pick up a new physical activity. Even worse, they may even lose the job they depend on to support their family as their body fails. They start to feel pain and soreness in their early thirties that healthy people will not feel until they receive their AARP card.
On the flip side, the non-believer always wants to pull out the opposite example of a ‘black swan’ and it goes something like this: “My grandfather never exercised, smoked a pack a day and lived until he was ninety-five.” Maybe grandpa is a ‘black swan’, but remember you only have twenty-five percent of his genes. Are you gonna roll the dice on that? And maybe if we look closer we can see he was not such a ‘black swan’ after all. Did his body become a cage? Was he tied to a sedentary life with the diseases associated with that life? Was he one of those fifty-year-olds complaining that it sucks to get old? How many surgeries did he have and how many medicines was he taking? How many weeks, months, and years did he spend rehabbing injuries and diseases?
Not too long ago quarterback Andrew Luck of the Indianapolis Colts retired in the prime of his career. It was not because he no longer loved the game, or could no longer play at a high level. It was because after many off seasons of rehabbing injuries he was sick of rehab. He couldn’t live the life he wanted because he was always in physical therapy. The solution for Andrew Luck was simple. Do not let 300-pound men tackle you. Maybe your grandpa was always in rehab from poor health as well. The answer may have been to drop the poor lifestyle that was his 300 pound defensive tackle.
I am an optimist, so let's assume grandpa really was healthy, happy, and content. Again, we may look and see that he was not a ‘black swan’. You may say he never exercised, but you failed to mention he walked his trusty dog Walker (named after Walker Texas Ranger) several miles a day. He hiked through the woods to get to his favorite fishing spot. He chopped his own wood. Grandma cooked mostly healthy meals of lean meats and vegetables. His life was low stress filled with a job he loved, a great family, and wonderful friends. Maybe smoking was the only bad thing he did. Not such a ‘black swan’ after all.
“The life of a man is like a game of dice. If the throw does not come up with the number you most need you have to use your skill to make the best of the number it gives you.”
-Terrance, Roman Poet
As I have discussed before, I like to think of our genetics as a game of chance. In other words, the genes you are given is the hand you are dealt, but how you play that hand can make a big difference. We can modify how our genes work with a healthy lifestyle. This means we can still win even if we are dealt what appears to be a losing hand. It takes willpower and habits to live a healthy lifestyle. This is why we should all focus on healthspan rather than lifespan. I see examples of people who lived into their eighties, but never saw a healthy, pain free day past forty. Other people die of an unforeseen event, but are healthy up until their critical illness.
“Fitness does not seem like it matters until one day it becomes obvious”
-Anonymous
If an unforeseen event happens, a life of preparation gives you the best chance of surviving. Whether you are trying to survive a cardiac event, or a cancer diagnosis, living a healthy lifestyle prior to the event is just as important as the fight you have ahead of you. Orthopedists see this all the time in practice. A musculoskeletal injury is often the beginning of a down hill slide in a patient's health. I often describe it as the little nudge that pushes the car over the cliff. If someone injures a leg, but has the upper body strength and opposite leg strength to stay mobile they will have a much quicker recovery. If someone injures their upper body but they have maintained the rest of their body they will be better equipped to manage the pain and adversity of the injury. For unhealthy patients, a simple leg injury can put them in the bed or chair from which they never get out. The upper extremity injury can be the straw that breaks the camel's back and leads to years of disability. What you decide to do with your own health is a choice you will need to make. I urge you to look at what gives you the highest probablity of an excellent healthspan and avoid using ‘blackswans’ as an example to base your decisions on.