Monday, August 30, 2010

What is Crossfit?

For the past five months, I've aimed to do four or five Crossfit workouts per week.  Crossfit is a very unusual fitness program that I would highly suggest to anybody who is easily bored with their normal gym routine and who likes to see results in everything from flexibility to strength to cardiovascular fitness.  But it's a little bit hard to explain...

First of all, let me give you an example of one of my mornings while attending Crossfit South Hills.  I would wake up at 6:30, mix up a protein shake, grab an Accel gel, and race over to the gym. The warm-up consists of the following:

3 rounds of ten reps each of the following exercises:
-dislocates (PVC pipe raise above head and rotated down to the lower back then back up and in front, etc.)
-overhead squats (again using PVC)
-dislocate + lunges (PVC)
-back extensions
Then, we were required to do a "Buy In", which is usually to practice a skill-based movement. But it could also be a sprint (400m, 800m, or mile), max rep body weight exercise, or a mini-workout.  You never know!
After the buy-in, there's a Workout-of-the-Day (WOD), which is normally a nightmare.  After that, you complete a "Cash Out", which follows the same formula as a Buy In, only it normally works the same muscles focused on in the WOD, so it's extra hard.

Here's is an example of a typical workout routine at Crossfit South Hills:
-Buy In-
Max Effort Burpees For A Minute
21 Renegade Rows
Row 250M
12 Knees To Elbows
15 Renegade Rows
Row 500M
12 Knees To Elbows
9 Renegade Rows
Row 750M
12 Knees To Elbows
-Cash Out-
25 Strict Chin Ups

 The idea here is to complete the workout as fast as possible.  The beauty of most of these WODS is that they don't take very long.  Sometimes, the WOD only lasts for 6 minutes.  Other times, you might be grinding through it for a half hour.  Every session is an hour or less, though.  So if you switch to Crossfit, those constant, drawn-out sessions at your local Bally's will be history.  Crossfit four or five times per week, and your body will thank you.

Another great part of Crossfit - and probably the key to its incredible results-producing regimen - is that when you walk into your Crossfit gym, you are totally surprised by the workout.  Indeed, their slogan is "unknown, unknowable". While those who program the WODs do have a formula in mind to keep their athletes balanced over the long haul, you  have to be prepared for anything when you walk into the gym.  You might work the same muscles multiple days in a row (this is body-building, it's general athletic preparedness!); likewise, you may go a week without doing any ab-concentrated movement, for example.  Some WODs include tire-flipping, rope-climbing, or pushing a weighted sled across a parking lot.  We use jump ropes, kettle bells, medicine balls, and sand bags.  Like I said, Crossfit WODs are murder, but you see results quickly in all areas of fitness.
Here's another example of a WOD:
21 Thrusters (95 lbs.)
21 Pull-ups
15 Thrusters
15 Pull-ups
9 Thrusters
9 Pull-ups

This one takes more elite athletes less than three minutes to complete, but it's a full body workout.  

Olympic lifting and virtually any exercise that uses a long barbell will engage your core whether you like it or not (you like it, trust me).  Because most Crossfit WODs include a barbell movement, every workout does something for your core.  
A lot of people are critical of Crossfit because they see it simply as a strong man competition because of its frequent resort to Olympic lifting.  Here's a WOD that displays the type of cardiovascular workout that you can get from Crossfit:
2 power cleans on the minute (205 lbs.) for 15 minutes
For the remainder of the minute, do as many double unders as possible.  
Keep a running total of double unders.

This workout requires both strength and cardiovascular fitness to finish with a good time.

The only way to experience the benefits of Crossfit is to try it out for yourself.  Affiliate gyms are located virtually everywhere nowadays.  Despite all of the perks to your health and body, the community fostered in these gyms is unbeatable.  You would be hard-pressed to find a group of Crossfitters that wouldn't welcome you whole-heartedly into their gym and cheer you on while you improve your fitness.  I consider my coach and colleagues at Crossfit South Hills some of my dearest friends.

I can also testify to Crossfit's effects on my performance as a triathlete.  In July, I competed in the Steelhead 70.3 half ironman.  I broke my personal records in the swim, bike, and run distances (1.2 miles, 56, and 13.1 respectively).  My times: 32:57, 2:48:55, and 1:33:11.  My training reached about 15 hours per week, but five of those hours were dedicated to Crossfit training, meaning only 10 hours per week of swimming, biking, and running.  Most triathletes at this level are training anywhere from 15-20 hours in swim, bike, and run.  At the race, I was particularly strong in my transition from bike to run, which is normally considered the hardest part of the race. I also required virtually no recovery time.  In fact, I had to jump in the car and drive straight back to Pittsburgh after the race in order to be in Philadelphia for classes less than 48 hours afterwards!  After having crushed the triathlon and then driving for 7 hours back to Pittsburgh and NOT having any stiffness or sore muscles, I can only attribute my great experience and times to Crossfit South Hills (and my adherence to the Paleo Diet, but more on that in the next post...)

Try out Crossfit.  Most gyms will allow you to work out a few times for free!  And all you have to do is show up ready to sweat.  I suggest Crossfit South Hills if you live in Pittsburgh.

Have fun getting the body you have always wanted, sleeping better, buying new clothes, making new friends, and freeing up some time in your schedule due to the brevity of Crossfit sessions!

Monday, July 12, 2010

Barefoot running and correcting your stride

As a FIT professional at Fleet Feet, I receive an increasingly greater demand for "barefoot running shoes" (how's that for an oxymoron?). Normally, customers are specifically looking for Vibram Five-Fingers, but the Nike Free is still a popular choice.  Most commonly, people saunter into a "Chi Running" class or read something featuring the "Pose Method" of running, or, my personal favorite, read Christopher McDougal's book Born to Run,, then coming looking for shoes that will help them apply what they have learned.  If you think I'm going overboard with links, then I accomplished my goal!  There is a ton of writing being done on the topic of barefoot running as well as methodologies that claim to make running easy, pain-free, and even comfortable!  

The truth of the matter is that running is a natural movement with which we have fallen out of touch.  Over millions of years of evolution (in case you haven't been able to tell from past posts, I love evolutionary biology!), the environment selected for minor tweaks here and there to our bodies.  As a result, we developed the ability to walk upright, freeing our arms to carry stuff (or pump to help us move our legs faster); an extremely complicated structure known as the foot; and a perfect arrangement of tendons, ligaments, and tissues that enabled us to walk or run whenever we needed to escape danger, hunt, move stuff, or have fun.

This is the barefoot runners' argument: evolution gave us a body that was not meant to wear shoes!  Many indigenous tribes and communities around the world have maintained near-barefoot practices.  The Tarahumara are a group of Mexican indians that lives off of ultra-distance running and booze, and they are virtually injury-free.  McDougall's book (mentioned above) centers around this tribe of amazing athletes who insist on wearing no more than a piece of leather and straps.

While this is true, evolution never intended for us to walk around on uniform concrete all day long.  The many bones in the foot enable it to adapt to uneven, rough terrain, meaning modern barefoot people - who wore shoes for the first 30 years of their lives - are probably doing more harm than good by diving into barefootedness.

Having said that, many people find that (slowly!) transitioning to barefoot running (or at least using as minimalistic a shoe as possible) helps them become not only a more efficient runner but also less prone to injury.  The reason can be found if we look at the evolution of the running shoe:

1832 - Englishman Wait Webster patents a process wherever a thin, rubber sole can be attached to a canvas upper
1860 - A croquet shoe is developed using Webster's process.  These shoes are noiseless when worn, hence "sneaker".
1890s - These shoes quickly began very popular as children's shoes.
1917 - The first popular sneaker is released in the U.S.  The company is called "Keds", which is likely a combination of "Kids" + "peds". Also, Converse introduces it's high-top basketball shoe.
1964 - Phil Knight and Bill Bowerman found Blue Ribbon Sports.  They begin selling Onitsuka Tiger shoes out of Knight's car at track meets.  Onitsuka Tiger eventually becomes Asics.  BRS eventually becomes Nike.
1974 - Bowerman experiments with waffle irons and creates the waffle sole.  He markets a new shoes called the Waffle Racer.

After the introduction of the Waffle Racer, the running shoe industry exploded.  Shoes became more complicated as time went on.  Currently, it's nearly impossible to buy a regular running shoe without a big chunky rubber heel, which enables us to land on our heel with each step.  To strike on the heel, you must lengthen your stride.  Don't believe me?  Try it yourself.  Go find an empty sidewalk and take off your shoes.  Walk a few paces, paying close attention to your feet.  You will notice that your natural walking pace is programmed for a mid-foot strike, not a heel strike.  Now, mark off about 20 yards on the sidewalk.  Jog first with your shoes on between the markings, counting every stride.  Repeat barefoot.

If you are indeed a heel-striker, you will count more paces during that drill barefoot than while wearing shoes.  Without the plushy heel, we naturally correct our gait by shortening our stride, transitioning our body weight forward over the feet, and landing on the mid- or forefoot as opposed to the heel.

Mastering this technique will make you efficient without losing the running shoes.  My buddy Dustin runs in Vibram Five Fingers occasionally, and, while he'll be the first to let the good vibes roll regarding minimalistic shoes, he confesses that the thin soles allow even the tiniest stone to jab into your plantar fascia. So I still like to wear my shoes.  A longer stride is inefficient because it is often accompanied by locking out of the knee.  When you land on a locked out knee, it acts to break your forward momentum.  There's no fluidity to this motion, as you'll see in the video below:

The alternative is to lean slightly forward at the hips and allow your body to almost fall forward. Your feet are forced to shuffle forward in order to keep you from falling on your face. That's pretty much it! If you watch elite runners, their heels never hit the ground because they don't over stride. They land on their mid- or forefoot, and their cadence is very fast (90-98 strides with each foot per minute!)

Another benefit to running (or just walking around your house) barefoot is that it strengthens the many muscles in your feet.  The 26 bones of the foot are controlled by a bunch of muscles that are required to do very little work from the day we begin walking due to our over-reliance on shoes.  Allow your feet to breathe, and I think that you'll find that you'll be less prone to injury.  Decreasing stride length = eliminating heel strike = lower impact running. By the way, flip-flops don't count!  There's still a nice chunk of rubber under your foot! 

My suggestions for improving your running are simple:
1) Slowly transition through very short distances if you wish to begin barefoot running.  If nothing else, go to a high school football field and run a few lengths of the field without shoes on after your workout.  Practice shortening your stride and landing mid- to forefoot.
2) Once you understand the basics, don't over think running.  The beauty of the motion is that it should feel natural. As Matt Fitzgerald says, Run Unconscious!
3) Take your shoes off around the house and in your yard.
4) Aim for a higher cadence rather than a longer stride when you're trying to go faster.  If you already are running with a high cadence, check out some of Joe Friel's writing (blog linked below) for drills to increase your stride length while maintaining mid- to forefoot striking.

Some more resources:

Happy running!

Send me questions if you got 'em:

Monday, July 5, 2010

Developing the "kick"

In 1983, Jeff Smith was leading the New York City Marathon at mile 26.  Rod Dixon, in second place, had been closing in on him since mile 20.  At mile 26, Smith looked over his should, only to see a possessed Dixon speeding past him.  At mile 26!  In the ensuing 0.2 miles, Dixon's legs churned, taking him straight to the finish line, increasing in speed the whole way.

This incredible drive by Dixon at the end of the marathon is something I like to refer to as "the kick". Developing the kick takes time and patience in your training. It's normally the result of regular fast, explosive workouts that focus on building anaerobic endurance.

Jeff Dixon is historically a miler, meaning he was a short-distance racer turned marathoner. Through regular speed work sessions, he managed to maintain his anaerobic engine in addition to improving his long course endurance.

Anaerobic work ranges from heavy weightlifting to short-distance sprints. If you're a runner, this obviously means running sprints. But you can build the kick in swimming or cycling in similar fashion - short, powerful repetitions.

Anaerobic work has benefits beyond developing the kick, a useful component of endurance sports competition. It also revs up your metabolism and builds muscle. As a runner, if you were to focus your time primarily on speed work at the track, you would look more like exhibit A as opposed to exhibit B:

Don't get me wrong. I don't think one body type is better than the other, but, physiologically speaking, the anaerobic giants tend to have more muscle mass, and aerobic runners, who would observe decreased performance from extra, heavy muscle mass, tend to be thinner.  Long-distance guys don't need the explosive power garnered from big muscles.

Anyways, "the kick" is one of the most incredible things to watch in sports.  When you see somebody turn on the jets at the end of a long event, you can't help but admire them.  It's so hard to develop the kick, but the result is well worth the price.

Friday, June 18, 2010

How to Fix the U.S. health care least partly

Anybody that claims that they have the solution to the U.S. health care dilemma is crazy.  I won't try to provide a secret recipe for health care reform, but I do think that there are some important facets of other health care systems around the world that should be implemented into our own system.

1) Insurance companies should be prohibited from making profits off of peoples' health.  Shareholders?  Gone.  Their primary function must be to keep people healthy.  There really isn't any way around this.  Health care costs money, so when you deny people coverage, you conserve more of it for your shareholders.  This must end, no questions asked.

2) Insurance companies can't refuse coverage based on pre-existing conditions.  In fact, they shouldn't be able to refuse coverage to anybody, period, if that person is willing to pay them for insurance.

3) To make sure that people don't abuse #2, everybody that can afford it must pay into insurance.  If everybody pays, then premiums are lower because costs are distributed across a larger population.

4) It should be illegal for pharmaceutical companies to spend so much of their budgets on marketing.  Currently, U.S. pharmaceutical companies spend about 24% of their budgets on marketing their drugs, which is over ten percent more than they spend on research and development.

5) A special advisory commission comprised of health professionals should negotiate all prices for any procedure, treatment, drug, test, and other health care service. These prices should be fixed nationwide for any patient, provider, and insurance company.  Insurance companies should focus on expanding their client list rather than on finding reasons to deny reimbursement to their clients.  Since prices are fixed, they have to pay no matter what, so they'll increase their income by enticing more people to sign on with them, and then by keeping those people healthy.

6) Prevention should become our primary objective.  This includes improving access to locally, sustainably produced food; better public health regulations (e.g. reduced air pollution, access to safe drinking water, vaccinations); steep taxes on all processed foods except restaurants that meet certain established dietary guidelines; steep taxes on cigarettes and alcohol; the encouragement of tests and screenings for cancer, diabetes, cardiovascular disease, etc.; and improving access to fitness facilities and programs.

7) Taxes collected from processed foods, cigarettes, and alcohol will help to fund health insurance for those below the poverty line, senior citizens, veterans, military personnel and their dependents.

8) A separate advisory committee established by the government should make recommendations for which screenings and test should be done on which populations and how often they should be done to produce the best results.

9) Physicians must regain the power to choose whichever treatment they see fit for their patients.  The commission suggested in point #5 will outline a fee schedule for every treatment imaginable (as long as they see a benefit in covering it), and the physician may choose whichever drug or procedure that they think would be most effective.

10) Medical schools should be free to the student.  In 2009, the average debt incurred by U.S. medical students was $156,456.  This is the figure achieved after graduation.  Add on 15-30 years of interest, and you're looking at a second mortgage on a very fancy house.  It's simply too difficult to pay off medical school loans on a primary care physician's salary.  If school was free, many more people would choose fields in internal medicine, which is currently desperate for more doctors, and which also happens to be the field in which prevention could reign supreme.

11) The USDA needs to revise its dietary guidelines, and these guidelines should be followed strictly in our schools.  Even with the recent 2006 USDA Food Pyramid Revision, it's suggested that we eat more carbs than necessary and not enough healthy fats and protein.   Processed carbohydrates should be forbidden on the food pyramid.  All of the carbohydrates that we need should come from fruits, vegetables, nuts, and legumes, as far as I'm concerned.  Soft drinks, candy, and pastries should absolutely not be allowed to be served in grades K-12.

12) Government subsidies should be reserved for organic produce and raising free-range, hormone-free, grass-fed livestock.  Evidence for the health benefits grass-fed beef and dairy; free-range poultry products; wild fish; and organic produce is overwhelming.

13) Brace yourself for this last one.  Every U.S. citizen needs to start taking personal responsibility for their health.  While there is probably some connection between genes and disease, the diseases that are most taxing to our health care system (those associated with metabolic syndrome) can be largely avoided through a healthy diet and frequent exercise.  Get your kids outside rather than buying them electronics to keep them busy.  Get yourself outside with your kids!  If you are young and feel healthy, start incorporating regular exercise into your life to maintain and improve your fitness.  The most important thing that we can all do is to educate ourselves about food.  Cook your meals at home rather than resorting to fast food every day, and slowly incorporate more produce into your diet.  Lastly, take it on yourself to pressure the government and school boards to fix the school lunches and physical education programs at your local schools.  There are countless things you can do to live a healthier life.  You know what to do.  


Considering the huge disparities in our nation's health when compared to other developed countries, it would be absurd to think that we can't do any better.  Our health care expenditure is nearly twice the next highest in the world, yet we get shockingly poorer results.  Health care costs continue to rise faster than we are able to accommodate them, due to constantly improving technology.  The most important reason to reform ourselves drastically is that people are dieing from diseases that were entirely avoidable in the first place.   When people do get sick for fault other than their own (e.g. genes, accidents, and natural disasters), we should have a system in place to help them out. 

Thursday, June 17, 2010

Global Health Care Systems - Canada

Notes on Canada's health care system: 

1. Taxpayer-funded national insurance program, which is titled Medicare (sound familiar?)
2. The system covers all hospital and psychiatric care.
3. Private health care providers, government financing.
4. Canadians generally love the program.
5. Medicare guarantees everybody health care who needs it while maintaining better health stats than the U.S.
6. Canada's system is going bankrupt though.  It hasn't been increasing its expenditures to match the rise in health care costs.
7. There is a lack of doctors due to poor compensation; Canada is also working to reduce the number of medical students because the system can't afford to pay so many doctors.
8. Service is available for all persons with acute illness, accident, and emergencies, but non-life-threatening problems may require a long wait.
9. Some people never even get to see specialists because of the long waiting lists.  They either get their care elsewhere, or they just give up on the pursuit.
10. Waiting periods differ between provinces and according to your particular needs.
11. Reports of Canadians fleeing to the U.S. for medical care aren't backed up by statistical research.  The actual number of such cases is tiny.
12. Those whose urgently need care will get it, but those who can wait must wait, and they seem to do it without much complaint.
13. Each province has its own Medicare plan, so Canada's system isn't a single-payer system. Some provinces require co-payments, others cover 100% of the cost.  However, the system works like single-payer system since the federal government provides most of the funding and sets regulations for the provinces (Canada Health Act of 1984).  Rules laid out in the Act are, for the most part, simply advised, but if provinces don't follow the rules, they forfeit their ability to receive government subsidies, which no province can afford.  So, the rules are effectively laws.
14. The basic principles of the Act are: a) administration must be done on a non-profit basis; b) each plan must pay for all "medically necessary" treatments; c) every resident within a province must have equal access to health care services; d) the plan must pay for services received anywhere in the country and often in foreign countries as well; e) patients must be charged the same fee, regardless of age or illness
15. Most Canadians pay nothing when they visit their doctor, nothing for screenings or tests, and nothing for vaccinations. Preventive dental care isn't covered, but dental surgery is covered when performed in a hospital.  Ambulance services are covered in most provinces.  Mental health care is largely covered, but expect a very long waiting list.  
16. Prescription drugs are much cheaper in Canada, but they aren't covered at all by insurance, except for the poor, senior citizens, and chronically ill persons, except for "lifestyle" drugs such as Viagra.
17. Two-thirds of Canadians have private, supplemental insurance to cover thing that aren't covered by Medicare (e.g. dental, private hospital rooms, prescription drugs, etc.) 
18. Private insurance won't, however, shorten your waiting time.  
19. Since Medicare covers all of the expensive stuff in Canada, private insurance is very cheap.
20.  To avoid a flight from Medicare, it's illegal for patients or private plans to pay for any medical service covered by Medicare.
21.  A physician must choose to be accept Medicare or provide private services - they can't do both.
22. The problem with this model is that there is no way to get around waiting lists, even if you would pay dearly for otherwise Medicare-covered services.
23. To respond, there is increasing pressure on the Canadian government to spend more money on health care and to train more doctors. 
24. Physicians are paid must less than American doctors.
25. All patient records are digital.
26. Medical schools cost about half the price of American med schools.

Wednesday, June 16, 2010

Global Health Care Systems - UK


Notes on the UK's health care system:

1. Nobody pays any part of a medical bill.
2. No insurance premiums, no co-payment.
3. There are private health insurance plans, but virtually nobody uses them.
4. Health care system is financed through heavy taxation.
5. There are numerous treatments and medications that aren't covered by the National Health Service (NHS).
6. The UK system is infamous for its long waiting lines.
7. No billing, no paperwork since everything is covered by the government, so it's surprisingly cost-efficient.
8.  Lower child mortality, longer life spans, and better recovery from major diseases.
9. The system only pays for what it deems necessary medical care.
10. The government owns the hospitals, compensates health care professionals, buys medicines, and pays the bills.  
11. This is the "socialized medicine" model.  The same system we use to provide medical services to Native Americans, veterans, and military personnel and their dependents. 
12. Physicians can still see patients on the side and charge their own fees, but few people take advantage of private services outside of the NHS network.
13. The NHS is the largest  employer in Europe (over a million full-time employees).
14. The only fee is for prescription drugs ($10), but this fee is waived for children, senior citizens, pregnant women, and the chronically ill.  Patients are, however, often required to pay for eyeglasses, contact lenses, false teeth, and some dental bills.
15. Government regulations are vast in an effort to contain costs.
16. A major reason for the cost-efficiency is the lack of billing offices and the bureaucracy required to review insurance claims that exists in the U.S.
17. General practitioners (GP) are private businesspeople, but most are paid solely by the government.
18. Every UK citizen must register with a GP.  To see a specialist, you must be referred by a GP.  This "gatekeeper" system is utilized to a large degree by U.S. insurance companies, and it is very effective at controlling costs.
19. GPs receive a set fee for each person that chooses them as their practitioner. Thus, there is an economic incentive to have more people, but more people means more treatments and procedures because the NHS pays GPs per patient enrolled, regardless of whether they come in for treatment.  For this reason, prevention is always first priority, since less people coming in for treatment means less resources used.
20. There are tons of campaigns promoting preventive behavior.
21. Waiting lines for specialist care are the biggest complaint in the UK system.   
22. Anything life-threatening doesn't require a long wait.
23. Primary and preventive care is not rationed. 
24. The NHS controls its budget by covering only certain medications, tests, and procedures.  This type of rationing also takes place in the U.S., but decisions are made by insurance companies behind closed doors.In the UK these negotiations are constantly in the news, open to public critique.  The agency within the NHS that makes these decisions is called the National Institute for Health and Clinical Excellence (NICE).
25. The UK's health care system operates on very egalitarian principles: how can we provide the best care to the most people.
26. Physicians make house calls.
27. Annual physicals are considered pointless.  They prefer to do screenings and tests for disease, but only those that would be considered appropriate according to your family history and other factors affecting your potential for disease.
28. If your complaint isn't detrimental to your quality of life, you probably won't get any treatment, unless you want to wait along time and pay for it yourself.
29. About 60% of physicians are GPs (35% of physicians are GPs in the U.S.).  This is because GPs in the UK normally make more than specialists, since they make more money if they see more patients.  Many GPs also see patient privately on the side. 
30. GPs earn additional income through the Index of Quality Indicators, which pays GPs for good performance.  This replaces the fee-for-service model so common in the U.S. Doctors are simply paid more for taking the necessary steps to keep their patients healthy.
31. Malpractice insurance is much cheaper in the UK than in the U.S.
32. In the UK, anybody sued for malpractice is off the hook if they can prove that they were following NICE guidelines.  This also leads less GPs to practice defensive medicine, suggesting multiple screenings and test simply to cover their behind like in the U.S.

Global Health Care Systems - Japan

Notes about Japan's health care system:

1. No waiting, no gatekeeper, no rationing, and a very high level of patient choice
2. Prices are low as a result of a rigid cost-containment system that benefits the patient at the expense of the doctors and hospitals
3. Even the best, most prestigious doctors are accessible at virtually no cost to the patient.
4. Japan's system is largely private.  
5. Competition between doctors, clinics, and hospitals is fierce.  Everybody claims their treatments or procedures are more effective.  There are billboards and ads (this one a cure for sweaty hands) everywhere in the cities.
6. The Japanese use more medical care than any other country.  They average 14.5 hospital visits per year, three times the U.S. average.
7.  Nearly all Japanese physicians make house calls.
8. The Japanese gets twice as many cat scans per year as Americans, 3x as many MRI scans.
9.  Patients enjoy twice as many hospital beds per capita as American patients.
10. The Japanese spend 36 nights per hospital visit as compared to 6 nights in the U.S.
11. Japanese women spend 8-10 nights in the hospital after giving birth, compare this to 1-3 days for American women. 
12. Japanese are much less likely to take advantage of invasive surgeries.  Physicians don't recommend it anyways because it's so expensive, and they receive high compensation.  The Japanese also have cultural hesitations about going through surgery, they prefer to take advantage of less drastic options. 
13. Drugs are usually preferred to surgery. The Japanese pop twice as many pills as Americans.
14. Despite incredibly cheap access to patients, the Japanese actually require less medical care than Americans.  There is less obesity, lower rates of blood-borne diseases, and less illicit drug use.
15. Health care costs are steady or even declining.
16. Medical providers' income is much lower than in most developed countries.
17. Patients are required to pay 30% of their medical bills as a co-payment, insurance picks up the remaining 70%.  Co-pay is lower for children and senior citizens.  There is a monthly limit on co-payment; nobody has to pay more than $650 per month.
18. Insurance plans cannot refuse coverage, regardless of preexisting conditions, and they cannot deny a claim.
19. Insurance companies are nonprofit entities; providers are private. 
20. Japan has over 3500 different insurance plans to chose from.  Three major categories: 1) plans set up by large companies to cover their employees, premium split 55:45 employer:employee, no government subsidies, companies subsidize premiums for pensioners, some companies (e.g. Honda, Toyota) even maintain their own hospitals; 2) in smaller companies, employer/employee split premium but with help from government subsidies; 3) Citizens Health Insurance plan, which covers retirees and the self-employed; individual and local government split the premium
21. Everybody is required to buy into health insurance.  If you don't choose one, you'll be assigned one by local government.  If you don't pay your premiums, you'll be hounded by collection agencies.  If you get sick, you're required to pay up on all past over-due premium payments before insurance will foot your bill.  If you're unemployed or unable to pay your premiums, the local government pays your premiums and bills instead.
22. When a worker loses his job, the government steps in to cover the employer's share of his premium.
23. Even the richest are required to buy into insurance. 
24. In Japan, you don't get to choose your insurance plan.  Rather, you are given a plan by your employer or the local city government.  Patient choice rests around physician, clinic, and hospital selection.
25. The Ministry of Health and Welfare negotiates all prices with providers.  Prices are set for every doctor, clinic, and hospital in Japan regardless of how luxurious or rural.  All fees for every procedure imagineable are published in a book called the Shinryo Tensu Hyakumihyo (Quick Reference Guide to Medical Treatment Points). Prices are renegotiated every two years.
26. Costs remain low  because of extremely poor compensation to physicians and hospitals.  Doctors don't get rich in Japan, they are average earners, "comfortably middle class".  Being a physicians, however, gives you sky high social class.
27. Multi-payer system that works like a single-payer system because of the strict fee schedule. Hospitals and doctors compete for customers, but fees are set.  This is like phone service in the U.S.
27. Doctors often drive innovation of cheaper, more efficient technology because they want to be able to make more money for the same procedures.
28. Many hospitals and clinics are on the verge of bankruptcy.
29. The list of procedures and treatments that are paid for by insurance is vast.  U.S. critics cite a lack of coverage for pregnancy-related care, but the government gives pregnant a maternity grant of $3000 to cover prenatal care, delivery, and postnatal care to mother and child.
30. There is a Confucian obligation for physicians to use their skills to treat people without expecting payment.

Tuesday, June 15, 2010

Global Health Care Systems - Germany


Notes on Germany's health care system

1. World's first national health care system
2. Health care is guaranteed to anybody residing in the country, legal or not.
3. Benefits include doctors, dentists, chiropractors, physical therapists, psychiatrists, hospitals, opticians, prescription drugs, nursing homes, health club memberships, physician-recommended vacations trips to the spa, and numerous others.
4. Ample supply of hospitals and doctors, so there's no queue for treatment. Waiting time for elective/non-emergency surgery and emergency care is less than in the U.S.
5. Patients can choose any doctor or hospital, and insurance must pay the bill.
6. There are over 200 insurance plans that you can choose from.  These different plans compete for your business despite fixed prices for services and treatments.
7. Insurance plans are known as "sickness funds".  They are private entities.
8. Health care providers are private businesspeople working in private clinics.
9. German hospitals are normally charity-run non-profits, but there is an increasing number of for-profit hospitals as well.
10. The private insurance companies negotiate prices with the private clinics and hospitals, and these negotiations are almost entirely government-independent.  There is much less government regulation than in the U.S.
11. Germany's system is understandably very expensive.  In an effort to control costs, Germany strictly controls payments to physicians.  They use a "digital health card" (die elektronischen Gesundheitskarte), which, like in the French system, eliminates a lot of overhead by eliminating administrative costs that go into billing, clerical work, maintaining medical records, etc.  The U.S. hasn't even totally switched over to electronic medical records, let alone a card that you use for all things medical.
12. Patients are only responsible for co-payments for covered services and treatments.
13. Because Germany's system covers non-surgical procedures, alternative therapies are always given as options in addition to heavy drugs and surgeries.
14. Premium is a fee that usually equates to around 15% of your paycheck (similar to income tax int he U.S.), split between you and your employer.  This is about the same amount taken from U.S. paychecks for medicare and medicaid, but then we pay an additional percentage for our healthcare.
15. Physicians complain about poor compensation. But government and sickness funds are constantly trying to reduce costs.  Health care reform is constantly being proposed, but the basic system has remained untouched.
16. Germans are required to pay into health care.
17. Price negotiations are differ regionally, prices are then fixed for every physician and hospital in a specific region.
18. Sickness funds are nonprofit (no shareholders!).  There is thus no incentive to deny coverage.  All plans are required to pay any claim submitted.  This is also good for cost control because they don't have to pay for the claim-review system for which we pay so dearly in the U.S.
19. If you lose your job, the government jumps in to cover your premium.  You thus are covered through the same plan while you look for a new job, regardless of the time during which you are unemployed.
20. It's very easy to switch insurance plans.
21. Competition between plans is tough.  A basic care package is required, and the premium is the same no matter which plan you have (percentage of pay), so plans compete by offering perks like quick claim payment, exotic therapies, and free neonatal nursing care. 
22. Insurance plan competition is driven by executives' desire to insure more people and thus make more money (think U.S. care insurance)
23. Richest families are excused from mandated insurance coverage.  They  may choose to buy private coverage from for-profit companies.7% of population takes this route.  These alternatives plans may cover fancier facilities or care provided by famous physicians.  
24. Co-payments are tiny (around $13 per quarter year)
25. Germany malpractice insurance is very cheap, but litigation is very rare.
26. Other than co-pay, no money changes hands at the point of care.
27. In 2002, a round of health care reforms installed caps in certain regions on patient expenditures per year or the number of patient visits reimbursed per year.

Monday, June 14, 2010

Global Health Care Systems - France

Notes about France's health care system

1. Every French resident carries a carte vital.  This card contains a patient's medical records, billing history, and doctors' notes for every exam, hospital visit, blood test, etc. ever performed.  This system eliminates a great deal of overhead costs present in the U.S. system.  Less than 5% of insurance premiums are used to finance administrative costs.
2. In doctors' offices, you will see a list of prices for every service offered as well as the respective amounts that will be reimbursed by insurance.
3. In France, there are more doctors and hospital beds per capita than in the United States.
4. The French swallow more pills and receive more vaccinations per capita than Americans.
5. The employer and employee split the health insurance premium.
6. There is a co-pay at the time of treatment, but it's mostly reimbursed by insurance.
7. One's insurance plan is set up according to your line of work or geographic region.
8. Insurance agencies are non-profit.  They don't refuse coverage, regardless of pre-existing conditions.  They can't terminate coverage if you lose your job (in which case, the government pays the employer's share of the premium).  They can't deny any claim, there is no deductible, there are no delays in reimbursement. 
9. Queues are similar to those experienced by the insured in the U.S., except for pediatricians.  There is a shortage of pediatricians in France, but all residents get free, full post-natal nurse care.
10. There is virtually no  limitation on a patient's choice.  They may choose any doctor, hospital, surgeon, or clinic and the system will foot the bill.  Ambulance service is also covered.
11. There is no "gatekeeper" referral system.  This means that general practitioners don't have to refer you to a specialist if you require one.  Requiring a referral is a means of conserving valuable specialized resources.  In France, insurance will reimburse you more of the bill if you do obtain a referral before seeing a specialist.
12. The French believe their system is too expensive.
13. It's illegal to opt out of insurance.
14. Retired people are covered by former employer.
15. The government pays the premium for unemployed.
16. Health insurance premiums are dirt cheap.
17. Supplemental insurance is available from non-profits for for-profit insurance companies (also cheap premiums).  This insurance would cover the share of the co-pays that the non-profit insurance company (mandatory policy) doesn't cover.  It also pays for elective procedures and conditions not covered by mandatory policies.
18. Multi-payer system, but it acts like a single-payer system because the Health Ministry dictates what providers can charge for most treatments and prices for drugs.  The government negotiates prices for procedures and treatments with doctors, hospitals, and pharma companies.
19. These negotiations are completely transparent.
20. Most patients pay full charge at the point of treatment , but the poorest pay nothing.  Instead, the government covers their fees through social security.  Those below the poverty line pay less for services.  Nobody pays more than $100 in a single day. 
21. Making patients pay up front keeps people in touch with the cost of health care.
22. Doctors get more paid vacation time than U.S. doctors.
23. Medical education is paid for by the government.
24. Malpractice insurance for health care professionals is much cheaper in France than in the U.S.
25. Physicians are paid less, but they have much more freedom to treat their patients as they see fit.
26. Major health insurance funds are currently operating a deficit, increasing costs.
27. The solidarity principle rules French health care: "when we get sick, everybody is equal"

Wednesday, June 2, 2010

6/2 Global Health Care Systems - Overview

With all of this chit chat over health care since before Obama's election, I figured it would be nice to take a look at some of the more successful health care systems from around the world.  I would prefer to not state any of my own opinions about health care with regards to what I think we should do, because, quite frankly, it is a pretty daunting task to fix fifty years of awful, entrenching health care policy.  But what I do know is that other countries from around the world have found a way to make it work much better than we have.  So why not try to take a lesson from them?

According the World Health Organization (WHO), the United States' health care system sucks.  In its 2000 Global Health Report, the WHO ranked the health care systems and overall health (among many other figures) of 191 countries. Our system ranked 37th and our overall health 72nd.  The report also looked at the amount of money per capita that countries spend on health care.  The United States spends $4187.  Second place? Switzerland with $3564.  Third place? Germany with $2713.  It just keeps falling from there.  We spend significantly more money on health care, yet we get increasingly worse results.  We can surely do better than this since our country IS the greatest superpower EVER.  Right? care says otherwise.

For once in our history, we need to start looking at what other countries are doing to try to learn from them how to improve our system.  Capitalism has done a lot of wonderful things for our great nation, but it doesn't work in health.  Health care can't be sold like computers, produce, or cars.  Sometimes people just get sick or accidents happen, and, without appropriate regulation, they may be left without treatment.  Something as important as health care can't be left entirely to the capitalists.  (OK, so I guess I will include some opinion)  Health care costs keep rising, Americans keep getting sicker, and the thing is starting to spin out of control.

What I'm going to do is write a series of blog posts, each focusing on one country's health care experience.  Just look at each system and ask yourself if you could live with it.  Easy, right?  My sources are plenty for this series of posts, but my research was primarily done on Maggie Mahar's "Health Beat Blog" and through two books: 1) The Healing of America, by T.R.Reid and 2) Comparative Health Policy, by R.H.Blank and V. Burau.

To start things off, I would like to outline the four primary models of health care systems that you find around the world: Bismarck, Beveridge, National Insurance, and Out-of-Pocket.

Bismarck Model (examples include Germany, Japan, France, Belgium, Switzerland, and most Latin American countries)
- health care providers and payers are private
- health insurance is financed jointly by employers and employees
- health insurance companies are non-profit
- a Bismarck system is often highly multi-payer
- there is tight government regulation of services and fees

Beveridge Model (examples include UK, Italy, Spanish, most of Scandinavia, Hong Kong, Cuba, and United States Veterans Affairs hospitals)
- health care providers and payers are mostly government
- health insurance is financed through taxes
- there is tight government regulation of every aspect of the health care system

National Health Insurance Model (examples include Canada, South Korea, and Taiwan)
- health care providers are private
- health care payer is government run insurance program
- no marketing, no profit to be made leads to low overhead and easy administration
- usually long waiting lines and limits on services provided

Out-of-Pocket Model
- need health care?  how much money do you have in your pocket...
- no government regulation since there really isn't a system
- health care providers are mostly private
- health care payers is the patient
- no health insurance

The countries that I will touch on in this series of posts are: France, Germany, Japan, UK, Canada, and lastly the United States.

Tuesday, June 1, 2010

6/1 Antioxidants and Free Radicals

I'm beginning to think that free radicals and antioxidants are the most effective focal point if you want to be healthy for longer.  We hear these terms thrown around all over the world of nutrition, but I'm not sure if they're understood very well.  This blog post is my official entry into the discussion.

First, let's define free radicals.  To understand what a free radical is, let's look at a standard atom.  All biological molecules are composed of different types of atoms.  Each atom is composed of three types of particles: neurons, electrons, and protons.  The nucleus of an atom contains all of the protons and neutrons.  Protons carry a positive charge, so they are just fine co-existing in the same space as neutral neutrons.  Around the nucleus, there exists shells of space within which reside electrons, which are negatively charged.  In its most stable form, an atom has an equal number of electrons and protons.  Under certain circumstances, one of the outermost electrons in an atom can be kicked out of orbit around its nucleus.  An atom with a proton/electron imbalance is extremely unstable, and an electron deficiency is called a free radical.

The electron knocked free from the atom is highly energetic and also unstable. It bounces around until it forces its way into another atom's electron cloud, which naturally knocks one of its original electrons out because an atom must contain the same number of protons and electrons to remain stable.  This free electron then knocks an electron free from another atom.  If this cascade spreads to important cellular material, such as DNA, it can be dangerous.

Let's pause to talk about DNA.  In nearly every one of our body's cells, an area called the nucleus (not to be confused with the nucleus of an atom) protects 23 pairs of chromosomes, which are tightly coiled strands of DNA.  These strands are comprised of millions of nucleotides, which are tiny building blocks, which, when aligned in certain three-letter patterns, represent codons.  A gene is a string of specific codons, which is used as a blueprint to produce specific proteins. 

Keep in mind that human cells are invisible to the naked eye, let alone chromosomes, let alone nucleotides, LET ALONE ATOMS!  So when we talk about free radicals, we are talking about some very very tiny particles.  DNA is the long line of nucleotides present along the strands of chromosomes.  These strands are simply millions upon millions of genes lined up next to one another.  At the beginning and end of each gene in the strand, there are specific nucleotide sequences that represent the respective beginnings and ends.  There are only four bases comprising our DNA, which we will simply refer to as T, C, A, and G.  A line of DNA may look like this:  CGATGCCTCGAAGCCTCGATC.  As mentioned before, genes are comprised of codons, and codons are comprised of nucleotides.  

When a cell requires the production of a specific protein, its internal machinery begins the process of transcribing the DNA into another type of genetic material called RNA.   In an RNA strand, we see the same nucleotides that we saw in DNA, only T is dropped, and instead we see U, so RNA is comprised of U, C, A, G.  The way that the enzymes do this is by first unwinding a part of the DNA near the beginning of the gene, then other proteins lock themselves in place.  This protein complex works its way along the strand, creating a chain of RNA that is complementary to the DNA strand.  Everytime it sees a T, it adds an A on to the growing RNA strand.  Everytime is sees a C, it adds on a G to the RNA.  When it sees an A, it adds a U.  When it sees a G, it adds a C.  The RNA strand complement to the DNA strand above is: GCUACGGAGCUUCGGAGCUAG.

This RNA is then worked on by other machinery to slowly build a strand of amino acids which are then folded into a protein.  The translation of RNA into protein is easy.  A series of proteins surround the RNA strand and work their way along the strand three nucleotides (one codon) at a time.  Each codon represents an amino acid.  As the protein complex passes over a codon, another protein brings the corresponding amino acid (eat lots of amino acids, dummy) from the surrounding area to add it to the growing protein.  The RNA strand thus gives directions for the construction of a protein. 

So...let's get back to our free radical discussion.  A free radical begets another free radical begets another free radical, etc.  This cascade isn't dangerous unless it begins to rip through the material in the nucleus of cells.
Free radicals can have debilitating effects on our DNA.  Cellular damage is easily managed by the waste management crews in our cells.  But our cells can't simply dispose of damaged DNA; that would be like throwing away your hard drive when you get a virus.    When a nucleotide is damaged by free radicals, it can cause a kink in the sequence.  Remember, the DNA sequence is crucial.  When transcribing DNA into RNA, every single nucleotide in a gene counts.  If one letter is removed from the sequence it causes sequence shift. This throws off the specific three-letter combinations that will later be used to call on amino acids when translating RNA into protein.  For example, if you eliminated the first base in the RNA strand from above, it would look like this: G CUACGGAGCUUCGGAGCUAG.  This sequence no longer calls for even a remotely similar amino acid sequence. A nucleotide can also be damaged, causing the gene to be un-transcribable.  The protein complex will simply stop transcribing once it hits the damaged nucleotide.  Very dangerous.

This is the danger of free radicals.  Our cells' nuclear material is so sensitive to change!  Proteins run the show in our body.  Enzymes are proteins, and they're crucial for all of the chemical processes that take place in our body.  The structural material of tissue is protein.  And proteins are required for the transport of many chemicals into, out of, and around cells.  If a gene is screwed up, it won't produce a piece of equipment (a protein) necessary for cell function.  Cancer is the result of the malfunctioning of programmed cell death.  A cell lives a health life for a while, but eventually it dies, or it malfunctions in some way that triggers it to commit suicide.  At the end of a cell's life, it kills itself through a process known as apoptosis.  Like most cell processes, apoptosis requires various enzymes.  An enzyme is a type of protein, which, as we know, is coded for through the DNA -> RNA -> protein program.  If all of the enzymes required for apoptosis aren't present or properly functioning, we get a cell that divides uncontrollably without the STOP! signal, and you are presented with cancer.  Free radicals are dangerous bastards.

But they are also an important byproduct of regular, oxidative chemical processes taking place constantly in our bodies.  Free radicals are kept in check by antioxidants, which stabilize free radicals by donating their extra electrons.  Our body produces antioxidants in huge amounts.

The problem is, that we have far more free radicals running amok in our bodies than we have the means to combat.  Many sources in the media have been advocating greater antioxidant intake through our diets as well as behaviors that reduce free radical production. 

We live in a toxic world.  Free radical formation is caused by:

1. over-exposure to the sun
2. pesticide-laden produce
3. chemical additives in processed food
4. a diet in high in trans fat, saturated fat or sugar
5. air pollution
6. pollutants in our water source
7. radiation from electrical devices
8. chemicals in food packaging
9. very strenuous exercise
10. chemicals in toiletries
11. chemicals used in detergents and dry-cleaning products
12. preservatives in processed food
13. smoking

The list could go on and on...I think you get the idea.  The problem is, we want to live in a world where we can consume as much as we want, and the efforts to meet these demands have led to the manipulation of natural products that our bodies have evolved to accommodate.  But with so many toxic sources producing free radicals simultaneously throughout our day, it becomes very daunting to begin to try to change our lifestyles to reduce the damage. 

There are obviously two routes to take, both equally beneficial: 1) reduce behaviors that cause an increase in free radical production; 2) consume more antioxidants to combat the free radicals.  Addressing both are your best bet.

According to this source, the top 20 foods in terms of antioxidant concentration are:
  1. small red beans
  2. wild blueberries
  3. red kidney beans
  4. pinto beans
  5. cultivated blueberries
  6. cranberries
  7. artichokes
  8. blackberries
  9. prunes
  10. raspberries
  11. strawberries
  12. red delicious apples
  13. Granny Smith apples
  14. pecans
  15. sweet cherries
  16. black plums
  17. russet potatoes
  18. black beans
  19. plums
  20. gala apples
Other foods I would add to the list are grapes, red wine (I know...made from grapes), green tea, oranges, dark greens, broccoli, tomatoes, and raisins.  I try to eat as many antioxidant-rich foods per day as humanely possible.  My typical day might consist of a cup or two of berries, a glass of red wine, three glasses of green tea, a serving of FRS, a serving of broccoli, a Resveratrol capsule, 2 tbsp of honey, a Vitamin C capsule, two servings of kale or spinach, a serving of beans, a variety of nuts, and about five more servings of various veggies and fruits.  

Free radicals are also now being linked to aging. Research into antioxidants and free radicals is still young and evolving, but if you want to live long and healthy, eating more antioxidants couldn't hurt, right?

Thursday, May 20, 2010

5/22 The Passion of a Generation

"What was I going to do with Italian? It would be more practical to learn how to play the accordion. But why must everything always have a practical application? Is this lifetime supposed to be only about duty? In this period of loss, did I need any justification for learning Italian other than that it was the only thing I could imagine bringing me any pleasure right now?" from Eat, Pray, Love by Elizabeth Gilbert

Passion.  It's difficult to define this word because it means something different to everyone.  It's used as loosely as the word love, and it has just as various meanings.  Everyone can agree that, as humans, we should possess it.  

 In Gilbert's passage above, she hits upon a very controversial topic, especially amongst my generation (those just getting into the work place).  We have watched our parents and their parents work their asses off for our benefit, yet this seems to have had a phenomenal effect.  Their progeny have the desire the work less, play more.  For the most part, we see our predecessors as workaholics.  Everything they do in life has a practical function.  The "American Dream" is not being pursued by my generation the way it was pursued by preceding generations.  

I like to attribute this change to passion.  People are more passionate about living nowadays.  Our parents criticize us for traveling so much (which is likely a reflection of jealousy if you ask me), taking "time off from school", resisting marriage, and delaying baby-making.  In my case, it's as if my parents have totally forgotten what drove them to love the 60s (I have pictures to prove that they loved the 60s).  My generation seems to focus more on the individual as opposed to fulfilling the "American Dream" --> house with a picket fence, happy family, and a steady job.  Instead, we gravitate towards the unknown.  We are curious about the world, and there is very little that scares us.   

My parents are passionate about me.  I'm passionate about the world.  I haven't lost my idealistic views of the world.  And I'm out to conquer the world.  I'm certainly looking forward to having a career, family, and children, but the exact framework for this future establishment is not so clear.  In fact, it almost seems as if those things will be possible only if I pursue my own interests in the meantime to ensure that my person is safe and sound before I set off trying to make a woman happy and raise children.  This seems radical to my parents:  "Why aren't you married yet?"  "You've been with that girl for so long, when are you getting married?"  "Don't you think it's time you settled down?"  "Are you a doctor yet?"  "Can you take a look at this rash?"  

My response to these frequent (very frequent) questions is always the same: I'm not ready, and I'm in no rush. 

My generation is bent on figuring out what it is that they are destined to do before they pour any concrete.  In my opinion, this pursuit is both beneficial and detrimental for our society.  The benefits are many.  If you don't know yourself, or if you're not comfortable with yourself, how can you possibly support others?  Furthermore, those who are most comfortable with themselves and their place in the world also seem to be the happiest.  In my generation, more people would find greater satisfaction in making less money as long as they enjoyed what they were doing.   

The problem with this approach is that finding something you're passionate about takes a lifetime.  We all have our quirks throughout life, but to find something that we couldn't live without is more difficult. To say that we are truly passionate about something means that it is just as important to us as life itself.  Take dancing for instance.  Passion defies judgment.   If dancing is your passion, you can do it any place, anytime, anywhere and feel wonderful doing it.  You're PASSIONATE about it!  

Our parents found passion in their nuclear family.  The idea of "working hard now to play harder later" wasn't lost on our parents' generation.  My parents are just starting to explore hobbies and other interests now that my sister and I are leaving the coop.  But my generation insists on pursuing the hobbies and dreams early on, rather than waiting until retirement.  And they certainly didn't pursue the career that they are most passionate about.  Rather, they pursued the career that offered the best benefits to their family, the passion they established early on, for better or for worse. 

Hopefully, the predicament is slowly revealing itself to you.  We are all evolutionarily hardwired to want a family, but what about the individual's desires?  It's impossible to fully discover ourselves - to be totally comfortable with our attitudes, beliefs, and ambitions - at 25.  But if we dive right into family life, we may be cutting ourselves short.  From observing our parents, it seems impossible to devote ourselves to our families while simultaneously maintaining our personal identities.  And it doesn't help that many of our parents' generation are divorced. 

Obviously, hindsight is difficult over the course of a lifetime.  It would be hard for somebody to look back on life and argue that they should have focused more on themselves.  As humans, we adapt well, and it's easy to change our positions in life, so we often don't live with elaborate regrets.  When we graduate from college and contemplate getting a job, we are faced with this dilemma: What do I want in life?  The obvious answer isn't (always) the American Dream.  The rigid constructs of a wife, family, and career is scary.  So we travel.  We take time off.  We start dressing like hipsters because we have no better solution.  We delay the process in an effort to "find ourselves".  But it ain't happening.  Not at 25. 

You have your whole life to figure out what exactly it is that makes you tick.  I think we would all be better off if we began practicing balance in life from an early age.  If any one of your physical, mental, emotional, or psychological needs aren't being met, you're in for a rough road ahead.  The more experiences you get while you're young, the better, but this doesn't mean you have to cease personal reinvention throughout your entire life.  Use your powers of adaptation to take risks and try new things in an effort to fine-tune your self-definition until the day you die.  Maintaining your own personal identity is just as important as maintaining the welfare of your family, and, in fact, your significant other and family may actually be instrumental in helping you find your path in life if you got off to a good start while young.  Finding your passions in life should begin when you're young, snowball in through middle age, and distill when you're an old, healthy man or woman. 

Start early, finish late, reconfigure along the way.