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The Trouble with Troubleshooting

Fifty years ago, a runner who had been doing all of his recent training before the sun rose shifted to a new schedule that had him running later in the morning. To his surprise, his first several daylight runs felt harder than normal, and it took him longer to complete his usual routes. (This was before speed and distances devices existed, so completion times were the only practical means of measuring performance away from the track.)

The runner (let’s call him Bob) couldn’t help but wonder what was behind these sudden changes. He even briefly entertained the thought that he wasn’t good at running in the sun and should go back to predawn training. But then he caught himself, laughing inwardly at his momentary loss of reason. Running is running, he remembered. Whatever might be different between running in the dark and running by daylight, that difference couldn’t possibly be more than superficial. Instead of wasting energy worrying about it, Bob realized, he should just keep running and trust that his body would soon adjust. So that’s what he did, and that’s what happened, and Bob lived happily ever after.

Fifty years later, a different runner, Sally, had a similar experience. Like Bob, Sally did all of her training before the sun rose but then shifted to a new schedule that had her running later in the morning. To her surprise, she found it harder initially to stay in the intensity zones dictated to her by her Garmin Fenix 6, which reinforced this perception by telling her that all of her runs were “unproductive.” Sally became so alarmed by the situation that she hurried online to share her concerns in an athlete discussion forum, initiating a lively thread in which other athletes traded theories about what might be wrong and what Sally ought to do to fix it.

Lately I’ve been reading a lot about the growing problem of overdiagnosis in medicine, sports medicine in particular. An example of my recent reading is an educational review published a couple of years back in the British Medical Journal under the title, “Preventing Overdiagnosis and the Harms of Too Much Sport and Exercise Medicine.” In it, authors Daniel Friedman of Monash University and Karim Khan of the University of British Columbia describe the emergence of a sports medicine establishment that empowers clinicians to turn athletes into patients the moment they experience any pain beyond the norm. The four key elements of this system, according to Friedman and Khan, are 1) the belief among clinicians that more intervention yields better outcomes, 2) so-called diagnosis creep, whereby the definition of injury keeps expanding, 3) the widespread commercialization of sports medicine and injury treatment, and 4) increased accessibility of sports medicine and injury treatment services.

In short, we now have a system in which (to exaggerate only slightly) athletes experiencing pain automatically call the doctor, doctors automatically subject athletes to diagnostic tests, and diagnostic tests automatically find some “abnormality” that is automatically pegged as the cause of pain. Now, you might be thinking, “Where’s the harm? Better safe than sorry, right?” Wrong. The overmedicalization of athletic pain and injury causes a good deal of harm, and in more than one way.

For starters, medicine’s domination of pain and injury management systematically deprives athletes of agency, robs them of the ability to make their own decisions, trust their own perceptions, and feel in control of the process. Second, the imaging and other diagnostic tests used to slap labels on pain experiences are wildly unreliable, producing scandalous amounts of false positives. These false positives, in turn, cause stress and anxiety and lower outcome expectations, which become self-fulfilling. And to top it all off, the medical narratives in which diagnosis and treatment are couched—“Your tissues are degenerating because you have flawed biomechanics because your muscles are abnormally weak and tight—engender a sense of fragility in athletes that, too, is self-fulfilling.

In reaction to this anti-Hippocratic state of affairs, a movement toward “dediagnosis” has sprung up within the medical establishment. In a recent paper, two leading champions of this movement, Marianne Lea and Bjorn Morten Hofmann of the University of Oslo, declare, “We define dediagnosing as the removal of diagnoses that do not contribute to reducing the person’s suffering, i.e., when the person is better off without it.” And where nontraumatic sports injuries are concerned, the person is “better off without” a diagnosis most of the time. For example, in a 2021 study by Indian researchers, forty-four individuals with low-back pain were given MRI’s, after which half of them were given a factual description of the findings and half were told that the findings were normal regardless of the results. Six weeks later, according to the study’s authors, members of the first group had a “more negative perception of their spinal condition, increased catastrophization, decreased pain improvement, and poorer functional status.” That’s not exactly an endorsement of diagnosis.

At first blush, all of this business about athletic pain and overmedicalization might seem to have nothing to do with Bob and Sally, our two hypothetical runners who had difficulty adjusting to a shift in their daily run time. In fact, though, it has everything to do with it. Increasingly, the devices that athletes use to monitor and regulate their training are doing the same thing doctors and diagnostic tests do to athletes. As device features and metrics multiply (Garmin’s new “body battery” takes the cake), so does the number of things that can go wrong. Worse, at the same time these devices raise (mostly false) alarms, they insidiously drain athletes of their autonomy, lulling them into placing more and more trust into the plastic oracles on their wrists and less and less into their own perceptions and judgments.

Someone should do an experiment where sports devices are coded to randomly produce an alert message reading, “You’re having a terrible workout.” I’m willing to bet that a majority of today’s tech-dependent athletes would take this message seriously, rattled by it even if they’re in the middle of a terrific workout when it pops up. Laugh all you want, but this thought experiment is only marginally more absurd—and disturbing—than Garmin’s all-too-real “unproductive workout” alert message and a variety of other device features and metrics.

What bothers me most is the effect technology is having on athletes’ appreciation for the value of self-trust. The most self-trusting athletes are the most successful athletes, plain and simple. And self-trusting athletes have a high threshold for becoming alarmed. Like anyone else, they pay attention and notice things, but they shrug off most aberrations. When such an athlete is caught off guard by some unexpected difficulty like adjusting to a shift in their daily run time, they lose no sleep, telling themselves, “It’s probably nothing. I’ll give it a week to resolve itself, and if it doesn’t, then I’ll troubleshoot.”

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In the old days, before the advent of sophisticated sports trackers, athletes had little choice but to allow small imperfections in their training to resolve themselves, or not. Nowadays, only the most self-trusting of athletes are able to resist sweating the small stuff, because temptations to do so have become almost atmospherically ubiquitous, a digital torrent of alerts and warnings and disappointing numbers to worry about shoved in our faces by our Garmins and Polars and Suuntos and Whatevers. It’s the training equivalent of an overzealous sports orthopedist moving into your home with all of his diagnostic equipment, hell-bent on finding something wrong with you.

Analytical reductionists—the kinds of people who are prone to say things like, “I’m trained in mathematical statistics and so inclined to examine numbers before making conclusions”—don’t understand this. They push back on the notion that there is harm in taking each and every device warning seriously. I call this hoarder logic. Have you ever tried to reason with a hoarder? It’s impossible! You choose an object from the pile and ask them if they really need to keep it. They respond with a pretty solid reason for keeping it. You then choose a second object from the pile—and a third, and a fourth—and they do the same, winning every battle yet losing the war. What makes hoarding a mental illness is not the hoarders’ specific reasons for holding onto individual objects but the very impulse to find a reason to keep all of them.

Analytical reductionists are the hoarders of the sports realm. They have solid reasons for taking each blip in the data stream seriously, but it is the underlying impulse to do this that’s the problem. Again, this impulse stems from a lack of self-trust. The ones who can’t stop troubleshooting are missing that assured sense of being in control of the overall process that makes the most mentally fit endurance athletes seem almost blasé to analytical reductionists, who look at them with mouths agape, wondering, “Don’t you even care? Shouldn’t you be worried?”

Regular readers of this blog will have noted that I’ve been beating the drum of device overdependence rather hard of late. Some of these readers might even suspect I have entered my crotchety old man phase, shaking my fist front my front-porch rocker and railing against technology, not because technology is so bad but because I’m weakening and beginning to feel left behind. That’s fair. If I were alone in my railing, this speculation might be worth entertaining, but in fact I am not alone. As I have taken pains to point out in past articles, growing numbers of scientists—the kind who are capable of big-picture, systemic thinking—are sounding the alarm as well. And it’s not just endurance athletes they’re concerned about.

Among the scientists banging the same drum as me are Peter Gamble of Auckland University of Technology, Lionel Chia of the University of Sydney, and Sian Allen of Lululemon Athletica’s R&D team, whose paper, “The illogic of being data-driven: reasserting control and restoring balance in our relationship with data and technology in football,” was published last year in Science and Medicine in Football. In it they write, “We propose that there is a fundamental need to reframe how we are seeking to employ data and more specifically make the necessary switch from being data-driven to data-informed.”

Remember Bob? Arguably, he was neither data-driven nor data-informed, if only because he ran fifty years ago when there wasn’t much data. But he was better off for it, at least compared to Sally and her fellow endurance athletes of today, who are data-driven without even realizing it. And what their device data is driving them to do, specifically, is train in a nearly constant state of troubleshooting, trying desperately to make up for a lack of control over the training process by responding to every cry of “Wolf” from their wristwatches with a full-scale wolf hunt.

How do you know if you’re in control of your training or not in control? How do you know if you are data-driven or merely data-informed? Here’s how: Imagine you had to train the way athletes did 50 years ago, trading your current gadget(s) for a basic stopwatch. If you are confident that this compromise would have little or no impact on your fitness development or competitive performances, then you are in control of your training and are not data-driven. The irony of it all is that you kind of have to get to the point where you don’t need your fancy athlete smartwatch to gain any benefit from it.