Why Warren Buffet may finally be making a mistake

When I saw that Warren Buffet was diagnosed with prostate cancer, I wondered, why did he even get his PSA checked?  I often tell my patients that if a man lives to be 100 years old, he will have prostate cancer and he will not die from it.  Granted, there are exceptions to every rule, but in my career as a geriatrician, I have seen two men over the age of eighty die from prostate cancer.  I’m pretty sure that both of them had the disease before they turned seventy.

I don’t know the specifics of Warren Buffet’s prostate cancer diagnosis.  It is theoretically possible that he has an unusually aggressive form of the disease.  It is much more likely that he has a PSA of 6 or 7, and that a biopsy showed that he had evidence of prostate cancer.  In this case, before undergoing treatment, he needs to take a long, hard look at the risks of treatment.  Being a multibillionaire will not keep him from the potential side effects of treatment!

Radiation has become a common treatment for prostate cancer.  While radiation will kill the prostate cancer cells, it can also cause side effects like radiation proctitis, incontinence and erectile dysfunction.  

Another common treatment are medications that lower a mans testosterone level.  This will also kill prostate cancer cells.  The problem with this is that low testosterone levels also have their own pathology.  The classic triad of symptoms of low testosterone in an older man is heart disease, muscle weakness and anemia.

Our health care system is structured to pay for treating disease, regardless of whether the treatment is beneficial to the patient.  In the case of prostate cancer, the doctors get paid, the pharmaceutical companies and medical device companies make money.  What about the patient?  Men over the age of 80 should look carefully at the risks of treatment versus the potential benefit.  We really have no scientific evidence that treating prostate cancer in men over the age of 80 either saves lives or improves the quality of life.  

For the past twenty years as a geriatrician, I have approached prostate cancer in my patients very conservatively.  Two stories illustrate my experiences and the potential consequences of treatment.

About five years ago, one of my 89 year old patients was showing evidence of decline in his functional abilities and overall health.  He was hospitalized for pneumonia and had been to the emergency room for episodes of passing out.  He had been treated for several years for his diagnosed prostate cancer so that his PSA was maintained at zero.  We discussed stopping treatment.  His urologist balked when I called to suggest not only discontinuing his hormonal therapy, but putting him on topical testosterone to get his testosterone level back to normal.  I pointed out to the urologist that there is good evidence that PSA’s under 20-30 are generally not associated with extension of the prostate cancer to the bone.  He agreed.  Over the past five years, my patient has maintained a relatively healthy and functional life.  In fact, he has not been hospitalized once during that period of time.  His PSA has slowly risen and now hovers around 17-18.  

Several years ago, I saw an 85 year old man for the first time.  He had moved from another state where for four years he had multiple hospitalizations for falls.  His medical records indicated that hundreds of thousands of dollars had been spent on his health care needs.  He was now in a wheel chair.  It turned out that he had been diagnosed with prostate cancer and had actually been treated with the least costly antihormonal therapy.  His testicles had been removed.  We put him on topical testosterone and within six months he was out dancing!  He lived another five years and died from natural causes not remotely related to prostate cancer.

If you are over the age of eighty and are diagnosed with prostate cancer don’t accept the recommendation of treatment without grilling your doctors about the risks and benefits of treatment.  Ask them to provide scientific evidence that the treatment is beneficial.  Make sure that they tell you all of the potential side effects.  

Warren Buffet, are you listening?

Last day of "work"

It's hard to believe that twenty five years ago this month I got my first paying job as a licensed physician.  Today, I head out the door for my last day of "work".  I'm not done being a Geriatrician.  There is still so much to do to advance the health care needs of seniors.  While I can truly say that it has never really been a job, from now on it will only and always be my passion.

It has been an incredible journey.  From the very beginning I have always loved what I do.  But, it has also been about making a living.  And, about making a difference.  Sometimes, it has been hard to discern between the two as I reached higher and higher up the career ladder.  This is something I will never have to deal with again.

My future as a Geriatrician will never be about making a living.  It will solely be focused on caring for seniors.  Through my new website (www.wassdoc.com), I am looking forward to sharing what I have learned in the past thirty years, and to carry on the journey of discovery that we should all do on a daily basis.  I absolutely know that I will volunteer to be an educator of young, and hopefully old, clinicians.  Needless to say, my passion for triathlon will continue to be an example for others that we can be physically fit as we get older.

I can not ignore the daily articles about the financial future of Medicare.  I have been part of an incredible group of people who have demonstrated that we can deliver compassionate, cost effective and appropriate care to seniors. My mission to share this knowledge with others, especially the legislators that have been tone deaf to hearing it, will not only continue, but in some ways has only just begun.

Last, and most importantly, when I wake up in the morning I can savor gazing at my beautiful wife.  I don't "have to" be at work, or at a meeting, or even getting a workout in because I "have to" get to work.  My journey and my passions would not be possible without the support that she has given me for the past thirty years.  I look forward to the next thirty.

Being "In the Moment'

I haven't blogged in a week, but a lot has been going on.  Fortunately, in some ways, less of it has been training.  Still it's funny how yesterday's 4 hour workout barely felt like 40 minutes.  Today's 90 minute run was over just like that.  I'm in the best shape of my life and may even be biking better than ever.  My run capability is about where it's always been, but as my coach reminds me, the ironman run is about the bike.  So, if I can hold up well on the bike, we'll see what I can do on the run.  I've been working on "being in the moment".  It's a good thing to do in life in general, but it is also a very good thing to do in any race, especially an ironman, which is going to be 11-12 hours long (hopefully closer to 11 hours this year).  Dwelling on ones past doesn't do any good in life or in racing.  If you had a bad patch during the race, thinking about it the rest of the day does no good.  Enjoying what the race feels like, the surroundings, the spectators, the energy of racing, that's what it's all about!  Life is the same way.  Enjoying things as they are, when they are, that's healthy.  That's where I'm trying to be.  In five more days I'll officially be "retired".  Not sure what that truly means, but I'm looking forward to enjoying every single day and doing the things I like to do.

We've continued to spend time packing, seeing old friends, thinking about where we're going to put things.  In 8 days, we leave for St. George.  After the race, we drive to California and then fly back for the final packing and the final move.  Lots of thoughts and feelings.  We have good friends here.  Our daughters are there.  We love our house here, but the new house should be everything we've ever wanted in a house, and what isn't we'll make it so!

Lots of ironman thinking.  Planning how I'll start the swim. In the front, go out hard, see what happens.  I've been swimming well and I think that I can maintain a solid effort without pushing into the red, but also without just going slow for no reason.  I've got a goal in mind for the bike based on what my training has been telling me.  The first 22 mile stretch will be key.  Ironically, I won't know my pace, because I don't plan to take any electronic devices with me.  Last year, I did the first stretch  @ 18.5mph.  My training suggests that I could do this leg of the race closer to 20mph.  That could translate to doing the whole race closer to 19mph and get me to my sub 6 hour bike split goal.  Whoops!  I'm not being "in the moment".  But, at least looking ahead is better than looking behind.  Besides, I do believe in visualization.    If I visualized a 5:54 bike split, maybe it will come true!  Finally, my run is taking shape.  I'll have the advantage of being 2500 feet lower than I am now, which usually translates well for me.  Going to sea level often gives me 30-45 seconds/mile.  I'll take 20 seconds per mile at St. George, do the marathon @ 8:40 pace, and call it a day!

My body is  reacting well to my taper, the workouts feel good, I feel good.  My throat is doing better today after making the mistake yesterday of swallowing an open capsule of Salt-Stick....potassium burns like hell, but it's much better today.  When it happened, I was just starting my workout, and I kept going and put it out of my mind, staying "in the moment".

Perseverance

I was out on my 17th long run since November in preparation for Ironman St. George when it happened.  I was just half way through a 14 mile run, just preparing to pick up the pace, when I felt the spasm in my back.  It's that spasm that makes it hard to take a deep breath, the one where it feels like you can't breath when you get it.  Sometimes in training, my body will tell me that it's time to rest, this may be one of those times.  Ironically, I've been having some trouble with pain in my left ribcage when I run.  It can get quite painful and can definitely slow me down.  During my run today, I felt some of this pain early on and began massaging the left ribcage, which I've found to help.  When the back spasms started, the ribcage pain stopped!  I actually wonder if something shifted, improving whatever was causing the rib pain, but at the same time setting off some other muscles to go into spasm.  One of the good outcomes of the muscle spasms was that I had already decided to push hard for the last 7 miles of my run.  I still wanted to do that.  So, the next six miles (I decided to run the last one easy), became a game of tolerating the pain, trying to relax my breathing and muscles, and just persevering.  It also became a visualization exercise for St. George.  What if this happened during the race, what would I do?  I would have no choice but to keep running and try to find a way around the pain.  My thoughts brought be back to Perth, Australia, just 2 1/2 years ago, after my bicycle crash.  Riding my bike in the aero position with a fractured shoulder and hip socket was the greatest challenge to dealing with pain that I had ever encountered.  I persevered then, and I know that I can keep going despite pain.

So, this was my 17th long run, that was part of the plan I made with my coach last October.  I needed to get in more long runs than I have in preparation for previous ironman's.  Last year I did 10 long runs.  My long runs this year have averaged about 2 1/2 hours and 16 miles each.  The 17 long runs don't include a few "two a day" runs I also did in order to improve my run preparation.  My history of running is rife with experiences where I couldn't run due to debilitating side stitches.  This has occurred during open marathons and in triathlons.  I remember watching the Hawaii Ironman in 2010, and seeing Macca rubbing his ribcage during the latter part of the run.  Side stitches and rib pain are not only my problem, the pros deal with them too and they need to find a way to manage them.  So will I.

I have also completed 13 long bikes in preparation this year versus 9 last year.  My long bikes averaged 5 hours and covered 80 miles each.  I also have done more transition runs off the bike, preparing me better for getting off my bike at St. George and running.  One thing I know, my legs usually feel fine after I get off the bike and start running.  The thing that slows me down are cramps, stitches and overall fatigue.  Hopefully, that won't be an issue this year.

What about my swimming?  Actually, this year I've done 7 swims over 4000 yards whereas last year I did four.  I'd say that also goes along well with how my swimming has been lately.  I feel like the longer swims don't bother me and I feel ok when I finish them.  Furthermore, my swim paces have been holding up pretty well, they really aren't any slower than in past years.

So, back to the main topic, perseverance.  At the end of the day, that's what it's all about.  Ironman is a long day.  It is about getting through that day.  However, at the end of the day, literally, I will be running a marathon.  In order to achieve my goals, I will have to run.  There will not be the luxury of walking this year, except at the aid stations.  If I have side stitches, or rib pain, or back spasms, I have to keep running. Today was practice for that, that's what training is all about.

I will persevere.

Making a Difference: Retirement and Another Chapter

When I was a young boy, I wrote a letter to President Johnson asking him to stop the war in Vietnam.  As a teenager, I wrote a letter to Manachem Begin suggesting a plan to  bring peace to the Middle East.  In 1980, I had a year before starting medical school.  I wrote a letter to President Reagan suggesting that, since he wanted to abolish the Department of Education, that I would be happy to run it for a year!  Just two years after joining Kaiser-Permanente, I applied for the job of Regional Medical Director.  As I look back at my life, it is clear that I have always been driven to make a difference.  Whether it be domestic or international politics, or related to work and business, I set a very high bar for myself.  It’s ironic, noting my recent blog regarding setting my race goals too high to achieve.  I guess that I set my life’s goals pretty high as well.  

Ultimately, I not only reached my goals, but in some ways, I may have exceeded them.  First, I became president of a physician practice management company in the late 1990’s.  Dealing with large insurance companies and millions of dollars at risk was not a simple or easy task.  I spent 3 years commuting from Denver to Orlando, working long hours away from my family.  I learned a lot, but ultimately decided to take the chance of developing my own business.  Co-founding Senior Care of Colorado in 2001, little did I truly know what type of bar I had set for myself and what the ultimate consequences would be.  When you own your own company, you have no choice but to put yourself at personal financial risk.  Hiring the right staff, making critical decisions on a daily basis, it wasn’t just about working from 9 to 5.  I spent most nights calculating budgets and planning strategy.  I also found myself dreaming, or having nightmares, about work just about every night.  This only served to highlight the fact that work was all consuming.  

I could recount the various stresses and crises that seemed to be around every corner.  There were highs and there were lows.  There were good decisions and bad decisions.  In the meantime, Senior Care grew from a small business with about 20 employees and $2 million in revenue a year to a complex entity with 160 employees and over $17 million in revenue a year in just 10 years.  The opportunity to sell Senior Care was not only a reflection of today’s health care environment, but it was also an opportunity to move on to a new chapter in my life.

People ask me if I’m retiring.  I feel uncomfortable saying yes, for a number of reasons.  Having been a workaholic for the past thirty years, it seems strange not to have a job.  At the same time, it makes sense not to have to go to work anymore.  What I’m entering is another chapter, where I will still have opportunities to make a difference.  This chapter can’t be defined by anyone but myself.  When I sold my business sixteen months ago the first thing I told my wife was that I never wanted to be in a position to have to fire or lay off anyone ever again.  That is not my nature.  That is not who I want to be.   

As I’ve been winding down at work this past month, it has become clear that I have a lot to share.  Normally, I share my knowledge and insight with a select group of patients and their families.  I want to share my knowledge with more than a small group.  Our society and health care system is woefully lacking in it’s ability to care for seniors.  At the end of the day, my heart has always gone out to the elders around me.  This is one of the places where I have been led to make a difference.  At the same time, this has to be on my own terms.  I am excited to be moving to a new home with my wife, who has been at my side for the past thirty years.  I look forward to not having anywhere to be in the morning other than in the kitchen making breakfast for her.  I will be near my daughters, who mean the world to me.  Work will not define me.  That is why I will be retired.  

My new chapter will be about my family and me.  That is where I will make a difference.  It will be about exploring all of the things that interest us and inspire us.  It will be about enjoying the little things in life.  There are a lot of things around us to appreciate.  There will be no more bars to set, just roads to travel.  As with my triathlons, it’s not about the results, it’s about the journey.  

Yet Another Ironman Weekend

I thought that I had done plenty of ironman weekends and that I was beginning a long taper.  Little did I know that my coach had a very interesting week in store for me.  Yes, I got more rest than usual, on Monday, Tuesday, Thursday and Friday.  But Wednesday was a very long hard day, and this weekend, well, I'll recount the weekend.  Saturday morning began with a 2.4 mile swim broken up into four pretty solid 600 yard efforts of swimming and then 1500 yards of pulling with paddles (good upper body workout).  I changed into my bike clothes, drove home and began my biking adventure.  101 miles of mostly ironman effort, so that I actually averaged about 19mph for the whole ride.  The first half of this was pretty comfortable, but it kept feeling harder.  I think I got enough nutrition, but I wonder if I went into the day a little light.  No matter, I made it through.  This was as mentally tough as it was physically, and took me 5 hours and 20 minutes.  Just 11 miles short of the full ironman distance, which I could have done, but I needed to get my 2 mile easy run in prior to going to the movies with my wife and daughter.  Oh, yes, I also needed to hydrate and nourish.  The popcorn and root beer was good!  I was feeling pretty fried all night, finally got to bed, wondering how in the world I was going to do a long run today.  Fortunately, as seems to happen all of the time these days, I woke up without any soreness and actually with some energy.  Grant you, I wasn't bouncing off the walls, but the instructions today were to just run easy and get as much mileage in as possible.  I did just that, running as easy as I could, never looking at my watch, so I had no idea how fast I was going, but I didn't care.  It just felt good to run easily.  I visualized the entire St. George course, starting with the swim during the first third of my run, shifting to the bike for the second third, then finishing up with the run.  By the time of got to mile 17, feeling good and not knowing exactly how long I'd been running, I did do one mile on the track fairly hard and then coasted  home for the last 2 miles.  So, 19 miles of running in 3 hours and 3 minutes.  The pace is slower than what I'd like to do at St. George, but that wasn't the point.  I realize that St. George is at lower altitude, which always gives me some extra speed, and, I'll be well rested going in.  Plus, this run did feel easy!  This was also one of those runs that make you think about doing ultra distance running.  I just enjoyed the weather and the surroundings and the feeling of running easy.  So, instead of stretching my ironman weekend over three days, as I have been doing recently, this time I did it in just two days.  In fact, 27 hours.  So, swim, bike, run for 10 hours over a 27 hour period.  I was just 11 miles short of a full ironman bike, and 5 miles short of a full ironman run.  Ironically, this puts me in the 11 1/2 hour ironman range.  Hopefully, that's a good omen for my goal paces!  I have absolutely no soreness today, and went to another movie with my wife and daughter (more popcorn and root beer).  Now, just chilling.

Goals and Dreams

They say to never set a time goal for an ironman.  I understand, you never know the conditions, how the day will go, etc.  But, I always set a time goal when I race.  One of the most interesting things about doing that is that I'm not sure if I've ever actually hit one of the goals I've set!  And that's ok.  There is actually some comfort in setting the bar high and just almost reaching it.  In a way, my goals are like that carrot that is just out of my reach, and I stretch my fingers ever so slightly longer, trying to grab it.  Considering that over the past several years of racing triathlons and running races, many of my results have been personal bests, one can't argue with this approach.  Besides, what do we have if not our dreams?  While my ultimate dream is getting a Kona slot, that doesn't seem realistic.  I'm reaching the other side of my age group, and the "younger" guys are just too good.  Last year I was 29th in my age group.  My goal this year is to break the top 10. That will still put me 30-40 minutes outside of a Kona slot, but one never knows.

So, for every race I've ever done, I love to analyze the probable time splits that I will achieve.  I'll usually set a "perfect" goal, and then a more reasonable range of times.  I tend to look at previous races, how I'm training, etc.

My swim has been up and down this year, but has really been coming into focus lately.  I'm pretty happy with my ability to get in the pool and swim 4000+ yards and feel good getting out of the pool.  My 100 yard pace is about where it has been in the past, so to summarize, my endurance is excellent and my speed is good.  I did just get a new wetsuit, and I'm hoping it's as good as they say it is.  Once again this year, I'll start in the front.  However, I'll try to go out a little harder in the first 100 yards in order to set myself up for some better drafting than I've had previously.  Also, I tend to get in this "go easy" mode at some point, and I think I've been learning that I can maintain a fairly solid constant effort for the entire swim and still feel good.  The last two years my swim has been 1:11.  If I have the best swim of my life, draft impeccably, take advantage of my new wetsuit, I think that a 1:05 is possible.  However, my main goal would be 1:08, and I certainly know that I can swim 1:11 (having done it twice before).

Transitions are usually my best event, the first year at St. George was horrible, last year was pretty darn good.  My goal here is 4 minutes.  I should be close to this, last year was 3:30.  Get out of the water, get my wetsuit off with the help of the wetsuit strippers, grab my bag and find a spot to sit down in front of the tent (I won't go in the tent again, it's too crazy).  Shoes on, sunglasses on, helmet on, put on race belt.  Stand up, let a volunteer slather me with sunscreen (didn't do that last year, won't forget this year), get to my bike, give my bag (with wetsuit in it) to a volunteer.  Walk/jog down the path, get on my bike and go.

The bike is going to be interesting.  I am probably in the best bike shape of my life.  That was the idea this year.  I've done a lot more volume, I've trained smart, and I've got a great new bike.  I really need to take it easy for the first part of the race, last year I averaged 18.5 mph for the first 23 miles, which I really did keep a low key effort, the first year just 17mph.  That said, I'm expecting a better pace this year with all of my training, and could even find myself starting out close to 20 mph.  The first year I did the bike in 6:49, my first loop was actually done at 17.4mph, but I bonked as I started the second loop and really slowed down.  Last year my bike time was 6:24 (17.5mph) and I averaged 17.5mph on the first loop and 17 mph on the second loop.  My power numbers are better this year, I'm definitely fitter and stronger, and I feel like I've finally got my nutrition dialed in (I did have some abdominal cramping on the bike last year).  If I can keep an average pace of 19mph for the entire bike, I would have a bike split of 5:54.  That would be spectacular.  Realistically, I think I can expect somewhere between 5:58 and 6:10.

T2 was 4:30 last year, it's simple, get off the bike, give it to a volunteer, get my run bag, go into the tent, sit down, take off my bike shoes, take off my helmet.  Put on hat, put on socks, put on shoes, grab my fuel belt (with arm coolers attached to put on once I get going), give my bag to the volunteer and get up and get going.  Stop again to let volunteers slather me with sunscreen, grab some water, and start jogging out of transition.  Again, I expect another 4 minutes.

Now it's time for the run.  This has been my Waterloo the past two years, but they have changed the run course and I'm excited.  Furthermore, my training has been great.  Six weeks ago I ran 21 miles, albeit on very flat course, @ probably ironman effort and managed an 8:35 pace.  I've been able to go hard off the bike in training on a course similar to this year's St. George course and hit 7:45-8:00 pace for a couple of miles (that's definitely unrealistic).  That said, I did run 5.5 miles off a hard bike two days ago on a course similar to St. George while maintaining an 8:15 pace.  I don't think that I can do that for 26 miles, but I have to say, I'll be tapered and ready and who knows?  I've also done twice as many long runs this year than last year, and I'm feeling good.  I'm excited by the three loop course, and my friend Rudy will be giving me splits along the way.  That should give me some adrenaline!  So, if by some stretch of the imagination, I can have a great run and maintain an 8:30 pace (wild and crazy dream, but that's what dreaming is for), that would give me a 3:43 marathon.  My "realistic" goal is to keep 9:00 pace, which would translate to a 3:56.   I absolutely would love to go under 4 hours, and I think that 4:02 is quite reasonable based on the fact that I've done 5 hours on a much harder course, walking 1/2 the distance and running 1/2 the distance each of the past two years (bonked the first year and abdominal cramps the second year), I think that my goals are reasonable.

So, time to add up the numbers:
             Best  Realistic Reasonable
Swim    1:05    1:08       1:11
Bike      5:54    5:58       6:10
Run       3:43    3:56       4:02
T1/T2               0:08
           10:50   11:10     11:31

On a personal note, my family's favorite number/time is 11:11:11.  I'll be really happy to hit the finish at this time, and judging on the past two years, that would put me close to a top ten finish in my age group.

No matter what, I'm looking to put plenty of distance in between last years time of 12:45 and this years time.  Going under 12 hours on this course will be an accomplishment in and of itself.

29 days to go to St. George, already did an easy recovery ride this morning, will be spending the day with my wife and daughter.  I think we're going to see Titanic 3D!

"Tapering"

So, this is what my "taper" is going to look like.  I spent Monday and Tuesday in rest/recovery mode.  Today I did a hard 3300 yard swim, and followed it with at hard 3 hour and 40 minute bike, with about 2 hours and 40 minutes of alternating 15 minutes at ironman effort with 5 minutes of olympic/sprint effort; and then, ran 5.5 miles about as fast as I could at the end of a  5 hour and 40 minute workout!  The best part of this is that after eating and drinking, I'm feeling great!  Tomorrow and Friday will be rest/recovery days and then, I repeat this type of workout on Saturday.  It's hard to believe that there are just 31 days before St. George.  I've never really felt like this prior to my first two ironman's, and it's really an awesome feeling!

Another Ironman Weekend

I've now spent two three day weekends in a row essentially doing the equivalent of a full ironman.  Friday I swam 3800 yards, then rode my bike for 5 hours, with 4 of those hours being at ironman effort and pace.  A total of 93 miles of cycling.  Then Saturday I put in another 3 1/2 hours of cycling, 61 more miles, with about 90 minutes forcing myself to push ironman + pace.  That was mental, all mental!  My body didn't want to cooperate, but I forced it to by setting an average wattage goal on my power meter and then holding it.  When I got off the bike, I went on a solid 3 mile run and my legs felt surprisingly ok.  Sunday was my run day and 15.5 miles later, I knew that I was ready for St. George!  My legs were dead, but they cooperated.  Included in this run was 5 one mile intervals at faster than ironman pace...and I held the pace pretty well!  Doing an ironman within 48 hours is a great way of tricking the body to get the work in.  I'm feeling a bit of Delayed Onset Muscle Soreness tonight (monday), but not too much.  Tomorrow is another recovery day and then back to the grind in Wednesday.  Two weekends in a row of doing ironman volume with tons of ironman effort is serving to improve my confidence levels to never seen before heights!  I'm even starting to have some "time goal" thoughts.  You're not supposed to do that with ironman, but, what the heck!  I might as well dream!