10K Goal

Two days ago I did a 5K.  I'm pretty happy with my time, considering I really haven't trained at all for running a 5K in many years.  Just 3 days later, I'll be doing a 10K.  Why? I'm feeling good, and I want to see where my 10K pace is.  My fitness is still pretty solid as I recover from Kona.  It's been seven weeks, and I've had my ups and downs.  On Thursday, I didn't really set any time goals, and I never looked at my pace during the race.  Tomorrow, I'll change that up.  I'll set some pace goals and try to focus on holding them.  How do I set these pacing goals?  A few months ago I did a half marathon on the same course as the 10K.  That day, in the midst of Ironman training, I actually ran seven miles before the half marathon as my "warm-up."  I actually did a 10K at ~8:40 pace in the middle of what was to be a 20 mile run.  That tells me that I can do a 10K at a faster pace than that.  The first two miles of my 5K were at 7:17 and 7:35 pace.  I certainly don't want to go out that fast at the beginning of a 10K.  So, what will I do?

First thing to think about is the warm-up.  Warm ups are an absolute necessity for a running race, otherwise you start the race "cold."  Since it will be cold out, warming up will be even more important.  The 10K starts at 8:15 am, so I'll need to get there around 7:30 am if I'm planning to do a 3 mile warm up, which is the most appropriate amount of warming up.  That gives me time to do the first mile really slow, the second mile comfortably, and the third mile with some short fast efforts thrown in to get my lactate system engaged.  That also means I need to leave my house by 7:15 am.  First part of planning done.

After the warm up, it's actually a matter of trying to minimize the time between warming up and starting the race.  That shouldn't be too hard to figure out once I get there.  The course is relatively flat, though it's very slightly uphill for the first half, and then slightly downhill for the second half.  That really shouldn't impact my pacing, in fact, it might help me a bit since the last few miles will be slightly downhill.  Runner's World has a race predictor.  Based on my 5K time three days ago, my 10K pace should be 7:55.  If I'm actually capable, which I think I am, of having run 23:00 for my 5K on a flatter course, my predicted pace would be 7:43.  That appeals to me, because my goal time would be 48:00.  On the other hand, just to be safe, I can start the first couple of miles slightly slower and see how I feel.  There I have it.  I can start the first couple of miles at 7:50 pace, and see how I feel.  If I feel good, I can pick up my pace and keep it closer to 7:45 for the next few miles.  The last mile is always a "guts only" mile anyway.  Whatever I have left, it will be what it is.  I'll be quite happy with a 10K under 50 minutes, but would love to get close to that 48 minute mark.  We'll see what happens!

Motivation

I woke up today thinking about what motivates me.  It's actually pretty simple.  I've always been motivated by the desire to help people. This goes back as far as I can remember.  As I got older, I "narrowed" this desire somewhat in terms of wanting to help older adults live better lives.  I often relate that to the close relationship I had with my grandparents and the fact that I've always had an affinity for older adults.  As a child, I'd hang out with the older adults at family get togethers.  Once I was on the path to becoming a physician, geriatrics was the natural course, despite my initial thought that I'd want to be a pediatrician.  Everything that I've ever done in my work life, and honestly, even in my personal life away from work, has been driven by my desire to help older adults.  That is my primary motivation.

There have been times and circumstances in my life where others have questioned my actions.  Recently, I've encountered a situation that may cause some to pause and ask why I am doing what I'm doing.  My response will be the same, consider who I am and what motivates me.  I've always lived by that credo, and will continue to do so. We all make decisions on a daily basis.  I like to tell people that being a geriatrician, I've never made a clinical decision where I had 100% certainty about the outcome.  I think that's pretty much the norm in or lives.  Rarely do we make decisions where we are 100% certain about the outcome.  There are always mitigating factors, complications, and complex dynamics involved in making decisions and finding our path.  Under these circumstances, I know one thing, and that's my moral compass and what motivates me.

I have never shied away from taking on highly complex projects.  Being a geriatrician, that almost goes without saying.  When I started my primary care geriatrics practice, many people told me I was crazy.  'You can't make money doing primary care geriatrics.'  When I became the CEO overseeing a nursing home chain with a very complex history, some people questioned why I wanted to do that.  In both cases, the answer was actually quite simple.  I wanted to make a difference in the lives of older adults.  That has always been my prime motivation.  It's easy to question anyones decisions, especially without all of the facts. Unfortunately, none of us ever have all of the facts.  We are left to make decisions on the best available evidence.  But we also make our decisions based on what motivates us.  For me, that motivation has always been clear.  It should be clear to others as well.

Turkey Trot 5K and 5K Memories

Twenty eight years ago I ran my first 5K.  It was in Canoga Park, I don't remember the exact date, and I don't remember my exact time.  It was 24 minutes and change.  The documentation of this race is long gone.  What I do remember is going out too fast and dying during the second mile, getting enough energy back to finish relatively strongly at the end.  I was hooked.  I've done countless 5K's since then.  In many ways, the 5K is my favorite distance.  You get up in the morning, put on your shorts and running shoes, maybe do a 3 mile warm up run on the course, race, and head home.  If I want, like this morning, I'm back in bed as I write this blog and may even take a nap!  And I still have the day ahead of me.  This is very different from an Ironman, or even a half ironman.  It's different from a triathlon and everything that goes into one.  It's simplicity. And, it's still a solid challenge.

Over the years, the 5K was my running north star.  In the 90's, as I began running and focused on marathons, I still made time for 5K's.  I got my 5K time down into the 21 and 22 minute range.  Somewhere along the way, I don't remember exactly when, I did a 5K at UC San Diego and managed a 20 minute and 12 second finish.  Tantalizingly close to the 20 minute mark that I'd set as my 5K goal.  Yet, that goal was elusive.  I worked on my one mile time and managed to do a mile on the track in under 6 minutes.  Then, in 2008, on the weekend of my 49th birthday, I ran a 5K in San Pedro, California.  I was living in Denver at the time, so there was a benefit of coming down to sea level.  My coach told me to "run like you stole something."  I was in the zone that day, and remember how easy it felt to run fast.  I crossed the finish line in 19:30.  My first, and only, sub-20 minute 5K.  They never published the results of that race online, but I still have the data.

In the last several years, my focus has been on Ironman training, and my 5K times haven't been under 23 minutes for quite awhile.  I wasn't sure what I could do today.  I'm still recovering from Kona, but I'm finally starting to feel like myself.  It was cold and raining today, which helps in some ways, but not in others.  I did a solid 3 mile warm up comfortably and got in a couple of 45 second strides at around 7 minute pace.  There's always a difference between training and racing, however, and once the gun goes off, the adrenaline kicks in and helps.

I ran the first mile today fast and relatively comfortable.  I like to call it comfortably hard.  I wasn't looking at my watch at all, and was pleasantly surprised to see 7:17 for my first mile, which had a slight net downhill to it.  I upped my breathing over the second mile, which had a slight net uphill, and started feeling the strain of a 5K.  Fortunately, I didn't "die," like I did in my first 5K twenty eight years ago, and felt very positive to see 7:35 pop up on my watch for my second mile.  Unfortunately, the third mile didn't turn out to be the kind of mile I'd wanted.  I had hoped to bury myself during the third mile, but my legs weren't feeling it, and honestly, I wasn't either.  I didn't slow down too much, and managed 8:17 for the third mile.  Somehow, if I'd left everything out there today, I might have gotten the third mile under 8 minutes.  I was able to run fast for the final tenth of a mile. about 7 minute pace, to finish the 5K in 23:37, my fastest 5K in five years, and not too shabby for a 60 year old.  It's a great starting point for the upcoming year, where I'd like to focus on my speed and seeing what I can do with my 5K time.  While I love goals, I think I'll just let this one come about naturally, and let it be whatever it will be!

Bullies are my Weak Spot

My weak spot is bullies.  They make me feel like I'm lacking in control. Ironically, worrying about being in control isn't really necessary if you can accept the fact that we're never fully in control of anything.  Still, it's a challenge.  Most of my life I've really struggled with bullies.  At the same time, I've usually been fine in standing up to bullies, but that doesn't change the underlying internal discomfort that they cause me. It truly has always been my weakness.  In 7th grade, I was bullied, and actually stood up and fought with the bully. In college, I was involved in a summer research program and a graduate student bullied me, and I quit.  There are many examples over the years.  When I've tried to accept a bully and not quit or fight back, it hasn't been healthy for me.  There are exceptions, though.

If I don't have to directly deal with a bully, or if they have little to no actual impact on me, I don't need to confront them.  That's where life balance comes into play. No matter what, though, the key is to not let bullies control ones life in any way, shape or form. Whether that is something I can control, or not, is really beside the point.  One thing that I know for sure, is that I don't do well when I let bullies take control of my life.  It's never felt good, and it never turns out well.

Bullies are my weak spot.  Standing up to bullies has defined most of my life.  I can't change that, and therefore, don't want to.  A weak spot isn't necessarily a weakness.  It's important to know your weak spots so you can address them. That's what I try to do.

Fartlek Time

Runners know the word fartlek, it's a Swedish word that means speed play. The operative word is actually play.  It's about having fun.  The past two days, I've incorporated the fartlek concept into my three mile runs.  And I've enjoyed it.  In the spirit of what I've been writing about for the past few days, I've realized that I both want to and need to have fun with my daily exercise.  I say daily because it's really important to do some physical activity every day.  I just need to do things that are fun for me.  That might be doing a bunch of pushups (I did 220 on Sunday), or it might be running a few miles.  It might also be walking a few miles, a habit I got into when training for the 100 miler.  Walking is great exercise.

I'd signed up for a half ironman in about 10 days.  I doubt that I'll do it.  For lots of reasons.  First, I signed up when I was in the heightened Ironman training state.  Second, I wanted to see how I would do in my new age group.  But, my body has been sending me other messages lately.  I want to have fun.  A half ironman might be fun, but it also might not.  I've often made it a point to listen to my body, and my body has really been talking to me lately. When I decide to spend the day laying down and watching television, with literally no exercise, I know that I'm beyond my limits.  That's happened to me a couple of times in the last week

The neat thing about this realization is what it means to me when it comes to life as well as training.  Why shouldn't I look forward to enjoying everything that I do.  There is no reason whatsoever to take on any project or endeavor that involves stress.  What's the point?  Now, the athletes might argue that we need stress in order to improve, but that type of stress is different.  There are good stressors and bad stressors. The idea is to avoid the bad ones and embrace the good ones.  And so, in two days I'll do a 5K (Turkey Trot).  Depending on how I feel that day, I'll run easy or I'll run hard, or I'll do both.  On Sunday, I've signed up for a 10K.  Similarly, I'll run easy or I'll run hard, depending on how I feel.  On Monday, I'll decide on the half ironman.  Most likely, I won't be doing it.  Right now, I'm enjoying taking each day as it comes, and having fun.  We'll call it the fartlek of life!

Being Me

I thought of various titles for this blog. I started with Being Bullied, and then considered Being Disrespected, but realized that what I was really searching for was Being Me.  Who am I? What matters to me? What's important to me?

For as long as I can remember, it's been important to me to be my own person.  To be independent. To do things my way. Ironically, I see that all the time in my grandson. He always has to be responsible for what he's doing.  I guess he gets that from me.  As I got older and took on work responsibilities, it was always important for me to take responsibility for things that I was involved with.  I've always been that way about life in general, whether it be work or family.  In fact, when family and work coincided, this took on a life of its own.

The challenge comes when the goal tied to this level of responsibility are either too broad, too high, or just simply unattainable.  It's always been easy for me to set lofty goals in triathlons or running races.  There's no consequences to not achieving them.  In work and in life, there are perceived consequences to not achieving goals. I say perceived because everything is relative.  We can only achieve what we actually achieve.

I saw a quote today from a 100 year old man who said, "You do the best you can. And the things you can't do anything about, don't give any thought to them." That's how he lived a minimum stress life.  You do the best you can.  Those are important words to live by, especially when it comes to being me.

The Squeeze is More Important Than the Juice

Outcomes and results are fleeting experiences.  Yet, we often judge ourselves on those fleeting moments.  If there's one thing that I've learned from Ironman, it's that the journey is what matters the most.  The squeeze is truly far more important than the juice.  In school we aim for high scores on tests, rather than on what it takes to achieve those scores, which is the process of studying.  In a race, we focus on the result, the time, which only can be achieved if we've trained properly and effectively.  In trying to make a difference in the world, we might look at a particular outcome, when in fact, that outcome can only occur if we put in the necessary effort and work to make it possible.  If we allow ourselves to only feel good based on an outcome, we're missing so much.

Outcomes occur at a singular moment in time.  Crossing the finish line of a 5K, or an Ironman, occurs in a split second.  The 5K itself might take 24 minutes, the Ironman 13 hours.  I've learned to appreciate every moment of these races, rather than wait for a single moment at the end.  But more so, is the time that goes into preparing for a race.  That's the time, and the moments, to appreciate.  Life is no different.  A year and a couple of weeks ago, I woke up to the realization that I wanted to have fun when it came to life and work.  Focusing on outcomes is aligned with being serious all of the time.  Focusing on the journey is aligned with feeling joy in the moment.  I see this all the time with my grandson.  He definitely is here to teach me some important things about life!

With all this said, there is something to be said about having goals. I've written time and again that I'm a goal oriented person.  I'm not sure what I'd do in life without goals. Ironically, I'm also proud of the fact that achieving a particular goal doesn't really matter, that it's really about the journey.  Maybe the issue is when actually achieving a goal unknowingly becomes the priority. Or maybe it's not any of this.  Having goals, enjoying the journey, attempting to achieve something and not being tied to the actual outcome. This combination has tended to define me and my approach to life.  Maybe the issue is deeper and more specific.  What if the issue has to do with what you experience during the journey, and when that experience is unhealthy.  Sounds like a good topic for tomorrow.

The "Empty Carbs" of Consulting

For the last year I've been looking at doing consulting.  Ironically, as a business person I always avoided consultants.  I often talk about wanting to make a difference.  How often do consultants make a difference?  They make recommendations, but don't have any authority.  It's just like taking in "empty carbs."  So, why do I want to do consulting?  Or, do I?  I'm not so sure, especially as I find things to do that have meaning to me.  I've always been a very serious person, ever since I was a child.  I still am, although having a grandson has helped me less serious.

It's difficult enough to make a difference when you're in charge, or when you have any kind of authority.  It's really hard to make a difference when you have no authority.  I've often said that I learned the value of true leadership when I was working for a quality improvement organization, because we were in essence, consultants.  In some ways, that's the reality of being in a position without authority.  You do have to learn how to be an effective leader if you're going to get anything done or get people to respond to your direction.  Of course, if you're a good consultant, sometimes people will follow your advice.

I suppose that my question really is about my balance.  One of the things I've learned over the years is that one is never fully in control, even if you own or run a business.  But nothing in life is 100%.  Still, I struggle with the consulting side of things.  First, I've never been a salesperson.  I don't really like to sell  myself.  Second, I'm a conceptual thinker.  While I appreciate detail, I don't really like focusing on them.  Third, I really want to focus on having fun.  I'm tired of fighting.  What can I focus on that will involve the least amount of fighting.  That may be a topic for a future blog.

So, maybe consulting isn't fully about "empty carbs." Nothing is perfect in life or in the world.  Consulting isn't the perfect job. But no job is perfect.  I've certainly learned that to be the case.  What matters is purpose.  Empty carbs don't provide purpose.  Maybe that's why this is important to me. Maybe that's why I'm obsessing over this question.  It comes back down to purpose and having fun.  There's nothing empty in that.

Being Focused Versus Being Distracted

Over the last few weeks I've had a number of opportunities bubble up.  While on one hand this is both good and exciting, on the other hand its been anxiety provoking.  I realized today that a little more than a year ago, though I was more stressed than I've ever been, I felt a singular sense of purpose.  While my workaholic tendencies were at an all time high, I knew what I was doing and why I was doing it.  Once I started getting over the worst emotional scars from that period of time, I became  focused on training for Kona.  That also felt right, although I knew that wasn't what I wanted to spend the rest of my life doing.  It was fine for nine months.  So, here I am now, still recovering from the impact that racing Kona with a sinus infection had on me.

It doesn't help that I alternate being tired with feeling ok every other day.  The last few days, I've spent some time in my new part-time job.  It feels right.  It feels good.  It feels fun.  Check.  So, why am I so anxious?  Perhaps because some of the other opportunities that are in front of me are overwhelming.  I've always had a tendency to take on everything that comes my way, and then some. I don't know if I'm just getting too old to handle too many things, or whether I really just want to focus on a few things that matter.  I do know that I've always struggled with letting go of things that I've committed to.  It's really hard for me to say no, or to back away from things.  In some ways, it's the Ironman in me.  At this point, however, it's not very healthy.

I don't want to be distracted by having too many things to work on.  I need to be focused.  I need to prioritize.  It's a good thing that I've got the weekend ahead of me.  It will be a good time to consider the various options that I have in front of me.  Being focused clearly matters far more than being distracted.

To Impeach or Not to Impeach, That is the Question

I've been thinking about this question all day.  My approach to this is actually to try to convince myself why NOT to impeach.  The most cogent argument that I can come up with is that the American people knew that Donald Trump was a misogynistic, narcissistic, egomaniacal person when they elected him to become President of the United States.  Nothing that I've seen in the impeachment proceedings has been inconsistent with this knowledge.  In fact, he's being impeached for behavior that is 100% consistent with his personality. When he was running for President, he encouraged the Russians to find dirt on Hillary Clinton.  This is a man who is brilliant at obfuscation, who thrives on creating chaos, who shows no loyalty to anyone but himself or to those who are complete sycophants.  From that perspective, we had an election three years ago and Trump was elected President.  The people who voted for him, knew the kind of person he was and chose him anyway.  Those same people are vehemently defending him today, as they should.  They say that impeachment overrides the will of the voter, and they are correct, from that perspective.  Looking at the situation that way, I can conclude that I would vote to NOT impeach.

Of course, there's another view of the situation.  What is impeachable?  What does impeachment mean?  Impeaching a person is about calling into question their integrity.  Plain and simple. The Democrats have plenty of reasons to question Donald Trumps integrity.  And even for those who don't agree with that, they have every right to question Trumps integrity.  Our country has a constitution and a system of government that clearly allows for this process to proceed.  The Republicans also have every right to disagree with the process and to complain about it.  That, in fact, is what our country is all about.  While impeachment, by definition, is about calling into question the President's integrity, the House has nothing to do with convicting the President.  That is for the Senate to do.  We can guess the political ramifications of the House voting to impeach. Will it upset voters?  I don't know.  Does it matter?  Only time will tell.  Ironically, we've heard some Republicans, and possibly the President himself, promote their desire to have the process move to the Senate so that other witnesses, such as the Bidens can be called to testify.  Great!  I'd actually like to see that.  There will be no opportunity for Republicans to complain about the process in the Senate.  Hopefully, we'll hear all of the witnesses state their cases with a minimum of the political nonsense that we've been hearing during these proceedings.  Looking at the situation this way, I would certainly vote TO impeach.

One last thing.  What are the clear facts?  We know that President Trump asked the Ukrainian President to announce that he was investigating Biden.  We also know that he didn't care if the investigation actually took place.  Doesn't really sound like someone who was really concerned about Ukrainian corruption, but, in fact was more concerned about smearing a political opponent.  Guilty.  Is it enough to impeach? Why not?

Wink and a Nod

One of the reasons that I am so emotionally troubled by the impeachment proceedings is that they remind me a lot of what I've seen in the nursing home industry.  Every nursing home says that they don't hire a medical director for the purpose of that doctor bringing patients to their facility.  Just because they say it's not true, doesn't make it not true!  Today, Sondland said that what Trump was asking him to do was a quid pro quo, while at the same time, Trump told him "there's no quid pro quo."  Give me a friggin break!  Donald Trumps modus operandi is to say he doesn't do something when in fact he does it.  At least he does that until his lie is fully exposed.  He didn't use the disgusting language in the Access Hollywood tape.  Well, he did, but it was just "locker room talk."  Utter bullshit!

But this isn't uncommon in the business world, or the world in general.  The concept of a "wink and a nod," is very common.  In the nursing home industry, one of my favorite lines is that when a nursing home administrator says "we're not hiring this medical director in order for him/her to bring us patients," and a speck of dust hits their eye and they wink...well, you get the point.  The nursing home industry is rife with this type of behavior.  Now we're seeing this portrayed in the impeachment process.  Only the Republicans aren't bothering to wink and nod.  They're just going right to ignoring the truth and common sense.

I don't know what's next.  I understand that this type of behavior has probably gone on since the founding of our country.  I understand that this stuff happens all the time.  I also understand that two wrongs don't make a right.  So, we're back to where we were the past few days.  The American people will hear the truth.  Democrats will impeach the President.  Republicans will not convict him in the Senate.  We have an election in one year.  Nothing's really changed.

Illegal Versus Immoral Part 2

I've set the stage for this discussion in my previous blog.  Just because something is legal, doesn't make it moral or ethical.  I'm going to let myself discuss the impeachment proceedings under this contextual construct.  I've been watching some of the hearings, and some of the commentary.  There seems to be a line of argument that nothing illegal was done, hence, the impeachment process is a sham.  I struggle with this because of what I've now learned is meant by "high crimes and misdemeanors."  I am not a legal or constitutional scholar, but it appears that this term is not meant to reflect straightforward, legislated laws. Rather, it is meant to relate to government officials who abuse their power in some way, shape for form.  It is specifically vague.  Ironically, one thing that has become clear during this and previous administrations is that there is a belief that the President can not be charged with a crime anyway.  So, we are left with the impeachment process if we believe that the President has done something wrong.  Wrong, however, does not have to mean strictly illegal.  So, there we are.  Impeachment, by its very nature, is a political process.  It's not surprising that one party, in our two party system, can hijack the process for its own benefit.

At the onset of the Nixon impeachment proceedings, there was a clear partisan divide.  It was only after specific digressions were exposed that it became bipartisan.  In the case of the Clinton impeachment, it was purely a partisan process.  Whether President Clinton perjured himself (the ultimate transgression for which he was impeached), is still debatable in my opinion.  "I did not have sexual relations with that woman," could still be reasonably understood to mean that he did not have sexual intercourse.  From his perspective, the things they did, didn't rise to the level of sexual relations.  Regardless of this nit picking, which, by the way, I don't buy, the real question was whether this rose to the level of high crimes and misdemeanors that is related to ones ability to carry out the roles and responsibilities of the office of the president.  Did any of President Clinton's philandering impact his ability to carry out the duties of his office?  Considering the fact that Hillary was probably well aware of his transgressions, I doubt it.

Which brings us to what's going on in Washington D.C. today.  I do not believe that anything illegal has taken place, although the more investigation that is done, the more we may find (not dissimilar to both Nixon and Clinton).  However, does it rise to the level of truly impacting the duties of the presidency?  Personally, I find much of President Trump's behavior despicable.  I think it's horribly wrong to cast aspersions on our own government servants to a foreign power.  I think it's ethically wrong to ask a foreign power to dig up dirt on a political opponent.  However, it's not illegal.  And, it's probably been done since the founding of our country.  We just never had the internet and news cycle that we have today.

While two wrongs don't make a right, the Democrats have as much right to impeach Trump as the Republicans had to impeach Clinton.  I keep hearing that we should let the voters decide.  They will.  The Senate will not convict.  I also hear that we're wasting the legislators time.  They should be focused on working for the people of the United States.  Sorry, that's bullshit.  The Democratic controlled House clearly limits what Republicans can propose legislatively. At the same time, the Republicans won't allow legislation passed in the house to even be debated in the Senate.  With or without impeachment hearings, nothing is getting done anyway.  So, we're left with impeachment hearings, controlled by the Democrats. I wish they'd give a little more time to the Republicans so that the "fairness" issue wouldn't be so contentious.  However, the Democrats control the House, so that's their prerogative, just as the Republicans control the Senate, and you can be sure they will control how a trial in the Senate goes.  So, we're stuck with a process that will actually give us information as voters to decide for ourselves whether something illegal, immoral, or just distasteful was done by the President.  And maybe that's how it should be.

Illegal Versus Immoral Part 1

The goings on in Washington D.C. these days brings to light a question that I have become very attuned to in the past year.  What's the difference between illegal and immoral?  Well, for one thing, illegal is a legal question.  Whether something is illegal is based on what the law says and ultimately how ones behavior is judged as it relates to said laws.  Immorality is an ethical question, and depending upon ones belief system, the judgement regarding immorality is ultimately based either on ones own ethical and moral guideposts, or, on ones religious and spiritual beliefs.  Do they cross over?  Absolutely, but most commonly on the extremes of each.  For example, murder is illegal and immoral, except in cases of self defense.  If a child steals food because they're hungry, that may be illegal, but one could question if it's immoral.

Over the past few years I have become intimately involved in the nursing home industry.  There are many legal constructs that have been nurtured and developed by both the industry and the politicians who create legislation that ultimately regulates the industry.  One of the favorite mechanisms by which individuals protect themselves from lawsuits is forming an LLC (Limited Liability Company) for their business.  Having an LLC generally protects the individual owner from personal liability from things that emanate from the business.  There are exceptions to how this works, and this is not meant to be a legal treatise.  However, from the perspective of the nursing home industry, the real estate that defines a nursing home is often owned within its own LLC.  There is often an operational business that coincides with the real estate entity.  The operational business also exists under its own LLC.  Finally, there is often a consulting business that makes recommendations to the operational business.  It, too, exists under its own business umbrella.

Here's how things play out.  If something goes wrong in a nursing home and a resident is harmed, who is to blame?  Well, the real estate entity will claim that all they are responsible for is the real estate and they have nothing to do with operations. They're not at fault.  The operations entity, theoretically responsible for the care that is delivered, will often point to the consultants who told them what to do.  Sometimes this works, sometimes it doesn't.  It's clearly the weakest link in the chain.  Nevertheless, even this link has some protections attached to it.  With that said, the operations entity is often the least profitable of all the entities involved. So, even if there is a judgement, there's no money to pay it.  Finally, the consulting company will say that their just consultants. They make recommendations, but they're not responsible for whether those recommendations are followed.

So, something goes wrong in a nursing home and a resident is harmed.  Was anything illegal done?  Generally not.  What about the ethical and moral side of the equation?  That's what I've been thinking about for the last year.  That's what I'm going to discuss in my next blog.

Journey to Kona Day 285: Recovery, Again and Again

My journey to Kona hasn't been completed.  I'm still recovering.  It's been a long process, and still is touch and go.  A two day business trip, concluding with a 21 hour day, knocked me back a few steps. I was going to bike and run this weekend, but instead I've been resting.  Though, not completely.  I am continuing to work on my strength.  Yesterday I managed to do a 30 minute strength set with pushups, air squats, lunges and planks.  Today, I woke up still feeling a little fatigued.  I knew that going out for a bike ride or run would not add to my fitness or race preparation.  In fact, it might knock me back a little.  Still, I want to keep working on my strength.  So, every hour today, I've been doing 30 leg lifts and 20 pushups.  I'm already at 180 leg lifts and 120 push ups for the day.  We'll see where I end up.  Most likely, I'll be ready to bike and run tomorrow.

My goal at this time is to stay fit and get stronger.  Racing is a fun bonus.  While I'm looking forward to doing a half ironman in three weeks, that's not at all the point of my training.  The point is the training itself, and the focus is on staying fit.  The way I've felt for the last couple of days tells me that I've really achieved all that I wanted from this past year.  Focusing on recovery is what training is all about as we get older.  I constantly battle with my desire to do an extra workout, especially with some intensity.  Now I need to battle with my acknowledgment of the need to rest and recover.  Of course, while doing some extra pushups and leg lifts.

Trying to balance recovery with training and life is an ongoing challenge.  But it's definitely part of the life metaphor that I regularly write about.  It's important that we take care of ourselves.  We should all focus on our own recovery, again and again.

Journey to Kona Day 284: Epilogue

It's been 5 weeks since I finished the Ironman World Championship in Kona.  While in some ways it's  already becoming a distant memory, it's still vividly with me like it was yesterday.  It is definitely a day I will never forget.  I'll always remember seeing the boat at the swim turnaround.  The realization that I didn't have any energy that day, while fleeting because I utilized the meditation tool of noting to great advantage, will be with me forever.  The thought of almost accepting a huge block of ice after the bike turnaround in Hawi still brings a smile to my face.  The fact that the one thing that mattered to me immediately as I finished was to congratulate the 75 year old who finished in front of me.  Those are some of the memories that will stay with me forever.

The last five weeks have been their own struggle, as the days following an Ironman often are.  Because I did this race with a full blown sinus infection, I crashed (metaphorically) a lot sooner after the race.  I'd already been battling physiological and hormonal ups and downs for several weeks, as I had pushed my body to a place it hadn't been to before.  Those ups and downs have continued, although generally for good and acceptable reasons.  I was literally at the brink of exhaustion yesterday, but that came on the heels of a 21 hour day, followed by the joyful, yet demanding, task of caring for a 4 year old.  So, today I rest.

I'm racing again in 3 weeks and looking forward to it.  It's just a half ironman.  I'm pretty sure that's a distance that I still like.  It doesn't involve 6 hour training rides or 90 minute swims to prepare.  In fact, for me, it doesn't really involve any specific training approach.  I've been doing Ironman racing for a full decade, and my body is used to certain things.  I know that I like just putting on my running shoes and going outside for a long run.  Time isn't important, and running has easily become my simplest form of meditation.  I enjoy cycling, and I'll always love the feel of the water.  Still, there are other priorities in my life.  I've checked off one box, and there are other boxes that need tending to.

This past week was very interesting.  I've had a number of business opportunities arise, and some tasks arise that are related to some unfinished business.  It's been a year since I quit my last job.  I am feeling purposeful, and focused on that feeling.  I'm accepting where I am in my life.  I can be in the moment.  There are no regrets, nor is there a need to worry about the future.  My life is now my Ironman.

Being Above the Law

I have encountered people who are so wealthy that they think that can buy anything and anyone.  I've seen this attitude lead to essentially feeling that they're above the law.  They can hire enough lawyers to obfuscate and prolong any battle.  There's no question in my mind that trump is one of these people.  I don't really know what he thinks or what goes on in his head.  He may truly believe that he's right about everything.  That he knows the answers to everything.  That's he's a genius.  That he's perfect.  But I do know one thing.  No one is perfect.  No one knows the answers to everything.  Watching trump and many of the republicans avoid the facts, and watching democrats cherry pick the facts that matter to them, reminds me that many of these politicians think they're doing what's right.  They know best.

In some ways, seeing some of these career public servants come forward reminds me that there are people out there who don't believe that they're above the law.  They do believe in being truthful.  I've never lacked in confidence or ego.  But I've always known that I don't know everything.  As I gotten older and gained more experience, I've tried to remain humble and willing to listen to others.

Money and power can influence people to believe that they can get away with anything.  There are natural human emotional responses to being around celebrities, wealthy people and powerful people. It's one of the reasons that many people won't speak truth to power or money.  I've always found it interesting that people without money think that they can become wealthy, even though the odds are miniscule.  Yet, they don't want to increase taxes on the wealthy because they think it might be them some day.  There are so many things that don't make a lot of sense about human beings and their reactions.  But, this natural behavior supports those that believe that they're above the law.  There are reasons that they think that they can get away with anything.

I don't envy those who are wealthy or powerful.  In some ways, I feel sorry for them.  I don't want to define myself or my life by wealth or power.  I sleep well at night knowing that I've been the best person that I can be.  I hope that I never feel like I'm above the law.

Comparisons

It struck me yesterday that Bill Taylor and Donald Trump had choices in the 1960's.  Bill Taylor went to Vietnam after graduating in the top 1% of his class at West Point.  Donald Trump got several deferment letters from a doctor alleging bone spurs in order to avoid military service.  Bill Taylor chose a life of government service.  Donald Trump chose a life of making money at all costs to others.

As I watched the proceedings, it became clear to me that Bill Taylor is a man of integrity.  He embodies the concept of speaking truth to power that I wrote about a few days ago.  Donald Trump has no integrity.  He feels it necessary to belittle anyone who disagrees with him, including his own supporters.  Bill Taylor is the definition of loyalty. He is a true patriot who clearly cares about our country and puts that feeling above his own personal goals.  Donald Trump pretends to value the concept of loyalty, except that he is only loyal to two things, money and himself.  If you disagree with him, there is no loyalty.

I have friends who are Trump supporters.  Yes, it's true.  They remain friends because they were my friends before Trump and they will be my friends after Trump.  As I've come to understand their support of Trump, it has become clear that they believe that the ends justify the means.  They also recognize that when it comes to politics and Washington, everything is cloudy.  I don't disagree.  I wish that the Democrats would all act like Bill Taylor.  Stick to the facts.  Avoid the name calling.  It's actually ironic, though, that we complain about Democrats "name-calling," and Donald Trump has made it an art form.

Bill Taylor could retire.  He's 72 years old.  Looking at his resume, there's no evidence that he is part of a "deep state" conspiracy.  Quite the contrary.  He is the type of man and person that we would hope works in our government.  He steadfastly does the work of representing our country.  He speaks truth to power.  In fact, he was critical of President Obama not giving anti-tank missiles to the Ukraine and was complimentary of the Trump administration for doing so.  Bill Taylor speaks truth to power.  Donald Trump speaks power to truth.

Making a Difference

Making a difference.  This is something that has driven me for as long as I can remember.  Surely, I was influenced by my father, but that alone doesn’t account for the feeling in my gut that has always driven me to want to make a difference.  When I was just nine years old, I wrote a letter to then President Johnson, asking him to end the war in Vietnam.  Less than 10 years later, I wrote a letter to Menachem Begin, sharing my thoughts on the ongoing tensions in the Middle East.  I actually wrote to President Reagan, offering to be the Secretary of Education, a Department he wanted to dismantle.  When Bill Clinton became President, I once again reached out.  Perhaps I’m fortunate that I never had the right connections to achieve anything through my efforts.  

When I was in the 6th grade, I ran for Student Body Treasurer, and when I was in the 7th grade, I ran for Student Body President.  Since I was a nerd who wore glasses and carried a briefcase, I wasn’t going to win.  I might have managed to get there as an 8th grader, but I decided to skip the 8th grade and start high school a year early.  I was so focused on getting through high school that my political efforts were put on hold until my senior year, when I did manage to get on the Student Body cabinet (I lost the election, but my opponent moved, so I got there by default). In college I once again was focused on school, and managed to ignore my leadership leanings until I got to medical school.  It was there that I became one of the students involved in running the National Student Research Forum.  

As I write this, I’m becoming aware of a pattern.  My drive to make a difference, and the effort necessary to be in a position to make that difference, has always been balanced by my passion for learning.  Time and again, I’ve not taken the initiative to market myself, thus limiting my upward mobility at times as it related to being in leadership positions.  This changed when I started working for Kaiser-Permanente as a Geriatrician.  I became actively involved in program development and somehow managed to get interviewed for the Southern California Permanente Regional Medical Director position while being a brand new partner, at the age of 32.  I had all sorts of ideas as to how I could change things.  What I was lacking was a thorough understanding of how to grease the skids, so to speak, in order to move forward.  In some regards, I was intolerant to what it took in order to do that.  I often say that during this period of my life, I was somewhat of a bull in a china shop.

Ultimately, I made the decision to leave Kaiser-Permanente and change my direction.  I gravitated towards a much more entrepreneurial approach to my profession, which had it’s advantages and disadvantages.  Ironically, being called an entrepreneur always made me feel uncomfortable.  Wanting to make a difference has always been more important to me than being financially successful.  I haven’t even written about the ways I’ve tried to make a difference over the past twenty five years, but I’ll skip to the here and now.

I’ve come to realize that one area that I’ve never balanced with my drive to make a difference is my personal life.  In fact, I must honestly acknowledge that is an area that I’ve always struggled with.  As I get older, I know that regret is of no benefit, and while I can’t make up for past decisions, I can achieve a better balance in the present moment.  That’s what I’m trying to do.  So, here I am, enjoying the time I spend with my incredible wife, and reveling in the joy of watching my grandson grow up.  At the same time, a number of forces and life circumstances have placed me at the vortex of a variety of initiatives and efforts that coincide with my desire to make a difference in the field that means so much to me.  

Maintaining life balance is a skill that I have spent a lifetime fighting.  If there’s one thing that my Ironman training has taught me, is that our lives are like a water balloon.  Pushing on one side inevitably has consequences on the other.  Our physical and mental health are tied together, and every decision we make has an impact on our minds and bodies.  For some reason, the next couple of weeks seems to have brought everything together as I search for direction on how best to make a difference while maintaining some semblance of balance in my life.  Meditation needs to be my best friend and companion as I approach the various opportunities that have come my way.  In the end, as my good friend and mentor, Ray Delisle, used to say, whatever I decide, it will be brilliant!

Pushing the Envelope

Today was a long day.  I started the day with a 30 minute strength workout.  I then took my grandson to preschool.  Afterwards, I got in a 40 minute swim workout.  A trip to the supermarket on the way home and an hour to go through emails, get in a 3 mile run, and I was back to preschool to pick up my grandson.  Bringing him home and getting him ready for his nap is an hour plus process that involves patience, negotiation and patience.  I had perhaps another hour before I had a business call, run an errand and pick up my grandson to bring him over to our house for dinner.  I took a break to go to my triathlon club's monthly meeting and then came home to bring my grandson back home and put him to bed, another hour long process.  Where does the time go? Small wonder that I'm tired.

I also, right after my swim, decided to see how many pushups I could do in 1 minute.  It turns out that the average 60 year old man can do between 10 and 14 pushups.  I'm not sure if this is specifically over a minute.  It turns out that in a study of 1000 firefighters whose average age was 39, doing 40 pushups in a minute was highly predictive of low cardiac disease risk.  So, after doing a strength workout and a swim, I still did 40 pushups in a minute!  That sounds like a great start.  To join the coast guard, I'd need to be able to do 29 pushups in a minute and run 1.5 miles in under 12 minutes and 51 seconds.  Hmm.  I could qualify for the coast guard at the age of 60.

So, I return to pushing the envelope.  I have a tendency to push myself until I can't push any longer.  That's always been my modus operandi.  At the age of sixty, I still tend to default to that approach.  While trying to stay fit, I try to get in my daily workouts.  When life adds other challenges to the day, the total stress can build up.  Sometimes it's hard to balance all of these things, but that's what I've done for a long time.  I'll continue to push the envelope.  It's what I do.

Telling Truth to Power

What do you do when you work for a powerful person and they're doing things that you believe to be harmful?  That's the question that is being asked today as we hear that president trump's Chief of Staff and Secretary of State were trying to subvert his decisions.  It's a fascinating question.  I can actually see Nikki Haley's point of view.  Those who disagreed with the president should have told him so, and even should have been ready and willing to resign in order to stand up for their beliefs. Seems pretty straightforward and simple, in an ideal world.  But we don't live in an ideal world.  We live in the real world.  In the real world, people with power and money make decisions and get away with them.  In fact, they may feel empowered to make any decision they want, regardless of the consequences.  This matters for powerful people in industry, and it matters for the president of the United States.  Where do we draw the line?

I understand that there are many people who have gone to work for president trump, believing that they could be the "adult in the room."  Most, if not all, of those people are no longer there.  The adults in the room have been pushed out, leaving only sycophants who do whatever the president's whim is. This almost answers the initial question.  If the people who have left had stuck around, perhaps they could be modulating to some degree some of the president's worst decisions? Or, maybe they'd be gone by now anyway.  It's impossible to tell.  The same question occurs in industry.  Do you stick around, trying to make the best of a bad situation? Ethically, it's a very difficult question to answer, because staying around theoretically means being associated with the same bad decisions that you were fighting to prevent.  That's not something that makes it easy to go to sleep at night.

Ironically, while Nikki Haley is sounding so proper over telling folks they should have stood up to the president, she has her head so deep in the sand that she's going to suffocate.  president trump is a narcissist, and doesn't like to be told what to do.  He has said on many occasions that he is the smartest person in the world and he has all of the answers.  It only takes one disagreement to get on his bad side.  Furthermore, John Kelly and Rex Tillerson were not idiots.  They had pretty strong pedigrees.  If they were in agreement that the president was off his rocker, why not at least ask the question, were they right?

Maybe I've watched too many episodes of 24, but there needs to be some recourse for when the president of the United States goes rogue.  The question is what rogue means.  Sucking up to dictators from Russia and North Korea would have set off alarms if this were any other president.  Image President Obama doing the same?  The Republicans would have been apoplectic!  But this is president trump.  He can do no wrong.  How many of his people have to leave, or get let go, before his supporters will realize that either everyone else is wrong, or president trump is just always right, like he says he is?

The Zen of Running

Today, I ran. For just a little over 2 hours, I ran.  Most of the time, I just ran at a comfortable pace, but did push my effort a bit during the second half of my run.  I don't have to run for two hours any more.  But, I like to run.  There's actually something quite meditative about running.  It's also hands down the best total body exercise that one can do.  Today was four weeks from the Ironman World Championship.  I've actually been looking forward to running for more than 45-50 minutes for the last couple of weeks, but I've held off, knowing that my body wasn't ready.  I almost ran yesterday, but I was tired, so I ended up doing 90 minutes of hot yoga.  That probably left me a little dehydrated this morning, and I decided to run without any fluids or nutrition.  There is a stop halfway on my run where there's a drinking fountain.  It also wasn't too hot out today.  Nevertheless, when I got home from my run, I had lost four pounds.  That's ok, but it did leave me a little tired and washed out, which ultimately led to me taking a nap.  That's ok too.  I ran for 12 miles today, uphill and downhill, for a little over 2 hours.  It was great!

When I was a teenager, I tried to run.  I couldn't last more than half a mile.  In fact, when I turned thirty, I'd never run a mile straight in my life.  After building up on a stair master, I started running on a treadmill.  For awhile, I ran with headphones and listened to music.  Then, one day, I was running along a path in a nature reserve and I took off my headphones.  I've never used them since.  A month before Kona I ran for over 3 and a half hours.  I loved it!  In the last few years, I've gotten in the habit of meditating during my long runs.  Other times, I just enjoy the run itself.  There is definitely a Zen to running.  The nice thing is that, despite having no Ironman plans in my future, nor any plans to run a marathon, I can run because I want to, when I want to.

The coming year will be interesting, when it comes to running.  I certainly want to work on my 5K speed, especially because I'm goal oriented and I'm 60.  But, just going out and running for an hour, or two, or three, will always be something that I can and will do.  That's the Zen of running.

Taking a Day Off

I've been writing about health care and politics for the last week.  These are things that obviously matter to me.  They are also things that, while I've been thinking about them this year, haven't been my focus.  My total and complete attention this entire year has been on Ironman training and racing.  Now that I've finished my life's dream, I've recalibrated my physical activity focus.  I'm not training for an ironman, or any other major endurance event.  I do have a half ironman coming up in four weeks, and will probably do a couple more halves next year.  After ten years of ironman training and racing, half ironman's aren't that daunting.  It's not like I won't be working our or training.  Far from it!

I'm sixty years old, and some days I feel like it.  My coach has correctly encouraged me to focus on building strength.  As a geriatrician and athlete, I know the importance of focusing on muscle strengthening as we age.  I've waited a little too long to start, hoping that my ironman training would naturally provide some of this.  But, I know that it's finally time.  Over the past couple of weeks, I've begun to develop some strength training.  Nothing fancy, which is the point.  I've been doing push ups regularly.  Yesterday, over the course of about 10 minutes, I did nearly 100 push ups.  I started with thirty straight.  Two weeks ago, ten in a row was a lot.  Progress.  I've been doing air squats.  Two days ago, I did a "fun" workout that my coach gave me.  Alternating running 1/2 a mile with either pushups and lunges or air squats.  This 40-45 minute workout ultimately included 150 air squats, 60 push ups and 60 lunges.  Progress.

I was going to run today.  I had, in my head, the idea of running 11-12 hilly miles.  I was really tired last night, and actually went to bed around 8pm.  I didn't get out of bed this morning until nearly 8 am.  My body felt ok, just a little general soreness, and a little general fatigue.  If I was training for another ironman, today would be a perfect day to go out and run.  It would be a perfect day for acclimating my body to training with fatigue.  But I'm done with Ironman.  I'm trying to get stronger and healthier.  So, today is a perfect day to rest.

The challenge of resting, especially at sixty years of age, is to keep the body moving and the blood flowing.  I find that if I just stay sedentary all day, it doesn't serve well.  So, I'll have to figure out how to keep moving today, without putting unnecessary stress on my body.  There's also the matter of mental stress.  I know that is something that we all tend to ignore and underestimate.  Similar to moving around all day, keeping my mind limber without stressing it, is also important.  Fortunately, I have some fun things to work on, and I have a great day of college football to enjoy.  It's a perfect day to take off!

The Influence of Money, Power and Celebrity

What is it about human beings that make us susceptible to people with money, power or celebrity?  I understand this, and have to admit that even I'm responsible for allowing myself to be influenced by these factors at times.  I think that many of us understand what it feels like to meet a celebrity.  You get a "giddy" feeling, you feel nervous, and you don't really know how to act.  This is not uncommon, but why? What is it about a celebrity?  They have notoriety, but are they really any different than you or I?  People with a lot of money often elicit the same reaction.  Is it because we think the we might have access to that money?  Do we feel some connection to power that money brings?  That brings us to the third type of person, and this type might be a combination of those with money and celebrity.  It's those who have power.  It may be an elected official.  It might be someone in a position of authority.  Again, most people feel some level of intimidation when we come in contact with someone who has power, money, or celebrity.  It probably doesn't do much to understand why, although that might lead us to understanding how we might change our response.

I've wanted to make a difference in the world since I was a kid.  It's hard to make a difference without money, power or celebrity.  But even with these, it's hard to make a difference.  Which begs the question, if one wants to make a difference, is it necessary to have connections?  What type of connections? It's often said, "it's who you know."  Ultimately, not the best way for determining who can actually make a difference.  As I watch the "Medicare for All" proposal from Elizabeth Warren, the usual names start coming up.  People who have been in positions of power. People who are well connected.  These are the people driving the discussions and the proposal itself.  I'm not so sure if that's good.

The final part of this whole equation is the question of whether one really wants to use get heard by using the traditional connections of money, power or celebrity.  On a certain level, I understand the concept of "if you can't beat 'em, join 'em."  On the other hand, there's something distasteful about using the same approaches that everyone else uses.  It would be nice if we could develop concepts through "grass root" approaches.  That's not so easy.  We have to keep trying.

The Tenor of Our Times

I think that Bill Gates was a little to flippant in his response today to a question about taxation.  He first said that he'd be fine with paying $20 billion in taxes a year.  That was ok.  But then he said, he didn't know about paying $100 billion.  Somehow, the media, and the progressive candidates, have jumped all over the latter comment as if he meant that he didn't want to pay higher taxes.  He also mused as to the impact of excessive taxation on business capital decision making.  Fair enough subject to ask the question of.  But, when you're a billionaire, your musings become fodder for assumptions.  I really doubt that Bill Gates meant for that to happen.  Yet, it did, and that demonstrates the tenor of our times.

Democrats have somehow put themselves in the position of being Robin Hood. Take from the rich and give to the poor.  Sounds great, if you're poor.  Maybe not so great if you're rich. I've never had too much of an issue with paying higher health insurance so that those less fortunate than me could have health insurance.  However, I've also come to realize that the health insurance we're paying for is significantly lacking in value.  On one hand, the Republicans have it right.  We spend a lot of taxpayer dollars wastefully.  They also try to paint the Democrats into the corner of being those wasteful spenders.  It's a ball lobbed gently over the plate for the Democrats to hit, and hit it they do! The leading Democrats today are gleefully going along with the idea that they want to spend tons of government money on any number of programs.

I've made the point in recent days that Medicare doesn't work nearly as well as it should.  In fact, I will argue that, if I could train every doctor in the United States to be competent in the Geriatrics Approach to Care, Medicare expenditures would drop by 30%.  That's a couple hundred of billion dollars.  Elizabeth Warren is correct on one thing.  There is a lot of wasted profit in the healthcare business world.  Health insurance companies don't care what their premiums are, so long as they make their margin.  The pharmaceutical industry. Need I say more?

Why can't Democrats be the adults in the room?  They should start talking about the deficit.  Republicans have dropped deficit discussion like it's a hot potato.  Democrats should pick that hot potato up and run with it!  Instead of talking about spending the tax dollars on new programs, let's talk about being smarter with the money we have.  I know that can be done with Medicare.  Social Security is a tougher topic, although there is the issue of retirement age.  On the other hand, life expectancy in the United States has been dropping (yes, that is a true statement).  Maybe, if we keep this up, we'll end up back at where we were when Social Security was enacted!  Wouldn't that be good for the tenor of our times?

Transparency and the Free Market

I went for a hike with my good friend Dave today.  We discussed healthcare, politics and religion.  Dave and I come from different places when it comes to these topics.  We both trust each others motives and values, so it always makes for an interesting discussion.  Dave's suggestion regarding how to fix healthcare revolved around two talking points that he's heard from some of the pundits.  We're going to hear a lot about these concepts in the coming months as those who are against Medicare for All try to propose alternative solutions to our broken healthcare system.  The two major talking points are transparency and the free market.  These two goals sound great, but they prove that simple solutions are not that simple.

The idea that price transparency will transform healthcare makes sense at a certain level.  If we understood where the money goes and who profits from every healthcare expense, we might be better able to evaluate the merits of that expense.  Unfortunately, the transparency discussion tends to focus on making prices themselves transparent to consumers.  This is not only misguided, but it's also impractical.  There's no way that a consumer is going to achieve substantial benefit from price transparency. Certainly not in an emergency situation, and probably not in most complex medical situations.  Transparency must exist at a different level, one where we see the financial benefits of specific healthcare expenses to the entities that are responsible for their delivery. We need to evaluate these benefits with the actual benefits of the care delivery itself.  For that, we need better outcomes measurements and evidence-based literature.  We're a long ways away from obtaining such data.  I'm not against transparency, but you can be sure that the health insurance, hospital, and pharmaceutical lobbyists will work hard to make sure that whatever system of transparency is developed, it won't shine the light on them.  We won't get real transparency.

I have long espoused the fact that the Medicare program is single-handedly responsible for the diminution of free market forces in healthcare.  Thirty years ago, if you were sick, you wanted to receive healthcare in the United States.  Our system was built on free market forces.  Medicare disrupted that connection, and since the incorporation of DRG's and HMO's, there has been no true free market as it relates to Medicare.  This has corrupted the rest of the healthcare marketplace.  I've written about how health insurance companies, hospital conglomerates, the pharmaceutical industry, and the AMA form the backbone of the healthcare-industrial complex that caters to the worst capitalistic tendencies.  They have been assisted by Medicare and politicians, through their lobbyists, to assure that they are hugely profitable, with little care for whether people are well served by the healthcare marketplace.  The devil is certainly in the details when it comes to putting the free market back into healthcare.  Taking regulation and oversight away might very well completely unleash the very worst in corporate nature.

Once again, I return to my soapbox.  We MUST return professional responsibility to the physicians to care for people.  However, if we don't assure that they're competent, especially as it relates to the care of older adults, we will all lose.  I became a physician at a time that we believed in the oath we took.  I still believe that physicians can be those people, but we must give them the training and the tools to do so.  A truly professional physician workforce, unencumbered by the constraints put on them by the government and insurance companies, will be the ones who can truly take advantage of real transparency and a true return to free market forces.

What's Wrong with Medicare

One of my colleagues posted on twitter today that he can spend an unlimited amount of money in caring for his patients.  That's because he's a geriatrician and his patients have Medicare.  Generally, he's right! And that's not good.  When President George W. Bush, the Republicans, and the Democrats passed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, I asked, rather than provide all this money for prescription drugs for older adults, shouldn't we be asking whether they need most of the drugs to begin with?  The bill was supposed to cost $400 billion, but ultimately cost nearly $549 billion over the next decade, and proved to be a huge windfall to the pharmaceutical industry.  It arguably jumpstarted the unfettered rise in Medicare prescription drug expenditures from ~10% of Medicare expenditures to nearly 20%.  The saddest part of this is that we still haven't addressed the issue of appropriate prescribing for older adults.  That's just the beginning.

The Medicare program spends over $10 billion a year training young physicians how NOT to care for older adults.  They build on this by providing the highest reimbursement to specialists who perform unnecessary procedures on older adults.  Very few physicians have any interest in geriatrics.  Many physicians are incompetent when it comes to the geriatrics approach to care.  This has led to a bunch of programs that try to work around the problem.  Care transition programs that have non-physician coaches encouraging patients to get appropriate care, readmission reduction programs that try to force physicians to reduce hospital admissions, are just some of the many programs that try to make up for a poorly trained workforce.

We MUST reform the way we train doctors, starting in medical school and continuing on through residency.  Geriatrics is just one part of this training that MUST be better incorporated into the educational process.  Palliative care, already an integral part of Geriatrics, is woefully lacking in medical education.  We spend a lot of money, time and resources training physicians the wrong way, and then we spend an inordinate amount of money on unnecessary care.  Adding on to that, we spend even more money on programs that try to make up for all of this!

So, what's wrong with Medicare?  It's an expensive program that provides a lot of unnecessary care at a high cost to taxpayers.  Most Americans like the program, because they can have what they want, even if they don't need it.  Medicare for All?  Are we really ready for it?  Shouldn't we fix what's wrong with the program first, before assuring that the entire healthcare market follows suit?

Time will Tell

I posted most of yesterday's blog on facebook, which I rarely do anymore.  I tweaked it a little when I realized that I had been looking at Elizabeth Warren's "Medicare for All" plan from her perspective as a politician, of which I'm not.  Since the politicians generally make their decisions based on the calculus of how many votes it will get them, I thought that this was an important approach to take.  I'm even more certain of this today.  At the same time, it's also clear to me that even if Warren becomes President, and even if Democrats manage to get a majority in the Senate, the likelihood of her enacting "Medicare for All" is nil.  From that perspective, it's an aspirational approach, and I can respect that.  It would be nice if she acknowledged that fact, but I have to defer to her and her advisors as to whether that makes political sense.  A colleague of mine pointed out that such a dramatic change to a program that constitutes 20% of all health care expenditures could potentially devastate the marketplace.  I'll go one step further.  While Medicare accounts for 20% of the health care market, its influence affects the entire market.  Many insurers utilize Medicare rates, or some variation of them, for their reimbursement methodology.  If we mess with Medicare, we could cause the whole system to collapse.

On the other hand, Medicare is working. It's a functional healthcare model that most of the people who are on it are satisfied with.  It even has shifted to allow for free-market approaches, as I mentioned yesterday in relation to Medicare Advantage plans.  Is it a given that "Medicare for All" will harm the existing Medicare program?  I'm not so sure.  The existing program is working.  "Medicare for All" would be a new program.  The devil is in the details of how it would be enacted.  Would it stand alone from traditional Medicare?  Would it be incorporated into traditional Medicare? Everyone is making assumptions at this point.  While I initially questioned the sanity of the Warren campaign putting this proposal out there, only time will tell.  Can she adequately describe what the proposal really does?  Can she connect with the American people in regards to how it will impact them as individuals?  Only time will tell.

One last thought.  I've said the Medicare is "working."  I say that from the perspective of most people who use the program.  I've also argued in the past that since it's founding in 1965, Medicare has corrupted free-market forces in healthcare.  It starts with subsidies for graduate medical education, and continues with how it can make or break varying healthcare delivery models.  In future blogs, I'll discuss some of the areas that Medicare has failed us.  The concern would be how that translates to a system that provides "Medicare for All."

Medicare for All Versus Healthcare for None

It's time for some quasi-political commentary. Elizabeth Warren has put out her "Medicare for All" program.  I have mixed feelings.  Where do I start?

I believe that everyone should have healthcare and it shouldn't be prohibitively expensive.   What's wrong with that concept and belief?  Today, if you are below the poverty level, or a little above it, you get your healthcare for next to nothing.  But what kind of healthcare do you get?  That depends on the state and how Medicaid is delivered.  It also depends on how the ACA operates in your state, and what insurance companies have done with it.

Healthcare in the United States today is about making a profit for insurance companies, pharmaceutical companies and medical specialists, many of whom are not providing evidence-based care with positive outcomes.  If your health insurance doesn't cost much, you generally don't have many choices. You rarely can choose your own doctor.  In fact, you might be stuck going to doctors you don't like.  Your healthcare choices are often taken away from you.  The focus for the insurance company that is responsible for your healthcare is shareholder profit, not your health and well-being.

If you're lucky, you have good health insurance through your employer, although how much you have to contribute might still be significant.  You might even be stuck with high deductibles.  The days of great health insurance coverage without substantial deductions to ones paycheck are pretty much over. If you've been fortunate enough to retire early, you're screwed. Health insurance is quite expensive.  But, since you're well off enough to retire, I guess it's ok.  If you're on Medicare, you're in great shape!  Hmmm.  Maybe Warren is on to something.

It's often said that people vote with their pocketbook.  If that's the case, Medicare for All has some potential.  For the vast majority of Americans, they will see more disposable income.  They won't have health insurance deducted from their paycheck and they won't have high deductibles. If you're relatively poor and have been getting lousy health insurance for free, you'll suddenly have more choices.

Who won't like this new program?  Billionaires won't like it, nor will people with high incomes and lots of capital gains.  Maybe Elizabeth Warren has done the electoral math.  The number of people who won't like the new program is actually very small.  For those who say that the negative impact on the high earners will harm the economy don't really understand high earners.  They'll figure out how to make more money!  They always do.

So, why do I have mixed feelings?  Because Medicare has many flaws, and by creating Medicare for All, we'll most likely be setting those flaws into stone.  I think that there are other fundamental changes that need to be made to turn around our badly impaired healthcare system.

What about those that say that health insurance companies will be devastated?  There's something called Medicare Advantage.  Why wouldn't Medicare Advantage continue to exist with Medicare for All?  In fact, just as Medicare Advantage provides the ongoing challenge to traditional Medicare, it should do the same for Medicare for All.  Health insurance companies may just have to work a little harder to develop competitive products that provide good health outcomes.  Hmmm.  Maybe Warren is onto something.

How Much is Too Much

I watched Ironman Florida live streaming today.  It was an exciting race amongst the male pros, literally going down to the last few miles of the run.  Did I have a little bit of positive feeling about doing an Ironman? Of course?  Did I change my mind about not doing another Ironman for the next five years? No.  I admit loving the sport, and the distance. But I'm also aware of the amount of time and energy it takes to train and the impact on the body.  What was remarkable about today's race was that the top two men just did Kona 3 weeks ago (finishing 6th and 4th, respectively). Three weeks later they shattered the Ironman Florida record book.  How in the world is that possible?

The human body is capable of some remarkable things.  In the last month, we've seen a man run a marathon in under two hours. We saw the Kona record fall.  Today we saw two men have the best races of their lives just three weeks after racing at Kona.  How is this possible? The simple answer is training.  How does someone like me complete 15 Ironman's over 10 years?  How does an 85 year old finish an Ironman?  Training.  The human body is capable of a lot of things, so long as we train it to get there.  Is it healthy? That's the $64,000 question.  That's actually something that I'm wondering.  I know that doing a 100 mile run is not healthy.

I'm capable of completing an ironman, but I don't really know the net effect on my body.  That's why over the next year I'm looking forward to doing shorter distances.  I'll certainly do half ironman events, and will absolutely do some sprint races.  I'll focus on 5K's.  It will be a different type of stress and stimulus on my body.  I'm not sure what the sweet spot is, but I'm sure that there is one.  We can certainly do too much.  I know full well now taking on and doing too much can affect ones health and well being.  It's all a balance.

There have been some remarkable athletes who have excelled in the ultramarathon world.  Ultimately, they break. And when they break, they break pretty badly.  There's no question in my mind that's too much.  It's harder to tell when it comes to ironman.  I know that it's taken me three weeks to recover from Kona, and I'm not fully recovered.  Of course, I did the race with a sinus infection, which has probably affected my recovery.  When I look back at Ironman Boulder, which I did in June, I was pretty well recovered after a couple of weeks.  I also realize that I had some fits and starts as I got closer to Kona, feeling like I was ready about 5-6 weeks beforehand.  Timing ones fitness for a race like this can be challenging.  Sometimes, we know when we've done too much. Other times, we don't.  I guess that's life!

Strength Training: Kicking my Butt, Literally

I'm sixty years old, and from a health perspective, that means one thing. I need to focus on strength training.  First, I need to recover from nine months of Ironman training and one of the hardest races of my life.  For the last week, I've been doing some pushups and squats.  Yesterday, I started a new routine.  My strength training set consists of 10 push ups, 20 squats, 10 lunges and a one minute plank.  I did three sets yesterday and it literally kicked my butt.  My glutes were sore yesterday, and were still sore today.  Yesterday, I was a little concerned that I might have overdone it, having strained my glute in the past. Today, my soreness of the good soreness.  I felt sore in my glutes and quads and upper body, all telling me that yesterday's workout was doing what it was intended to do, make me stronger!  So, the only thing I did today was swim.  Tomorrow, I'll do the routine again and see how I do.

The balance for me when it comes to strength training has always been to avoid overdoing it.  In fact, that's the balance I've always had with every type of training that I've ever done.  So, I need to pay attention to the signs.  And, take things slowly.  There's no rush.  I can build up slowly.  Strength training is arguably the most important form of exercise that one can do as they get older.  I've tried in the past, but have usually gotten injured, and thus have never persisted.  Sixty is a real number.  I must develop and maintain a strength routine for the rest of my life.  It starts now.

I started the year recovering from running and walking 100 miles over the course of 42 hours.  It took me a solid month to fully recover from that experience.  The Ironman World Championship definitely kicked my butt.  I'm still recovering.  For the past three days I've slept between 9 and 11 hours every night.  I never do that.  My body is talking to me.  I'm recovering. Sleep is critical to a healthy recovery.  I've been eating incredibly clean for the past 8 days.  I'm on the right track.  It's time to get back on the bike, and I can feel some runs in my near term future.  It isn't surprising that it's taken me three weeks to recover, and once again, I need to still be cautious for the next week.  But, I'll continue to strength work.  It'll be good to kick my butt!