Why I'm a Geriatrician

I was probably destined to become a Geriatrician from the time I was a kid, although I didn't know it then. I was definitely destined to become a Geriatrician in the summer of 1983, although it took me the greater part of a year to figure it out. I can remember the day like it was yesterday. I was doing my cardiothoracic surgery rotation at UTMB in Galveston, Texas. I had five hospitals to go to and 13 patients to see before morning rounds. The first hospital on my way in from our apartment was St. Mary's Hospital. It was a private hospital and there was an elderly woman there who'd had an aortic aneurysm repair. I had been seeing her two straight weeks. As this was my first stop, I would wake her up at 4:30am every morning, and in her Texas accent she would cuss me out something fierce every morning. On the last day of my rotation I was leaving her room and she called out, "doctor". Now, I wasn't a doctor, just a medical student, but I turned and went back to her. I remember the moment like it was yesterday. She said, "I'm sorry for yelling at you every morning." To this day I remember feeling, I'm the one waking up this poor lady every morning, and she's apologizing to me. I felt genuinely bad and told her, "you're the patient, I'm waking you up every morning. It's ok if you yell at me." And I meant it. Whether I knew it or not, that was the moment that I realized that I wanted to take care of older people the rest of my career.

I subsequently focused some of my fourth year elective rotations on Geriatrics, working with Tom Cole and Dr. Derek Princely. I even wrote a paper on why I thought that Geriatrics should be a primary care speciality. I then went on to do my internal medicine residency as Cedars-Sinai Hospital. But, it was always a Geriatrics residency. I read everything I could about Geriatric Medicine. I tried to see my patients through the eyes of a Geriatrician. I was fortunate to have as one of my mentors, Mark Levinstein, a Geriatrician who spent a year at Cedars while I was there. I even took the initiative and did a research project that I ultimately published on the value of the white blood cell count and the peripheral blood smear in diagnosing bacterial infections in the elderly. I obviously then did my Geriatric Fellowship at UCLA before beginning my career with Kaiser-Permanente in Woodland Hills. But I'm getting ahead of myself.

From a young age I always wanted to be around "the old people". Whenever family was in the house, I always wanted to sit around and talk and listen to the older people. I was close to my grandparents. My grandfather and I shared a love for sports. He always had the Dodger game on the radio or television. My grandmother was just about the nicest and most non-judgemental person I've ever known (a gene I think I inherited). My grandparents would take me to the horse races at Hollywood Park or Santa Anita. When I was 17, we traveled to Chicago to visit our relatives. I always had an affinity for being around older people. I also had an affinity for wanting to change the world. I was writing letters to the President of the United States when I was six years old, telling him to get us out of the war in Vietnam (yes, my father was an anti-war protester). I wrote letters to Menahem Begin with my ideas of how to solve the problems in the Middle East.

Once I realized that I wanted to be a Geriatrician, however, my life began to revolve around that concept. The paper I wrote as a fourth year medical student was but one example. I digested everything thing I could about Geriatrics, about the politics of health care as it related to Geriatrics. It's funny, but I've always told people that being a Geriatrician is not a job, it's a life. You have to be a doctor, a clergy person, a social worker, an economist, a financial planner, even a politician. And I've been and done all of that. From the moment I made my decision, everything I have ever done has been focused on trying to not only be the best Geriatrician that I could be, but also to try to make society a better place for seniors to live.

I have been quite fortunate to have had some great mentors. I've already mentioned a few, but that was just the beginning of a list that I look back upon in some degree of awe. John Morley, David Rubenstein, David Solomon, Al Sui, Joe Ouslander, Dan Osterweil, Dave Reuben, Mark Beers, Fran Kaiser, Richard DellaPenna. This virtual who's who of Geriatricians were my source of information and inspiration. These were the people who touched my life during my training and first years as a Geriatrician. They inspired me to want to make a difference.

Somewhere pretty early along the way I realized that just seeing patients was not enough for me. I wanted to touch more lives than the ones that only I could see and personally care for. This lead me to pursue administrative duties while at Kaiser-Permanente. It ultimately led me to leave California to move to Denver to join a company called GeriMed of America, a geriatric medical management company whose purpose was in line with my goals and dreams. When this didn't work, I founded Senior Care of Colorado with Don Murphy. I would create my own practice and allow myself and others to practice Geriatrics the way it was meant to be practiced. There was always one obstacle clearly in the way of this path. It was the government. Medicare is a federally legislated program. Congress determines how it is run, how physicians are reimbursed, etc. It wasn't long before I got involved with my congressmen and senators. I believed that this was going to be necessary in order to make a bigger difference. That, unfortunately, has been a frustrating path (more on that another day).

Senior Care of Colorado grew from six physicians and two physician assistants over nine years (2001 to now) to close to thirty physicians and thirty five physician assistants and nurse practitioners. I find myself employing over 150 people. Is this what I signed up for? It has to be, because I'm still the young medical student feeling guilty because an elderly woman apologized for yelling at me. I'm still the idealist wanting seniors to get the best possible care. I revered my grandparents and I love working with seniors. Their stories and insight are of great value. We live in a society that sometimes forgets this and treats our elderly like children. In fact, I was reminded of this today by the sudden death of Fern Osborne. Those who knew Fern knew her to be a tireless and headstrong support of senior issues. She was someone to look up to and she will be sorely missed. I am fortunate, however, to interact with many children who care deeply about their parents and try to juggle everything that society throws us in dealing with very complex issues. Some children have their frail elderly parents living with them at home. Others visit them daily in their assisted living, retirement and nursing homes.

Being a Geriatrician is about making a difference. It's about doing whatever it takes to help seniors live a better life. It's about listening and understanding. It's about being there for people who are vulnerable, and their families. When I think about it, it's not ever really been a hard decision to see me having gone in this direction. It is who I am, and who I always will be.

St. George Here I Come!

So, yesterday I loaded my new St. George Ironman Bike Course Real Interactive Video onto my computer and computrainer and rode my bike (indoors) for 4 hours. This is exciting for a few reasons. I got to actually see the course from T1 through mile 57, which basically covers all of the uphill portions and some of the downhill portion of the course. I always ride slower than my wattage would suggest on my computrainer, so my relatively small distance for 4 hours doesn't concern me (It typically takes me close to 3 1/2 hours to ride the 56 miles of the 5430 course on my computrainer, and I've done that course in 2 1/2- 2 3/4 hours on race day). Anyway, I'm excited for two reasons. First, here it is, early December, and I'm riding 4 hours indoors. It's actually the longest indoor ride I've ever done. Second, I only have a small amount of soreness in my quads the day after doing this ride.

I'm five months from race day and I know that I'll be in great bike shape for the race. I'm really not worried about the swim, that will come once I can use my left arm again, although I continue to be encouraged by my one armed swimming! That leaves the run, and that will be whatever it is, but I'll have between 3 and 4 months to get in run shape. Having completed an open marathon several years ago on very minimal run training (about 15 hours a week, longest run of 5 miles), I know that I'll be much better prepared than I was for that marathon!

Took today pretty easy, swam in the morning, did a radio show after that (that was fun!), and then did a recovery ride on my bike. We had company this afternoon and saw the latest rough cut for the first two episodes of Little Blossom, on our big screen t.v.! It was awesome! I continue to be so proud of my daughter. She is an editing genius!

Lots going on at work, and I have a pretty full week ahead of me. I'm trying my best to ignore the political situation, as I have no control over it.

I'm six weeks removed from my bicycle accident and feel like I'm healing pretty well. I let someone hug me yesterday, however, and my shoulder hurt the rest of the day. No more hugs:(, at least not for several more weeks.

Rest Day:)

Realized that I've actually done some type of workout every day for the past two weeks, so, in preparation for this weekend, I took the day off from exercise. My allergies/sinuses have also been bothering me, which tends to happen when I've pushed the exercise a little too hard anyway, although that's always hard to tell.

Spent the afternoon with my family, we went to Best Buy and raided the $4-5 movie bin! Now that I'm a television producer, I've really got to watch as much as possible to learn more about the business:)

Justine is "in the zone" with her editing for Little Blossom. She will be finished with the rough edit of the second episode this weekend. It's looking terrific, I couldn't be a prouder father.

Had a great week at work, really getting back in the groove and doing what I enjoy. Did some house calls today, and spent some delightful time with the sharpest 98 year old I've met in awhile! My two little fractures don't really mean much compared to some of the things that my patients live with.

Will be kicking back and taking it easy tonight!

50 yards in 50 seconds

Interesting day in the pool. Did my one armed stroke focusing on my form and feeling very relaxed and comfortable in what is now my typical time of 75 seconds. I then tried to go a little faster while maintaining my form and got it down to 60 seconds. Finally, I gave it everything I had, but really had to keep my form and alternate hard kicking with solid form and managed to do 50 yards in 50 seconds. This wasn't all out, and I'm not sure I can actually swim "all out" with one arm. This was a real confidence builder insofar as I'm now quite certain that I can begin to regain my swim endurance and keep my form. I'm not really worried about my left arm not being as strong, as in the end it's still all about the form.

On a side note, the Republicans are making a big deal about the recent suggestions by a very competent task force regarding mammograms. It's amazing how politics keeps bpeople from being logical. Tests can actually create problems, and abnormal results can lead to procedures and complications. Data is data and it's not politics. That said, while I support the present health care reform bill, it's not because I think it's going to do much, it's just going to move a very large rock out of a very large hole and begin to try to change a system that is broken. So, the Democrats have their political rhetoric as well.

one armed swimming:)

Tired today, but hit the pool at the end of the day for about 20 minutes. Did one armed drills and kicking drills. You can't cheat on the one armed drills when you can really only use one arm! This may actually be good for my form. Did some dolphin kicking, which is good for the core. All in all, a good way to relax after work. Went home and just hung with the family. This is what life is all about:)

Recap of last week: 12 hours, all on a computrainer. Depending on who you talk to, this is the equivalent of 16-18 total hours of riding outside, which would be like riding 300 miles. The 220 "actual" computrainer miles is the second highest volume I've ever done for a week. The neat thing is that my quads would be a little sore the morning after riding, but fine within 24 hours. I keep thinking that I am going to be in the most awesome bike shape come St. George! Now, I just need to get the shoulder and hip healed up:)

3 Hours on the Computrainer

Right now the hardest part about riding my bike indoors is my butt:). So, every hour, I got off the bike for 1-2 minutes to just stretch out, and actually it worked out ok.

Yesterday was exciting, I got in the pool for 10 minutes and swam with one arm for all of 200 yards. It felt wonderful to be in the water, it really is relaxing. Also, my form had to be good with one arm. I couldn't fake it. In fact, it's interesting how I did one arm swimming better and with better form than ever before.

I also spent 10 minutes on an elliptical trainer. This was tough, but I kind of got my bearings as I went along. I'll keep working on this.

So, how about my bike ride today. In terms of my endurance, I'm doing quite well. Three hours on the computrainer is solid and my legs felt absolutely fine. I went pretty easy for the first two hours, keeping my HR mostly in zone 2; then, at my coach's request, did 5x5minutes hard (pushing just into my lactate threshold HR range); and then spun easily for 5 minutes in between each one. My ave wattage for each of these was 180, which is probably about 30 watts less than where I normally am when my bike fitness is good. Not bad for the dead of winter and over 5 months to go before St. George. If I keep putting in the time and effort, I'll be in great bike shape come May 1st.

I'm just taking it easy this afternoon. My shoulder was a little sore this morning, but didn't hurt on the bike ride, that is, didn't hurt any worse on the bike ride. So, it was aching a bit, but it was aching before I started riding. I think I may have jarred it slightly last night by accident, but doubt I did anything bad. The hip seems to be doing ok. The more time I spend on the couch the better right now.

I'm now back to work for two weeks and really getting back in my groove. We're nearing the end of the year and it will get a little crazy in about two weeks. But things are going well, which always helps. When things are tough it's easier to get anxious or stressed. I have to remind myself sometimes that when things are going well nothing should really get to me.

I'm expecting some more bike time tomorrow, this will be one of my biggest bike weeks ever!

Making progress

Worked this morning and rode on my computrainer this afternoon for almost 2 hours. I'm making progress on the bike, getting my fitness back. It's actually pretty remarkable, here I am, I can hardly walk (not really, I can walk, I just shouldn't be walking), but I can ride my bike just fine. That's really good news for my St. George preparation. I looked at some blogs about the course today and the bike course sounds reasonable. There will be a few 8-10% grades of short duration, but generally 8% will be about the worst climb. I know from my ride in Colorado Springs back in September that this won't be a problem. That said, I'll still have to figure out my max effort for such climbs. An ironman is all about pacing.

So, right now, I'm just plugging away, putting in a ton of aerobic bicycle time. Well, not a ton yet, but I will be soon. It's nice to know that I can go almost two hours indoors right now and survive mentally. Thank goodness for West Wing DVD's.

One of the really neat things about this week is that I literally did nothing for three weeks after my accident and clearly lost some fitness. That's generally not a bad thing, allowing your body to recuperate, but I was pushing wattages at about 70% of what I had been doing for a similar heart rate. Already, in less than a week and a half, I've increased my wattage by ~10%. It will be interesting to see what happens over the course of the next 4-8 weeks if I persist in putting in a lot of bike time at zone 2 effort.