The Race is O’re…

The race was Saturday. After hints of rain earlier in the week, the day turned out to be absolutely beautiful. It was dry, about 60 when we started and 70 when we (well, I) finished. A little over 1100 in the half marathon, so the traffic wasn’t too heavy, but there are always people around you. A flat, flat, flat course, but at about 4500 feet altitude.

It all went pretty well for me. No problems (except for too little speed training and too much age). I was really happy that I was over 4 minutes ahead of my schedule at 5 miles, and a little further ahead of schedule at 10 miles. My downfall was the last 5k (a half marathon is 10 miles plus a 5k). I really slowed down in the last 5k, and lost the 4+ minutes I had banked at the beginning. The final result was a finish that was right on schedule: 2:37:30.. Just to show how bad the slow down was, I talked with a woman I had been running with in the first half of the race. She picked up in the second half and finished around 2:23. That’s a big difference

Overall, I was still pretty happy with my performance. I finished 4th in my age group. I’m still pretty unhappy to realize that I was running 2:10 less than 10 years ago. But, abdominal surgery and age took care of that.

I’ve largely accepted the age related decline I’m experiencing. But there is still that voice in the back of my head that says “more training and you’ll be back where you should be.” Another case of high expectations meeting reality, I guess.

Do you notice age-related declines in performance or ability? How do you deal with it?

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Primary Health Care

Today’s New York Times had an interesting article featuring Iora Primary Care, a startup with a business model more like Starbucks than your current primary care facility (except that you can’t walk in off the street and buy a cup). You can read the article, A Starbucks for Medicine, in the Business section.

Iora is a subscription service that only works with employer partners (not with individual patients), so your company has to buy in. The value proposition to the partner is lower costs that are more or less fixed. The value proposition to the patient is more individualized customer service, and, sometimes, service that goes well beyond what we have come to expect from primary health care providers.

One of the features of their model is a “health coach”, a much lower cost person than any of the medical staff, whose function is to help the patient with not-necessarily-medical, peripheral issues, such as transportation, diet, exercise and advocacy—at least within the practice office.

Iora is a startup, and there are still many issues to be resolved. They aim for a large number of practices instead of the one, or a few, that most innovators expect to have. Some things in the model scale well, such as knowing what to stock when a new practice opens. Some things scale poorly, such as the CEO interviewing most of the new staff. It isn’t clear yet whether they will actually be able to reduce costs for employers (mostly by trying to provide care that will head off trips to the hospital and ER, I think). On the other hand, the kind of care described in the article seems attractive from the patient point of view, and finding ways to move in that direction has got to be good.

From the provider’s point of view, they aim at far fewer patients per provider, allowing the provider more time with each patient. And, (here’s a note for you Victo) they have a staff of about 20 engaged in building their own proprietary EHR system. On the one hand, that means that individual providers will have more input into how it works, and more influence when it doesn’t. This could also be a cost reduction idea—EHR/EMR systems are already a very big business. On the other hand, as the number of small practices increases, this effort may be hard to sustain—another area that doesn’t scale particularly well.

On the surface, Iora looks like a good idea. I currently get primary care through a corporate entity. While I like and respect the providers and other staff, the corporation stands in the way of getting to them and pretty much controls what I get from the providers. I admit I haven’t yet had much interaction, and so far, I’m glad because the interactions have been painful or at least irritating. I’m interested to hear what others of you think of the Iora idea or other innovative delivery ideas, particularly those in the health care industry.

Race Prep

I recently mentioned in the post My Daughter…Again that we were planning to do a half marathon together in March. A half is not something that most people can do without preparation, and certainly not at my age (73 on race day). By now, I know what has to be done—I’ve been doing this for many years. But, somehow, more important things always seem to get in the way of the training dates I pick out, and I get to the race under-prepared. So, this time I decided to try something different. I put all the training distances on my calendar, just like any other appointment. It’s pretty daunting when you see it all written down.

I’m pretty slow these days. Six years ago, before abdominal surgery, I was running 2:10 for a half (yes, I know how slow that is) and looking for ways to get under 2 hours. I don’t think my running ever really recovered after the surgery, and lately I’ve been looking for ways to get under 2:40. That is made more difficult by me being more ornery than I was before, and unwilling to do some of the things I know would improve my speed. For example, I never did like interval training—a proven way to get faster. So, I’ve retired from that: I won’t do it any more. I’ll still do pace runs, but in truth, I run pretty much at the pace I’m going to run (in the race) all of the time—unless, of course, I slow down. I can feel serious runners cringing at this attitude, but that’s the way it is.

When I was around 40, and a relative neophyte at running (25 or so years experience), I realized that longevity was more valuable to me than winning races. I decided that I wanted to still be running when I was 80, and if that was going to happen I had to have a different attitude toward injury prevention. My style changed. I stopped doing other activities where injury would prevent running and poured my athletic energy into the pleasures of the road. So far it has worked. When I’m 80, I’ll have 65 years experience running and I’ll have covered 75 or 80,000 miles. No regrets about the decision, and I’m proud of how much I’ve run even if I’m very slow. The good side of getting older is that a lot of the wimps have dropped out, and I now often win my age group.

So far I’ve held to my training schedule, except for a change I had to make this morning because of too much snow where I planned to go, and I don’t have any trips planned before the race, so I should get there ready to go. My daughter and I ran together just after Christmas, and her grace and beautiful style were an inspiration. Even after being sick for a year, she’s still a lot faster than I am, so I hope to see her long enough in the race to be inspired again. In any case, her older sister is going with us also to do the race. Her brother lives in DC, and a step-brother from New Jersey may join us, so we will have a grand family weekend.

ACEs

A few days ago, Victo Dolore posted a piece titled Quagmire in which she discussed being at a loss in dealing with an obese patient. No approach that she had tried seemed to connect with the patient about the need to lose weight. This communication problem sent her on a quest for other possible approaches that might work, a quest that eventually led to a post on another blog, ACEsTooHigh, titled The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of — began in an obesity clinic. The ACES post reports on work carried out by Dr. Vincent Felitti and Dr. Robert Anda. Dr. Felitti noticed that patients in his obesity clinic would lose 100 pounds or more and then drop out just when they were making real progress, and he wondered why.

Studying 250 of his own patients he uncovered a strong connection between obesity and what have since been called Adverse Childhood Experiences, ACEs. ACEs include events such as abuse and neglect, violence in the home—abuse of mother or siblings, violence in the neighborhood that a child has witnessed, alcoholic of drug-addicted parents, or a parent that has been in jail. And, obesity wasn’t the only problem connected with ACEs. Other adult problems, such as alcohol or drug abuse, depression, criminal activity, and even diseases such as COPD, IBS, and fibromyalgia are much more likely in adults with non-zero ACE scores, and increasingly likely as the ACE score increases. After having some surprising difficulty getting his peers to believe his results, Dr. Felitti, together with Dr. Anda and others, conducted a much larger study involving over 17,000 patients.

The article has some stunning stats in it (you should read it). Perhaps the most surprising to me was the possibility of long delayed effects (decades in some cases) of childhood trauma and of ongoing trauma having the effect of permanent changes in brain structure as a result of toxic changes in brain chemistry. I’m not in any health care field, so I’m sure that I think I know more than I really do, but I found those effects surprising.

I also found stunning the quotation from a rape victim ‘Overweight is overlooked, and that’s the way I need to be.’ According to the article, she had gained over 100 pounds in the year after she was raped, and the weight gain appeared to be a (semi-)conscious protective measure against being raped again.

I was led to read more from the ACEsTooHigh blog and followed some links to other sites. One that was particularly interesting dealt with Trauma-Informed Care (TIC). It was a power-point presentation by Tim Turner from the Substance Abuse and Mental Health Services Administration (view it here) that had a list of what is TIC and what isn’t. My first impression was “that sounds pretty good—what do I have to do to be treated that way?”

So, what about the treatment of adults? Not knowing anything about toxic stress, I went looking for more information on the network–not the best way to search for scientific results, I realize, but a good place to find an overview or pointers to more scientific results. What are the effects of toxic stress on adults, and can what has been learned about treating children be applied to adults. I thought I would find information about how adults are being treated to alleviate the effects of stress, or at least find information on PTSD as a result of stress. Nada. Maybe I gave up too easily or was guilty of Google Incorrectness, but I found only one site, and that was about how to deal with a micromanager. Good stuff, I suppose, but “watch funny movies and get some exercise” wasn’t what I was after.

There doesn’t seem to be much to read, so we’ll have to resort to MSU (making stuff up). Let’s do a little thought experiment. Suppose that we applied the general principals of TIC (which distill down to things such as basic respect, asking what the patient wants, trying to be collaborative instead of authoritarian, involving patients in their care) to residents in nursing homes. Could that do something to lessen or even reverse what seems to be an almost universal revulsion for nursing homes? Could it make them feel less like warehouses or places of incarceration? (The only thing my mother ever said about the way we cared for her was “Don’t put me in a nursing home.” She lived in an Assisted Living Facility at the time, and her experience was that people had a medical event of some kind, were trucked off to the hospital, sent to a nursing home, and never heard of again. To her, a nursing home was a death sentence.) Do your own thought experiment and tell us what you learned.

Let’s try one more thought experiment. What if we had Trauma-Informed Policing? (I know you haven’t looked at that power-point yet. You better go do that before trying this one.) For this experiment, suppose that we have already reversed the current fad of militarizing police departments and gotten that toxic idea out of our systems.

If you have gotten this far, you should go back and read those other posts now. Then report the results of your thought experiments. Happy experimentation.

The “End of Life”

End of life is a phrase with several meanings, each of which is a complex set of issues. I have watched my parents age, decline,and finally, pass. Have watched their worlds close in as they aged: world travelers after retirement; later San Diego county; then their town; their house and yard; finally, inside their heads. I see how that goes as one’s interests become more local and more immediate and the rest of the world fades in importance.

I have passed through my own spring and summer and am now in the fall of my life. I don’t see any New Year’s baby yet, and I’m looking for a long Indian Summer, but it will turn cold and I’ll want to be inside by the fire, surrounded by art, with a glass of wine, and a good book (or 50). So, I’m pretty interested in how to keep life being good for as long as possible. I’m through with denial (see my post on Denial for how much and how long I’ve been able to avoid all of this), but I have been thinking about the issues–ugly as they may be–for quite a while.

My Muse is a professional musician, or possibly an angel disguised as a musician. She works for a hospice and plays her harp for patients in their last hours or at most their last days. She is called in to help with pain management when, often, drugs no longer help, or she may help with “terminal agitation” when the reality of the situation has become apparent and denial no longer works. She is very good at this and has helped many patients achieve a graceful passage. This is one of the meanings of end of life, and an area where most of us would agree on what is important. The issue is how to achieve a graceful passage; what must we do and how should we so arrange our lives in advance to make this end is possible.

But, there is another, often much longer, period of life, leading up to those final days and hours that can determine how graceful our passage will be or whether a graceful passage is even possible. The beginning of that period is sometimes difficult to identify. It may begin when others start to feel that they need to check on you frequently, or when they become concerned because you are still driving, or when you begin to need help with activities of daily living. This longer period can also be referred to as the end of life. If you are lucky, it will come on gradually. If you aren’t, it may begin catastrophically with a heart attack or a stroke or a bad fall. If it begins with a catastrophe, you may be left with a life situation you do not like and do not want, but can no longer change. That is why I’m taking up these issues now.

I have just read an excellent new book, Being Mortal: medicine and what matters in the end, by Atul Gawande (Metropolitan Books, 2014), a surgeon from Boston, that leads me to thinking about these issues in greater detail. Another interesting piece that prompts me is Why I Hope to Die at 75, by Ezekiel Emanuel in the September Atlantic. They bid me for different reasons: Gawande because he is objective and lays out the issues so nicely; Emanuel because the pessimistic position he lays out, while carefully argued, is wrong.

I know that it is time for me to be working through the coming decisions, but you may think that you are “too young,” or you may not yet have given up the notion that you are immortal. Or, you might be starting to think about these issues on behalf of your parents because they still think they are immortal. Or you might already have assumed responsibility for your parents’ care and are wondering if there is anything better that can be done for them. How lucky you are in that case to be given the opportunity to take the lessons you learn for this experience and apply them to your own case. Your time is coming, unless, of course, you actually are immortal.

I’m thinking of this as the beginning of a series of posts about aspects of aging, maintaining a high quality of life (whatever that might mean to you), dignity, and control. I invite you to join a conversation about these subjects. What are your thoughts?