Sunday, June 27, 2010

Welcome back, intervals

My running seems to be getting nowhere.

Last week, we ran a marathon that was supposed to be a training run and I ended up dropping out. I ran the first half in 1:26, which turned out to be too fast. I think the problem was that I had expected to easily finish in the top 3, based on last year's times. It was won in 3:02 last year, but this year the winner came in in 2:44. Not sure what happened there.

Anyway, I got really nauseated at 30K and couldn't run anymore. The legs still felt ok, but things just weren't passing through my stomach anymore and I decided to quit. I used the same nasty gels that I used at the Copenhagen marathon, where I got stomach cramps, so I have promised myself never to use them again.

Overall, the picture is clear, bad gels or not. This spring, I have run a 50K and three marathons about a month apart. I tapered for each one and they all left me too sore to run for a week afterwards. The first race, Hells Hills, went really well. The next, Copenhagen Ultra (I just ran the marathon), also went really well (2:50 without really trying). Then the Copenhagen Marathon didn't go well (2:49 while really trying) and this last one just plain sucked. The overall picture is that I need to train more and race less.

The good news is that I have a decent base and I'm 95% injury free. My right ankle still bugs me a little but it feels like it will abate on its own. So, starting tonight, I'm doing two interval sessions a week.

I don't have any big races coming up. Sometimes, it's nice just to be able to concentrate on training.

Tuesday, June 15, 2010


Natali is almost at the end of her first school year here in Denmark. She has come a long way from the first day I brought her to school and all the girls stared at her. I told the class that she could understand a lot of Danish, but couldn't speak much, because she had lived abroad for so long. They stared some more.

And she was different from them in other ways. They are almost all blondes, and the ones who aren't are still of much fairer complexion than her. Mind you, she doesn't get her melanocytes from me. She also dressed differently with her jean shorts, t-shirt and flip-flops. Her hair was short and rarely, if ever, organized or combed and she never wore (or wears) two matching socks. The girls in her class wore very expensive fashion-conscious outfits.

Her first few weeks were tough and she took a nap on a couch in school on two occasions, because trying to fit in was so taxing. She simply lay down to sleep, because it was a way for her to get away for a little bit. But thankfully her Danish kicked in very quickly and she inched her way into a trial membership of a group of girls.

Natali weighs a little bit too much; she has always been a little heavy but gained a few dangerous pounds during the divorce. But she carries it well and certainly didn't stick out in her school in La Crosse. In Denmark, her weight is something the girls comment on, sometimes to be mean, sometimes simply because it's something to talk about.

I worried about the girls teasing her; but it didn't turn out that way at all. I think her accent helped a lot, and the fact that she could sing along with the Jonas Brothers and Miley Cyrus. The accent disappeared quickly but she is still able to throw in an unusually constructed sentence to seem exotic. She is not a great singer but when I asked one of her friends how music class was, she said that Natali was, of course, the best singer in her class. Amazing. She even composed a rap song about how people shouldn't call her Natali but Natty (Natty is very un-Danish), and people made their own versions of that song.

So, to my surprise, my little poorly dressed pot-bellied daughter became supremely popular in school. She pressed her luck by asking Simon to be her boyfriend; she was turned down immediately by email. A few boys made fun of her, but the girls stood by her.

She is still bothered by the fact that we live in an apartment, as opposed to her friends' big houses by the river. She begs us to buy a house in the neighborhood by the school, so she can walk over to her friends' houses to gossip and jump on the trampoline. Even though she is popular, she is still different from the other kids, and they are all very aware of it. Right now, my ex-wife has only allowed me to keep Natali here until the summer of 2011 (which is sooner than we plan on moving back, so there is a shock waiting on the horizon), and Natali talks about this with her friends. Even though it's more than a year away, she worries about having to leave and told me the other day that she wants to stay in touch with everyone on Facebook.

Lately, I have worked a lot of nights. When I leave, Natali often breaks down in tears and cries herself to sleep in bed, because I am not there. Not that she doesn't like the Girl, but they are more like friends than mother-daughters. I read the Hobbit to her these days (or, actually, she reads it to me). We lie in bed and whoever is not reading gets hair rub from the other. It's heavenly quality time but when it's over, she wants me to tuck her in and come check on her again and again. It's separation anxiety to the extreme, brought on by the divorce and the constant changes that followed.

She leaves for a long summer in la Crosse in less than two weeks. Her first trip as an unaccompanied minor, from Copenhagen to Chicago, where her mom will pick her up. when we went back in March, she loved her new step-sisters and had a great time. She didn't want to return to Denmark and cried for days, because she missed her mom so much. I worry about how she will feel after 6 weeks.

I worry about her about her in so many ways every day but she also brings me so much joy in life. I often think of how wonderful it is to have a 9-year old daughter and be able to see the world through her eyes. I worry about her, feel gut-wrenchingly guilty about my son in La Crosse, and feel confident that, no matter what, the Lorax will turn out okay.

Friday, June 4, 2010

The Evils of Screening

The other day, the Girl wanted to try her fancy ophthalmology equipment on me, before unleashing it on the population of Southern Zealand. She checks vision and refraction with a fancy machine, checks for strabismus and color blindness and then takes a photo of the retina. I cruised through the first parts of the exam and was diagnosed with perect vision and refraction. Ahh. Of course I knew that doctors are immune to illness, but confirmation is always nice.

Then she took a high-resolution photo of my left retina. No signs of diabetes, hypertension, age-related macular degeneration or other disease. She focused in on my right eye, the blinding flash went off and, almost before I could see again, she exclaimed "huh?". She took another picture to make sure what she was seeing wasn't an artifact, but whatever she had seen was apparent in both photos. She let me walk around to the doctor side of the room and see what had surprised her. There was a little crescent-shaped brown lesion between my optic nerve and my macula. She had no clue what it was, but it wasn't supposed to be there.

The Girl being a lowly resident, I hoped her attendings, including a renowned retinal speicialist, would be able to tell her it was nothing to worry about. Instead, after getting multiple opinions, she told me that it was "most likely not cancer" and that it might be a scar or toxoplasmosis. The advice was for me to get it checked out. How, I asked, followed by a pregnant pause. By getting a new retinal photo in a few months. Good thing I am married to the woman doing a population study using retinal photography, huh?.

Or maybe not. Ironically, I have always told the Girl that she has to worry about the incidental finding on her screening exams. She plans to have a clinic day a week, dedicated to the patients with newly discovered disease. Or at least to the ones with disease beyond the scope of a regular ophthalmologist. It has been a complete unknown how many patients she would have to work up through that clinic, and what problems they will have. Thing is, no one has ever done a study like hers before. Right now, her only patient is me (and my odd lesion that's probably not cancer).

Her study starts on Monday.

Screening for disease is an accepted medical practice in clearly defined areas of medicine. Pap smears, colonoscopies (or at least sigmoidoscopies), cholestoerol and blood pressure screening have solid data behind them. A yearly TSH, checking for thyroid disease, might; I am not sure. The screening exam known as the annual physical exam has no data but is still performed in some parts of the world.

Then we have the controversial modes of screening, PSAs and mammography. Honestly, if one cuts out emotion, these tests would have a place in medicine, but they wouldn't be used in population screening. Some studies have shown no benefit, but considerable harm; others have found a small benefit, but considerable harm.

Screening is a huge industry. Take a woman, who carries a small early cancer that most likely will disappear on its own. Imagine the money involved in the follwing process: first she get s mammogram, where a density is seen. Then, she gets an ultrasound or maybe an MRI. A biopsy shows cancer and a lumpectomy is performed. She may get adjuvant radiation and chemotherapy and almost certainly hormone treatments for five years. That's a lot of money. And, a woman in her 50s with no other health problems, is a perfect patient. She has good insurance, shows up on time, pays her bills and has no annoying questions about other health problems.

Drug companies and makers of medical equipment make tons of money on this. Every time a patient is brought into the sick group, it's a boon for the industry. Most physican opinion leaders are sponsored by these companies and the studies conducted by them are sponsored by the same companies.

Many studies have shown no benefit of PSAs and mammography but, interestingly, people aren't happy to hear this fact. Well, some men are happy they don't have to worry about PSAs (and some aren't), whereas most women all determined to get their mammograms. The typical news release talks about a study showing no benefit, as though the result is controversial. Experts then talk about all the limitations of the study. It's rarely mentioned that the experts are sponsored by the drug companies. Sometimes women, whose "lives were saved" by screening, comment too.

And I think there is the rub. The men and women, who have "been saved", are hard to ignore. Of course, out of a hundred women with minimal cancers at diagnosis, only very few (if any) have been saved statistically. But we can't tell who is who. The 98% of women with parts of their breasts missing, having gone through radiation, chemo and hormone therapy, would have done just fine without their mammograms. Of course, we tell them they have been saved. Who the heck wouldn't say that? I have done that over and over again, myslef, and I'm not sponsored by anyone; it's just human nature to paint an optimistic picture.

Drug companies are everywhere. At my previous department, the makers of the different hormone treatments, came to visit all the time. I should say that chemo and radiation are both pretty cheap, but the hormone treatments, including anti-estrogen therapies, aren't. They bought fancy lunches, paid the attendings well for speaking to patient groups and invited all of us on trips to various conferences. Needless to say, as doctors make less money these days, the companies are very influential. I know an MD/PhD, who works in endocrinology, which is generally not very well paid. I imagine he makes more money doing drug talks than he does working as a doctor. And he is the one making guidelines for the hospital about when to use which drug. He is a nice guy, but does anyone really think he isn't biased?

So we have patient organizations, doctors, hospitals, drug companies and makers of medical equipment all in favor of screening that has minimal or no effect. No politician or even insurance company will dare come out against screening.

Imagine a pill that prevented an occasional cancer. Some studies even showed it prevented no cancers. It had horrible side effects, including severe anxiety, humiliation, pain, the loss of a prostate, impotence and incontinence. And it was supremely expensive. Would that pill ever get approved? Then what is it about PSA screening that makes it acceptable?

I worry about the future. People are getting screened with CT scans, sometimes out of trailers in parking lots. This screens for atherosclerotic heart disease and aortic aneurisms, and a lot of incidental findings better left alone. Every time a diagnosis is made, a work up plan is formulated and a medication is started, someone is making big bank on it. The industry wants people sick; that's just the way it is.

Take a field, where no one is making any money: old folks with multiple medical problems. Care is getting so fragmented that an old patient often sees 6 specialists, who treat "their" organ with disregard for the overall picture. Having been briefly in primary care, I can testify to the fact that being the quarterback on such a patient is impossible. Often, the patient complains of fatigue, pain or general decline. Each specialist points out that their organ is doing well and generally presents an overly optimistic picture to the patient. It takes a brave and skillful family doctor to cut through the clutter, start reducing meds and discuss the fact that old age is cathing up to the patient.

Reimbursement is extremely poor in these complicated old patients, so there is little incentive to improve care. Many folks have miserable deaths, because there was no time and money to formulate a living will or simply have a talk about what the patient's wishes were. A fraction of the cost of screening could sponsor the palliative care programs and multi-disciplinary meetings that are so sorely missing.