Why your doctor might not be on time

I wish I could be prompt in seeing all my patients.  I wish I could guarantee that if you have a 9:15 appointment, you will be called back at 9:15, seen by the doctor at 9:16, and on your way out of the office by 9:30.

But, as much as I would like, I can't make that promise.

A follow-up patient, one who has seen me before, has a 15 minute slot on my schedule.  That doesn't mean that is the amount of time you spend with the doctor.  If you're doing great, blood pressure and labs look good, medications are okay, your visit with me might just be a few minutes.  If you aren't doing as well, I may spend more time, getting information, looking at test results, maybe even calling one of your other doctors to discuss the case.  All of that can take well more than the 15 minutes allotted on the schedule.  And that will put me behind. 

If you have an appointment, you will get the time that you need to get the care that you need.  I will promise that to all my patients. 

I'll give you an example of a recent morning in my office.  Names and identifying details have been changed to protect patient identity.

My clinic on this particular day starts at 8:30 am.  But, it is 8:30, and my first patient has not arrived, so I am sitting at my desk, catching up on lab results and renewing medications.  My 8:45 patient has arrived early at 8:40, so I go see her.

Tara, my 8:45 am patient, is a woman in her late 60's who has a lot of medical problems.  But, in spite of her health issues, she's incredibly active and works in her family's day care center.  She is here today because she's been very short of breath and fatigued over the past month, has been using an oxygen tank at home that she usually does not need.  I put a pulse oximeter on her and have her walk around the office to see if her oxygen drops below the normal range.  I examine her, and we talk, and we decide on an echocardiogram to evaluate a murmur that I don't recall hearing before and some lab work.  She's also in tears, frustrated at how ill she feels, and I reassure her that I'm going to help her find out what is going on.

By the time I see my 9:00 patient, it is now 9:15.  Anthony is in his late 70's, has a very weak heart and a severely abnormal heart valve, is very short of breath, and smokes a half of a pack of cigarettes daily.  At past visits we have talked briefly about the possibility of a valve replacement, but he has also had a cancer scare, so until we knew more about whether he had cancer, we did not make any plans for heart surgery.  Fortunately he does not have cancer.  We adjust his medications, and discuss his heart condition and the benefits of surgery.  I refer him to a surgeon.  And of course we discuss quitting smoking.  That visit takes about 20 minutes.

Now it is 9:35, and apparently my 8:30 patient Leann has shown up after all, and is in a room.  She's a lady I saw over a year ago  for a fairly routine clearance for a colonoscopy.  Since I had seen her previously, she was booked as a follow-up appointment, and was only given 15 minutes.  However, in the year since I had seen her, she had had a stroke and a heart attack, and had been told that she needs to undergo heart bypass surgery.  So, before I can go in to see her, I spend ten minutes reviewing hospital records, and pull up the images from her recent coronary angiogram.

When I walk in to see Leann, it is 9:45.  I see a very depressed woman in a wheelchair, her left side limp from her recent stroke.  Her husband sits next to her, expresses his frustration that much of the time she gives him a hard time about taking her medications, and sometimes flat out refuses.  Further, they do not know the full list of medications that she is taking.  It becomes apparent that heart surgery right now is not a good option.  I discuss the importance of taking medicines to keep her recent stent open.  I'm very worried about her, and we make plans for her to return in a month, and for him to call later that day with a complete medication list.

It is now 10 am.  My 9:15, 9:30, and 9:45 patients are in rooms and waiting to see me.  The rest of the morning is behind.  My 10:30 patient, who I do not see until close to 11:45, tells me that she is upset that she has been waiting, and I genuinely feel bad and I apologize.

My morning clinic, which is scheduled to end at noon, finishes at 1:20 pm.  I have ten minutes to walk to the break room and eat lunch before my afternoon clinic begins at 1:30 pm. 

Not all mornings in my clinic are like this.  But, it does happen, a few patients who are in need of attention can set a clinic schedule behind.  And I'm sure every physician can relate.

Please understand, as your doctor, I want to respect your time.  However, I also have to provide the care that my patients need, and that can take more time.

When I hate my job

I love my job.  I get to save lives.  Whether it's someone in the throes of a massive heart attack, on whom I can perform an angioplasty to open an artery to restore blood flow to the heart, or help someone to control their risk factors to prevent a heart attack in the first place, I make a difference.

On the other side of that, I care for some pretty sick people.  Usually I can help them.  But sometimes I can't.

It is beyond frustrating to do everything in my power to help heal someone, and in spite of this to see him or her die.

I'm often asked, do doctors feel pain when they lose a patient?  I would say absolutely yes.  When we put our own heart and soul, our time, our deep thoughts, into a patient's care, it is hard to see him or her die.

Thankfully, I have far more moments of saving lives and helping my patients to live better.  And, that makes what I do for a living worthwhile.

Coming Off Medications

Frequently, patients tell me that they feel they are taking too many medications, and in some cases want to come off of all of their medicines.

Remembering to take a medication can be challenging, and a prescription pill can be a stigma that a person is unhealthy.

I am a big proponent of patients taking as few pills as absolutely necessary.  I emphasize food as medicine, exercise and movement as critical for health.  So, for some, it may be possible to stop medications, with appropriate lifestyle changes.  

One patient had a cardiomyopathy (weak heart muscle) which recovered, he switched to a plant-based diet, and at this point he no longer needs blood pressure, cholesterol or diabetes medications.

Another patient who I regularly follow is a man in his mid-30's with hypertension and elevated triglycerides.  When I first met him a few years ago, his blood pressure was wildly uncontrolled and his triglycerides quite high, and I had him on three medications in order to control his blood pressure.  He has gradually improved his diet, eating more fruits and vegetables and less processed foods, has taken up regular exercise including Crossfit three times a week.  I see him every three months in the office, and we've been able to gradually decrease his blood pressure medication.  At this point he is on two low-dose blood pressure medications.  I think that in time he may be able to come off of the blood pressure medication entirely.

A man came to me in his late 30's after having quadruple bypass surgery.  He had a list of eight medications.  At that initial visit, I was able to streamline his medication list down to three, and now about five years later, he is only on two medications, an aspirin and a statin, the appropriate medications that anyone with coronary artery disease should be on.

That said, coming off of medications isn't necessarily an option, and should not be undertaken without a physician's guidance.  For example, a patient with a cardiomyopathy who stopped his medications on his own came back to me months later extremely short of breath due to congestive heart failure.  Or, a patient with uncontrolled diabetes and cholesterol and a history of a heart attack who "doesn't like medicines", this is not someone whose focus should be on stopping medicines, but rather on controlling his risk factors and regaining his health.

Some people should never be off of all of their medications, that simply isn't reasonable.  For example, type 1 diabetics don't produce insulin, and injecting insulin is their lifeline.  Or, a patient with coronary artery disease, whether he's had a heart attack or coronary stents or a very high coronary calcium score, he should remain on an aspirin and a statin likely for the duration.

There are many people who take several medications who may actually be surprised that their list could be shortened.  An obese man on three blood pressure medicines, a medication for high triglycerides, and one medicine for esophageal reflux -- with effective weight loss, his reflux symptoms could resolve, his triglycerides would drop, and he would need far less, if any, blood pressure medication.

It is possible to shorten a list of medications, or even come off of all medications entirely.  But, this needs to be done carefully and with thought, working with a medical provider.

Foraging Run

I'm not training for anything right now.  Exercise is about being fit, on my own terms.  It's about working out when I want to work out, because I want to do it, not because I have a race to train for or a scheduled workout or time goals to achieve.

Today I knew I wanted to run a bit longer, because I want to keep my endurance.  I'm also on call, so I wanted to keep my run nearby.  

My neighbors have a huge avocado tree.  Based on the quantity of avocados that have fallen on the street, it seems that they do not like to eat avocados.  But I do, and I've been picking them up, rinsing them off, and slicing them into my salads for the past couple of weeks.

.

I hate to see delicious avocados go to waste!

If there were all these avocados just next door to me, how much available fruit could I find in my neighborhood?  So, today I decided to run with the goal of finding as much fruit as possible.

Now, normally I don't pay attention too much to the trees, or nature.  On a typical run I'm staring at my watch to see if I'm meeting my time goals or if my heart rate is in the correct zone.  Today my focus changed as I looked for fruit.

Once these oranges behind me become ripe, I'll be back!!!

I'm not sure how I never noticed the abundance of fruit, all of which is reachable from the street or sidewalk!!!  I found sweet grapefruit (as opposed to the sour grapefruit growing in my back yard and on most trees in the neighborhood), pomegranates, clementines, limes, pears, hachiya persimmons, and multitudes of oranges that aren't yet ripe.  I stopped at my house twice to drop off my haul, because I couldn't hold everything.

I love being able to change my focus from competition and training to just getting out and putting one foot in front of the other.  And, I love fruit.  Definitely a successful run today ;)

After the Ironman....

After my first marathon, or my first Ironman race, I remember feeling lost.  I had achieved my goal, and didn't have anything to aim for, to train to achieve.

I don't feel that way after Ironman Boulder.  Actually, I'm happy.  I took three days off from exercising after Ironman, then went swimming.  Three days may seem like a short period of time, but by then, I had no aches.  I felt energetic.

Now that I'm not training for an Ironman race, I can work out on my own terms.  If I want to run, I can run.  If I want to swim, I'll go swim.  If I want to bike... no I don't want to bike, so I haven't touched my bike in 3 weeks.

I still exercise six days a week because that's what makes me happy.  I've been doing a lot more swimming, and more strength training.

I swim with Golden Road Aquatics, a masters swim team in Burbank.  What if I swim five days a week with a team... what will happen?  I've never done that before.  Coach Mike Lucero has given me a few pointers on my swim stroke, and it's a great bunch of folks who show up at the pool.  Maybe one day I could swim in a meet.... we'll see.

photo courtesy of Shiggy Ichinomiya www.goshiggygo.com

And, I'm doing more strength training.  Leading up to the Ironman, I curtailed my heavy lifting for about two months, and was doing more functional training in the weeks before the race.  Now, I'm doing more strength training, and getting back to some of the heavier stuff.  

Yesterday at Tru Fit, I did 90 air squats, swung a 35 lb kettlebell 80 times, did 70 pull-ups, 60 burpees, 50 snatches with a 45 lb bar, 40 box jumps, and 30 push-ups.  That's all I got done before time was up, as that wasn't the entire workout, but it kicked my butt.

Did you know.... if you want to get skinny and get in the best shape of your life, an Ironman is NOT the way to do it???  I put on a couple of pounds, and definitely lost some muscle tone.  With weight training, I'm hoping to get some of that muscle back.

Malibu Triathlon is coming up on September 20.  I may put a bit more structure into my training before that, but for now I'm just having a good relaxing time doing what I want.

Ironman Boulder -- Race Report

Five years ago, after completing Ironman Lake Placid, I loudly declared myself  "one and done", that I would never race another Ironman distance triathlon.

And yet, one year ago, I signed up quietly for Ironman Boulder.  Outside of my coach and members of my team, I didn't tell anyone.  After so vehemently proclaiming my disdain for the Iron distance, I didn't want the pressure, or the mocking, to distract my training.  So I didn't blog about it, I didn't post on Facebook about it, I didn't tweet it... I just trained.

Why would I put myself through another Ironman race?  I wanted to prove to myself that I am a stronger athlete than I was five years ago.  And, with at least 40 other friends and teammates, and my coach, racing, it seemed like the perfect opportunity. So, not only did I arrive four days in advance to acclimate to the altitude.

Boulder Reservoir.  Day before the race

The Swim

Water temperature was 78 degrees.  When the temperature is above 76 degrees, participants are instructed that wetsuits are permitted, but if you wear a wetsuit you will not be eligible for age group awards or a Kona slot for Ironman World Championships.  I am in contention for neither, and I know I swim fast in the sleeveless wetsuit that I borrowed for the race.  So, I opted to wear the wetsuit.  The vast majority of competitors made the same decision.  The problem is, this was supposed to be a "rolling" start, with people starting based on their anticipated finishing pace.  The minority of participants who were not wearing wetsuits were seeded, but the 1500+ of us who were in wetsuits were not.  

As a result, there was no order to who entered the water when, and I would say the first ten minutes of the swim was utter chaos, with fast and slow swimmers intermingled, and CROWDED!!  I found myself closed in by other swimmers, hyperventilated and panicked like I can't recall having done in a long time, and actually did the breaststroke for about a minute until I could calm myself down.

It took a little over ten minutes to feel normal in the water.  From there onward, I felt comfortable.  Though the water felt a bit warm, I was grateful that I chose to wear the wetsuit, as I passed a lot of people swimming in tri kits.

I hoped to finish in 1:20.  I finished in 1:21, two minutes faster than in Lake Placid five years ago.  Close enough.  I run out of the water, dashing around the folks who are meandering and walking, grab my transition bag, rip it open outside the change tent, grab my helmet and shoes, run to the folks with the sunscreen, let them lather some on me, run to my bike, and off I go.


The Bike

Compared to where we train here in Southern California, this wasn't a hilly course.  Two loops, with a couple of gradual hills, and then a third separate loop with a couple of steep climbs.  Temperature was upward of 90 degrees throughout the bike ride.  My nutrition on the bike consisted of coconut water mixed with water, four Skratch Labs packets of gummy blocks, a peanut butter and jelly sandwich, and a carrot cake LaraBar.  In addition to about 32 ounces of coconut water, I drank about seven bottles of water.  I had some cramping in my toes around mile 80, but those got better with eating another packet of the Skratch blocks and chugging a bottle of water.

Overall, I felt pretty good on the bike.  My shoulders were a bit achey, and I got out of aero position about every 5-10 minutes to stretch.

Photo by Kelly Walsh-Barrios -- thank you Kelly and Vera for the cheers on the bike course!

The course was a little short, about 109 miles instead of 112, and I cruised into transition, left the shoes on my bike and ran in my socks.  Again, people walking their bikes through the transition frustrated me, and after I had my transition bag, I quickly changed socks, threw on my running shoes and hat, and off I went.

Bike time -- 6:24.  A huge improvement from my 7:38 in Lake Placid.


The Run

I dash onto the run course, and there is my friend Rhonda directing traffic at the start of the run, a location that each runner would pass four times during the 26 mile run.  I was so thrilled to see some friendly faces.  I declare, "I feel awesome!!" and off I went on the run.  My first mile was about 9:30, my second just a bit slower, and then the next four miles at about 11 minutes per mile.  Then the legs got heavy.  Really heavy.  Mile pace dropped to about 14-15 minutes per mile.  Nothing specific hurt, my legs just ached.

And my stomach.  I didn't want to eat anything.  I wasn't nauseous, I just felt uncomfortable.  So it was a very good thing that I ate well on the bike  On top of that, I was a little grossed out by the hygiene of the food at the aid stations.  Trays of grapes and fruit that triathletes were dipping their dirty little hands into.  But, at every aid station I did drink a small cup of water and dump another cup over my head.  I had a few sips of Gatorade at one aid station, but that was it, I just don't like the taste.

Getting some much needed encouragement
(Photo courtesy of Jennifer Hochman Urban)

I kept on running.  Or shall I say slogging.  Out toward a river recreational area, with lots of families and kids, occasionally dashing onto the run path.  Fortunately a few volunteers were keeping the kids off the path.

After mile 14, the miles dragged.  Each seemed to last an eternity.  My nutrition from mile 10 onward consisted of a Clif pureed sweet potato packet and some medjool dates from my special needs bag.  I had stashed a bottle of coconut water in the bag, and drank about half before I chucked it in the trash.  My stomach is definitely misbehaving if I'm throwing out coconut water because coconut water is one of my favorites.

Every so often, I walk a little bit, but I know I have to run if I want to keep up a reasonable pace and get this awful run over with.  I see a lot of people walking, but I remind myself, as much as it hurts, even a slow jog is faster than a walk.

At mile 23, I know I have one more out and back to do and the end is sort of in sight.  So I pick up the pace to an astounding 12:30 per mile, which is all my heavy legs could muster.  In the last mile, I couldn't see the turnoff for the finish line, and I asked volunteers, and someone who I thought was a volunteer, did I miss the turn off for the finish line?  None of them knew, so I kept on running, until I saw a clear sign to turn off the path.

Finally!  I run off the bike path, onto the street, see an arch ahead of me, then hear music and people cheering.  I let a couple guys run past me because I want them to have their own moment at the finish line, but more importantly, I wanted mine!  As I approached, I grinned, tears welled in my eyes (yeah, cheesy, I know), I hear, "Heather Shenkman, of Sherman Oaks, California, You are an Ironman!" and I cross the finish line.

Approaching the finish line

The Recap

What a day!  Total time -- 13 hours and 33 minutes, 46th out of 112 finishers in my age group.

I'm thrilled with my swim and bike, but my run was not very good.  At 5:31, I was six minutes SLOWER than I had been in Lake Placid.  What happened?  I'm not entirely sure.  I think I hydrated well enough; other than some brief cramps on the bike, I didn't feel like I was dehydrated.  I drank at every aid station.  I don't think I destroyed myself on the bike either.  Maybe it was just a tough course and the altitude caught up with me.  That said, my rank on the swim was 36th, bike 41st, and run 46th.  So the run wasn't that far off base from the other two disciplines, relatively speaking.


How do I feel?

Two days later as I type this, I feel pretty awesome.  I am walking like a normal person.  My legs are a little achey, but really, nothing hurts.  I am full of energy.


Thank yous!!!

Coach Gerardo Barrios, for saying, "I knew you'd sign up for another one" when I took the leap a year ago, and preparing me for the big day.  Thanks to his training, not only did I have a good race, I'm not in a world of pain and feel like a normal person two days after the race.

Friends/teammates on the course, including Kelly and Vera at mile 102 on the bike when I was so glad to finally see a friendly face, Lori and Shay in the first transition area, and Rhonda on the bike course and in the finisher chute.


When will I do my third Ironman?  The answer to that is never.  And this time I mean it.  I don't love this distance, I feel like I proved what I came back to prove, that I'm faster than my 14:45 time in Lake Placid, on a tougher course, at altitude, and five years older.  Nothing more to prove.

The Maligning of Vegetables

Fruits and vegetables, in their natural form, whether fresh or frozen, benefit our health.  They reduce the risk of heart disease, diabetes, several forms of cancer, and help maintain healthy weight.

And yet, they are getting a bad rap.

Is kale toxic?  One alternative medicine researcher published on his web site that he found high levels of thallium in the urine and tissue of patients who consume large amounts of kale.  He then suggested that their ailments were due to thallium accumulation.

As a result, you'll find sensational titles on the web, like "People are getting seriously sick from eating kale"  or, "Sorry Foodies: We're About to Ruin Kale."

Image taken from www.bentleyartist.com

But if you look closer, you'll see that for all practical purposes, this was a completely unscientific pursuit, not published in a peer-reviewed journal, and the findings spread by someone who profits from selling "chelation therapy".

Or what about carrots?  "Oh, I don't eat carrots -- they're too high in sugar".  I've head the same from patients about grapes.  I'm still looking to find someone who's obese from eating too many carrots or grapes.  With all the carrots that I eat, I'd be a very large woman.

I'm going to keep on drinking my morning green smoothie, with my handful of kale and a handful of carrots.

Surround Yourself with Greatness

This evening, I went to Tru Fit Boot Camp, at a time I don't usually work out, but a time when I know a lot of tough athletes show up.  We were asked to split into workout groups after a warm-up run.  During the run, I saw one woman who absolutely flew, could probably run circles around me.  I followed her and joined her group.  Throughout the hourlong workout, I kept my eye on her.  Whenever I felt like stopping, I saw her out of the corner of my eye, and I kept on plugging away.  My workout this evening was awesome.

I don't like to be the slowest or least fit, because that's just not good for the ego.  But I sure don't want to be the fastest.

I like to be pushed, physically and mentally, to my limits, because that's how we get stronger.

I seek out challenge.  I've worked out with personal trainers who have pushed me to the point of sweating, grunting, and cursing (Corey, Rick, Kiki all come to mind).  I ride century cycling events with Ruth, who even though she's 60 years old, can ride circles around me and climb better than most women half her age.  I swim with my team, including Michelle who smacks my feet when I'm going too slow.  And I'll run with Kelly, a 3:33 marathoner, who as I grunt my way through 800 yard repeats, is just ahead of me running effortlessly.

Challenge yourself and get stronger and fitter.

Rest Days

When you exercise regularly, it's hard to take a day off, and taking a few days off is even more challenging.

Here is how I often feel about rest days:

But, truth is, the body needs rest.  Rest days allow the body to recover, which ultimately helps to build more strength and improve athletic performance.  Some would argue that the greatest fitness gains are made while the body rests.

I find it challenging to take a rest day.  I feel lazy, because my default for any given day is to have at least one, if not two, workouts to complete.  And, if I'm not working out, I feel more sluggish.

My coach routinely schedules about one rest day per week for me.  I'm not always the best about abiding by my rest, and often I'll move a strength training workout or a swim that didn't get done earlier in the week to a rest day.  I'll rationalize it in my mind that it's not *that* tough a workout, and I'll "rest" for the duration of the day.   And I need to be better about that.

I have a cold.  I don't get sick very often, which I attribute to a healthy diet, exercise, and hand sanitizer.  So, I've taken three days off from training.

My gut feeling would have been to trudge on through and do my two hour run, hour long swim, and all the other workouts on my schedule.  Fortunately, I have level heads advising me, my coach and my personal trainer boyfriend, who have urged me to get some rest.

My three days of rest have done me some good.  I've slept in, something I rarely do.  I'm going to attempt a brick workout this afternoon; I think I'm ready.

Mulholland Challenge 120 miler

One of the toughest local rides.  121 miles, 13000+ feet of climbing.  I did it last year, proud to complete it, wanted to do it again.

This was not an easy ride.  But that's why I do it, to prove I can.  And I faced some challenges, may have thought about cutting the ride short, but I did finish.

Climbing "Rock Store", mile 50ish

 I have to admit, I wasn't the best prepared.  My longest ride was a bit over 5 hours, I had missed a couple of mid-week rides over the course of a few months, and spent the week before the event on vacation in Costa Rica.

I felt good until the Decker Road climb, around mile 75.  Then exhaustion set in.

Descending "Rock Store", mile 85ish

The last major climb was Stunt Road.  Stunt is 4 miles long.  It's not very steep. I've done it before.  In fact, I've done REPEATS on Stunt, where I've spent a couple hours just riding up and down the hill.  But at about mile 97 on the course, it's bruital.

And, it's at about this time that a killer cramp set into my left foot.  Every pedal stroke killed.  And yet I had more than 20 miles to go...  There were a couple of guys who I could tell were hurting too.  I got behind a couple of them to draft so they could pull me up the hill.

Mile 100.  Feeling worn down, in pain.

With one mile to go from the top of Stunt, the pain became unbearable, and I had to get off my bike, shortly after this picture was taken.  I took my left shoe off.  I stretched my toes, wiggled them around.  The pain got better, surprisingly, and I put my shoe back on, and started walking my bike a bit.

The SAG vehicle pulled up and asked if I was ok, if I needed water, bars, anything.  Ice, I asked?  Nope, they had no ice.  But I knew there was an aid station in a mile that had ice.  Clumsily, I got back on the bike and slowly, and with less pain, rode to the top of the hill.

I tried to troubleshoot the situation --  why did I cramp up in my foot?  Not enough electrolytes?  After all, I was drinking only water on the ride and not an electrolyte solution because it wasn't too hot outside.  Maybe I needed caffeine?  How about icing the foot, a suggestion from a friend I texted when I had gotten off the bike a mile earlier.

So... I drank some Perpetuum with electrolytes, took a salt tab, iced my foot on a can of Coke Zero and ate three peanut butter and jelly half sandwiches.  Was the PBJ therapeutic to the situation?  Probably not but it made me happy.  And then I drank the Coke Zero, telling myself that maybe a little caffeine would help.

After about 10 minutes at the aid station I was back on the bike.  20 miles to the finish.  I felt more energized.  A couple shorter climbs, and I was done!


Pleased to be done.  I will use the experience from this ride for the L'Etape ride up Mount Baldy next month, which might be even tougher.

Fortius Racing Triathlon Training Camp

For some, lying on a beach drinking a Mai Tai is vacation.  Triathlon training camp for me is a fun vacation.  For this long weekend, I am spending time up at Lake San Antonio, the location of the Wildflower Triathlon, for Fortius Racing triathlon training camp.

I love getting to go away and just be an athlete.  Sleep in.  Ride long or run long.  Do yoga.  Stretch.  Share healthy meals with teammates.  Learn from coaches about cycling and running technique and how to get stronger.

Heading out for our long bike ride

Yesterday, we ran the Wildflower short course run course.  Today, we rode the 55 miles of the long course.  With 4900 feet of climbing, including the infamous Nasty Grade hill around mile 43, this was a challenging ride.

Tomorrow, we ride the Wildflower short course bike ride, 24 miles of rollers, and then a trail run, and some yoga. Then on Sunday we run the Wildflower long course.

And, of course, good healthy food is important.  Dinner tonight includes miso soup and spinach and avocado salad with garbanzo beans.

Coach Gerardo cooking up healthy stuff

So far, it's been an amazing weekend.  I'm a little sore, but I feel amazing.

Definitions Fitness Magazine

Please check out this online fitness magazine that I write for.  Definition Fitness Magazine is written by and for plant-powered female athletes.  Issue Four featured an article about me, "Tofu-Powered Triathlete", and in Issue Five, I have written an article about my experience as a heart patient with an arrhythmia.

Click here to subscribe, only $14/year.

A Bump in the Road

I haven't talked about my running in a while.  And that's because I haven't been doing much running.  I strained my right calf about five weeks ago.  I can't recall a specific injury, but ultimately every time I would try to run, it would ache.  So, I had to stop running for a couple weeks, and as a result I'm not running the Napa Marathon.

What happened?  I'm not entirely sure.  Much of it has to do with my left leg being stronger than the right.  I'm not sure how that came to be, possibly a lingering effect of having fractured my right foot a year ago and relying so much on my left leg, enough such that even a year later my left leg was stronger than my right, leading to an imbalance?  That's my current theory.  Nonetheless, I'm working with a physical therapist, who has given me exercises to help strengthen my right leg.

I am back to running, but it's limited so far.  I am being very conservative.  Today was my longest run since the injury, two miles, pain-free.  I have strict instructions that the second I feel any pain that I am to stop running and rest for another several days.  Luckily, in the past few days of running, there has been no pain.

That said, unable to run, I have started picking up my cycling, and have done a couple of good challenging rides, gearing up for the Mulholland Challenge 120 in April.  I have also started swimming more, and have taken on the challenge of swimming 24 times during the month of February.

Here's a video that Fortius Racing Team coach Ray Barrios took of me swimming:

Lots of swim technique things to work on.

So, with good healing, I should be ready for the Chesebro Half Marathon on March 28.  This should give me plenty of time to recover.

A Trip to the Cardiologist

I see a lot of anxiety associated with a first time visit to the cardiologist.  Chest pain, palpitations, fainting, and shortness of breath can all be scary symptoms related to heart disease.

Or they may not be.

I may surprise you when I say this:  More often than not, for patients who come in for an initial consultation for one of these symptoms, the cause is not cardiac.

Chest pain can be due to many things other than the heart -- a pulled muscle, esophageal reflux, anxiety or stress.  While palpitations may be an arrhythmia, they may be due to anxiety and stress.  And the most common cause of fainting is a vasovagal event, which is completely benign and improved with lifestyle changes.

A common scenario is a patient who comes in with symptoms that after a thorough evaluation I determine is not related to his heart, but that same patient has multiple uncontrolled cardiac risk factors.  A typical patient would be a middle-aged man with chest pain that is burning in nature and worse with eating spicy food and worse at night.  We determine that his pain is due to esophageal reflux and is not due to his heart.  HOWEVER.... he has uncontrolled diabetes and high blood pressure, smokes, doesn't exercise, and eats poorly.  So, once I reassure him that his chest pain is not coming from his heart, we discuss the uncontrolled risk factors that are the true threats to his heart health.

That said, I see some pretty serious stuff.  I'm sending one recent new patient for urgent heart valve surgery.  Another in all likelihood has pretty severe coronary artery disease, so we're getting him tested very quickly before we proceed to more invasive exams.

My point is this:  Being referred to a cardiologist can be scary, but doesn't necessarily mean you have a life-threatening heart ailment.

More Pills!!! More Pills???

A new study called the IMPROVE-IT trial presented at the American Heart Association Scientific Sessions in November demonstrated that adding ezetimibe (Zetia) to simvastatin in higher-risk patients is associated with a decrease in LDL cholesterol and also decreased risk of cardiac events.

Another study, the TRA2P-TIMI 50 trial, found that a new antiplatelet medicine vorapaxar (Zontivity), when added to aspirin and clopidogrel (Plavix), reduces the risk of cardiac events in high-risk patients.

First off, two big wins for big pharma.  Two on-patent, in other words not generic, medicines that have positive clinical outcomes.  But, should we start prescribing them widely?

In the IMPROVE-IT trial, the primary endpoint of cardiac events occurred in 32.7% of patients on simvastatin alone and in 34.7% of patients on simvastatin plus ezetimibe.  It comes out to an absolute risk reduction of 2%, which isn't a lot.  In other words, to prevent a single cardiovascular event, you would have to give ezetimibe to 50 people over the course of six years.  That also means that 49 of 50 people receiving the medication would not have an event prevented.

Similarly, in TRA2P-TIMI 50, patients taking vorapaxar had an 11.2% risk of cardiovascular events, and those not taking it had a 12.4% risk.  Again, a statistically significant difference, but a 1.2% absolute risk reduction, and yields a number needed to treat of 83.  83 patients need to get a daily pill over three years to prevent just one event.  And if you're on vorapaxar, you will have a significantly increased risk of a dangerous bleed.

I want to give my patients everything that I can to keep them healthy.  But do I want to give them more costly copays?  Is that where my energy should be focused, putting my patients on more medications?

source:  reason.com

What if we can get these patients to change their lifestyle?  What if we can get them onto plant-based diets, get them walking 30 minutes a day, help them to lose weight, and get those who are smoking to quit?  How many cardiovascular events can we prevent if we can do that -- a lot!

Or more practically, since we know not all patients are so motivated, let's say we can get our patients to eat less meat and dairy, eat a few more fruits and vegetables a day, eat more meals at home instead of at restaurants, and walk a couple days a week.  Even with those more modest lifestyle, we can prevent a lot of heart attacks and strokes.

Is there a role for these two medicines, ezetimibe and vorapaxar?  Maybe.  But before we pull out our prescription pads, let's make sure we're giving our patients all of the tools that they need to be healthy, not just another pill.