Taking the First Step...Then Taking 26.2 Miles More

How Your Doctor Finished a Marathon (Again) and What He Learned Along the Way

If you knew me twenty years ago, you would likely be looking at the title of this post thinking, "Oh yeah!? Big deal! He did another endurance race!" Throughout high school and college, I ran. A lot. Like a lot of kids in South Florida, I tried to play more mainstream sports. Frankly, I was always too scrawny for football, couldn't hit a baseball to save my life, and soccer just never clicked. What I discovered I could do well, as I tried all of those sports, was run. While others complained about running laps (no wonder, since so many of our coaches used laps as punishment!), I loved it. I ran my first organized 5K in high school, starting what looked to be a long love affair with running. When I started college, I joined the Tri-Gators triathlon club at UF (there was no running club). After doing a relay triathlon, I started doing sprint and international distance triathlons. In 1994, after several dozen triathlons, I ran and finished the first Walt Disney World Marathon, the ultimate accomplishment for many runners.

That all stopped with medical school. Yes, there was a lot of studying required, and yes, there were extremely long hours in the hospital. Honestly, though, there was no reason I couldn't have kept running. In fact, I did get back into running briefly from time to time, but just couldn't "re-stick" the habit. It wasn't until residency that I picked up on routine endurance sports again. Yes, residency...that time in a doctors training fraught with 36 hour shifts and 110 hour weeks. I was busier than I'd ever been in my life, but I made time to go cycling three times a week. Post-call was always a great chance to ride 70 or 80 miles. So, as I started training for this marathon, all while struggling to get the new practice open, I called upon the lesson I learned during that time:

LESSON #1: THERE IS ALWAYS TIME, YOU JUST HAVE TO MAKE IT. No matter how busy you are, there is time to regularly exercise, even at extreme levels. As many of you have heard me say, "Man was not built to sit on our butts for eight hours a day." We were meant to spend our waking hours hunting and gathering our food for the day. All it takes is 30-90 minutes a day at least three times a week. By the way, I was very fortunate to have a wife and daughter who helped me make time to run.

Another thing most of my friends and co-workers know about me is that I am extremely goal-oriented. If I set out to doing something, it will get done, in no uncertain terms. This applies to exercise for me, which is another reason why, I think, I got into running, cycling and triathlon. There is always some race you can target. Last June, I made a wild leap and signed up for the 2014 Walt Disney World Marathon (the same one I'd done in 1994). I now had a deadline.

LESSON #2: SET GOALS. Mine happened to be pretty big. Twenty-six miles or so of "big." Yours doesn't have to be. Just set a goal for yourself. Make sure that goal has a definite deadline - "What are you going to do, by when?" Programs like Couch to 5K work because there is a definite end game.

Having done a marathon once before in my life, I knew this wasn't something, with apologies to Nike, you "just do." You need a program. Which is to say, you need a schedule for preparation and progression, especially if you are trying to do something which is a challenge for you physically. Fortunately, Disney made this easy, as they had programs right on the marathon website. I picked one (the "Just Finish Upright" program!) and put it in my calendar. It was now as much a part of my routine as hospital staff meetings and meeting with the architect designing the office. Two months into the schedule, though, I knew what I had to do without even looking at the calendar.

LESSON #3: USE A SCHEDULE UNTIL HABITS FORM. Habits take about 6 weeks to form, so until then, make exercise part of your daily schedule. Seriously, if you have to put it in that 5:30pm to 6:00pm appointment slot, then do it!

As the final few weeks of the training program approached, I was feeling pretty confident. My long runs had been a struggle at the end, but they were meant to be. Only by pushing past your physical barriers can your body adapt. I knew what pace I was capable of and to my surprise, I was looking at a 4:45 finish, about 30 minutes faster than I had finished twenty years ago!  However, in the last two weeks, something felt a little "off" in my left Achilles tendon, the same one I ruptured and had surgically repaired about a decade ago. Plus, I was supposed to do my longest run of the program (26 miles) that weekend. I resorted to the same advice I give many of you about injuries: Rest, Ice, Compression, Elevation (RICE). I cut that final long run to 22 miles, and spent as much time as possible with an ice pack ACE-wrapped to my propped-up ankle. Guess what? It worked!

LESSON #4: DON'T IGNORE ACHES AND PAINS. Taking a little relative rest and attending to my injury early on kept it from being a bigger issue, one which might have derailed by running plan and significantly affected my finish time. In fact, I had to learn this lesson the hard way. In training for the 1994 Disney Marathon, I developed Iiliotibial Band Syndrome, a common runner's malady. Instead of taking some time to heal, I "ran through" the injury. I ended up so hurt by race day that I missed my goal of a 4:00 marathon by over an hour!

On race day, I got up and headed to the start. My wife can attest to the fact that I get everywhere early. It just calms my nerves and clears my head so I can focus on what I need to do. Before I knew it, we were off. I did remember that, as odd as it sounds, the mental aspects of a marathon are far more difficult than the physical aspects. The first half of a marathon, when you've trained properly, feels almost effortless. It is very easy to go too fast, especially when you're running around Walt Disney World. You just have to mind your pace, and prepare yourself for the rest of the race. The infamous "wall" is in the second half of the run. So is the "runner's high," if you can "break through the wall," or if you can manage your nutrition sufficiently that it never comes. Twenty years ago, after a week of cargo-loading with nothing but rice, pasta and fruit, "the wall" presented itself early, as an unbelievable craving to quit, get back to the hotel and order a bacon cheeseburger, fries and a chocolate shake. That was a stronger impetus to quit than my lungs or legs were. I made it through that time by playing mental games with myself. "Make it to the next aid station, an you can walk a bit while drinking." "Make it to the next mile, and you can make it a bacon double cheeseburger." This year, I somehow managed my nutrition (those sugar gel things) well enough that I would say I never really hit the wall from a fatigue standpoint. Mentally, I had to play a lot of the same games, though. I kept running, as I was expecting to see my wife and daughter in a couple of spots (unfortunately, traffic was so bad, they could get to neither, so went to the finish line), and didn't want them to see me walking. My 22nd mile was as fast as my 4th. Then, my hamstrings just got as painfully tight as they could without actually cramping in the 24th mile. I resorted to walking a bit, stopping to stretch a little, too. At that point, though, I knew, thanks to all that training, that I was going to finish. My legs were protesting, but my mind was saying, "Shut up, legs! Move!" I crossed the finish line right on target - 4:45:34.

LESSON #5: DON'T LET YOUR MIND BE A BIGGER OBSTACLE THAN THE ACTIVITY ITSELF. Really, how many of us don't exercise because we rationalize our way out of it? I'll admit, now that I am post-marathon, I'm still running, but I do it. "Hmmm, it seems a little too hot out." "I'd rather go to brunch and have a mimosa than run 10 miles." What a lot of folks find out is that the mental barriers to exercise are usually so much harder than just running, or walking, or biking, or whatever.

What have you learned about exercise as you've done it? What keeps you from doing it?

The PSA Conversation

"To screen, or not to screen?" That is the question. Every day, I have conversations behind closed exam room doors about whether or not to do certain tests, and how to find certain diseases before they become serious. The decision to do a PSA, or prostate specific antigen, is probably among the most controversial of these conversations.  

For years, and as it turns out, with very little evidence that it actually works, physicians and patients have advocated for this test as a way to screen men for prostate cancer. Cancer is the second leading cause of death among American men, and prostate cancer is the most common cancer, so it goes without saying that screening for it makes sense? Maybe not! The first hint at why routine screening might not make sense lies in the numbers. The while about 138 out of 100,000 American men might develop prostate cancer each year, only 22 out of 100,000 die of the disease. Indeed, the National Cancer Institute shows that an American man has a 16% lifetime risk of developing prostate cancer, and only a 3% chance of dying from it. Some of this discrepancy could be the result of highly effective treatment and cure (in other words, we do a great job of screening and finding early, curable disease). However, a deeper dive into the data reveals this may not be the only factor, and may not even be true!

Autopsy studies show that nearly 2/3 of elderly men die with, not because of asymptomatic prostate cancer. Is it possible that prostate cancer just isn't all that dangerous a disease, and that screening doesn't actually do anything but find a cancer that would never actually kill? A systematic review published in the British Medical Journal in 2010 pooled the results of six randomized controlled trials (the gold standard for medical research) to examine that very question. The results were a bit surprising: PSA screening did not change a man's chance of dying from prostate cancer, though more cancer was found (only 2% more, though). In fact, the screening did not change the man's risk of dying from any cause. Closed case then? Well, almost! In what has become "par for the course" with studies about the PSA, one of those six trials published follow-up data in 2012. It did show a slight reduction in death due to prostate cancer (1.07 deaths per 1000 men screened). However, the risk of dying from any cause was unaffected. Essentially, finding and curing prostate cancer, according to this study, does not change life expectancy. 

Thus far, this article has only addressed the benefits, or lack thereof, of the PSA. What are the risks? After all, this is just a blood test. Isn't an unskilled phlebotomist the worst thing that could happen? Not really. Since the day the PSA came out, we've known it has a high false positive rate. Some studies put this rate as high as 75%. In layman's terms, out of four positive PSA tests, only one will turn out to be cancer. How do we know which one? Well, that's where the risk arises. The only true way to tell is by sending all four men for surgical biopsy of the prostate, a procedure which carries the risk of infection and bleeding (around 0.7% which isn't insignificant given the large numbers of men being screened). Other studies show a high rate of lasting psychological harm cause by false positive PSAs. The far greater concern lies in treatment for prostate cancer. Keeping in mind that treatment may not actually change life expectancy according to some of the studies I referenced earlier, the rate of complications from treatment, traditionally removal of the cancerous gland, is fairly large. Thirty-six percent of men will be left with erectile dysfunction. Twenty-eight percent will be incontinent of urine after treatment. This infographic puts the numbers into perspective.

As a result of the confluence of studies, the U.S. Preventive Services Task Force (USPSTF) recommended against routine screening for prostate cancer in men using the PSA. So, I never order the test, right? Wrong! The word "routine" here is an important one, as it was when the USPSTF recommended, to much ado, against routine mammogram in women 40-50 years of age. I still order the test fairly often, but only when there is some factor increasing a man's risk (family history, African-American race, etc.) or after a this long, and relatively complex discussion of risks and benefits have occurred. If you have not had a similar conversation with your physician, I'd encourage you to do so before having the PSA done.  

Medical Information on the Internet: Who Do You Trust?

I have a confession to make: I've done it too! Yes, I, Dr. Acey Albert, have Googled a diagnosis and treatment plan. Of course, at the time, I needed to figure out why my toilet was leaking and how to fix it. That said, the internet is full of information for "do-it-yourselfers." 

Now, let's lay this right out there - Doctors have a "love or hate" relationship with the world-wide web and patients who try to "do it themselves." Some are annoyed, irked or outright offended by patients who try to develop their own diagnosis online, and even more irritated when patients try to treat themselves. Personally and professionally, I believe that informed and enabled patients are fantastic!

The problem with the internet is that some of the information is great, and some of it is, well, either harmful or just plain quackery. So, how do you know what to trust? Follow some of these simple tips:

• Stick with names you know! Many of the same hospitals and health care organizations you'd trust with your medical care in "the real world" also happen to be great resources in the virtual realm. Mayo Clinic really sets the bar here.
• Professional organizations aren't just for the pros. The American Academy of Pediatrics is a great example. Their HealthyChildren.org site is an indispensable resource for parents. 
• Get down to the heart of the issue. Organizations which focus on specific diseases or groups of diseases can be very helpful. Just see tip #1, above, and make sure the organization is one you recognize instantly, such as the American Heart Association or Livestrong.
• Look for HONcode certification. The Health On the Net Foundation, a non-governmental, non-profit organization, certifies websites as trustworthy health information sources. The certification will usually be on the bottom of the home page for a site. 
• Pay attention to the "dot whatever." The two or three letters of an internet URL can tell you a lot! The endings ".edu" and ".gov" correspond to educational institutions and official federal government sites. These are probably the most trustworthy sources on the web. Sites which end with ".org" are typically non-profit organizations, while ".com" URLs are typically for-profit companies. This isn't always the case, and it doesn't mean you can never trust a ".com" site.  It should should raise your level of distrust a bit, but not nearly as much as two-letter endings other than ".us" should. Most of these sites are foreign, or more frighteningly, scam artists hosting in a foreign country where there is less likelihood of investigation or prosecution.
• Watch out for "amazing," "miracle," "breakthrough" claims! Or, for any site trying to sell you anything, for that matter. Chances are, there is at least some degree of a scam being perpetuated on the site. The most offensive of these sites will target the most hopeless of medical situations, often alluding to a cure "they just don't know about." This isn't to say your doctor knows everything, but if it seems too good to be true, it probably is. You're always safe checking with your doctor, first.