University Place

Welcome to the last "Better With Age" presentation of 2015. I'm Marje Murray from UW Health, and I am thrilled to be able to introduce our speaker tonight, Dr. Dave Watts. Dr. Watts is a geriatrician at the UW Division of Geriatrics. He is also a medical director for Oakwood Village, Capitol Lakes, and Attic Angel. He has been seeing older adults for a couple years and is now preparing to be one himself and retire next year. Retire, not older. And he is here to share what he has learned in 30 years. So, if you'd join me in welcoming Dr. Watts. (audience applauding) Thank you. If I'd know there was going to be such a wonderful turnout of such illustrious people, I think I would have prepared better. I'm really afraid that when you leave here, you'll walk out saying, "He didn't really learn very much, did he?" (laughter) But, you know, actually, I want to say that I know that I've learned more than I'm actually going to be able to tell you in the next hour, but most of the rest of it I've forgotten, unfortunately. (laughter) But, really, having been a geriatrician for 30 years now, it seems like such a... strange and wonderful experience. And when Marje asked me to do this talk about what I've learned, I really didn't know how to answer. But I went to a source that I hope most of you are familiar with, and that is The Wizard of Oz. "What have you learned, Dorothy?" "If I ever go looking for my heart's desire again, "I won't look any farther than my own backyard "because if it isn't there, "I never really lost it to begin with. "Isn't that right?" And I think there's so much truth in that statement, that I've been fortunate to be able to practice in the setting of my heart's desire in geriatrics and work with such wonderful people as are in this room. To be a geriatrician at UW is a great privilege. And UW, ironically, is the same acronym as for Oakwood University Woods. To be a practitioner at Oakwood is an especially great privilege, but I didn't know there would be people here from Capitol Lakes as well. So, I, if I'd been giving this talk at Capitol Lakes, I would have changed that to be inclusive of Capitol Lakes as well. So I want to welcome my friends from that location as well. I'm very pleased to see so many of you here. But these are just a few, maybe a smattering of perspectives I've learned over the years. And because it's kind of a smorgasbord, you could say, I hope there will be perhaps some opportunities for questions toward the end of this presentation. These are some themes that I'm going to focus on. And the first being that of prevention, but with an emphasis on physical activity. Then a physician's perspective on Medicare. A few words about electronic records. And I didn't want to, you know, leave this session without a few more words about pharmaceutical advertising, and maybe a couple of words about pharmaceuticals and some of the biotechnology that is causing some changes in our pharmaceutical practices. And then, lastly, maybe a word or two on death and dying as well. Dorothy, "How do you talk if you do don't have a brain?" Scarecrow, "Well, some people without brains "do an awful lot of talking, don't they?" (laughter) Well, I think we've all seen that phenomenon, but it's so important, I think, to be protective of our brains and allow them to be as healthy as they possibly can. But one thing I've learned, and maybe this will seem such a basic truth to you. You've already, you learned it maybe long before I did. A key principle of prevention in later life is to slow the rate of physical and cognitive decline. One key to doing both is exercise. Robert Butler, the late Robert Butler, who was chief of the National Institute on Aging, said, "If exercise could be packed into a pill, "it would be the single most widely prescribed mediation." Well, sometimes we keep looking for that pill to take so we don't have to exercise. You know. Okay, look, I'll be honest, I try to exercise, but maybe not every day I'm actually feeling up for it. So, yeah, if I could take a pill instead, there are a lot of days when I would actually do that. But at age 50, I had to do something. Midlife crisis. I either had to get a convertible, a pretty expensive convertible, or do something else. So I took up competitive swimming. It's really a lot cheaper, competitive swimming. I mean, look at the clothing you wear. I mean, it's very scant. You know? Sure, you can actually spend quite a lot on swimwear for competition, but you can actually get by on relatively inexpensive clothing for the sport of swimming as well. Swimming has some advantages for aging bodies. It is a total body workout. It's an individual effort, but it's, you can do it with a group as well. For example, an hour ago I was in the pool in the UW Natatorium and I was with a group of other people, and we, you know, commiserated, said how hard we were working, and you know, talked a little bit about some things going on. Yeah, we did some swimming too. Some good quality, you know, hard swimming included with that. But so it's a group, a team, a social activity, and I've had the good fortune of being on some relay teams as well, and that's fun. You want to swim as fast as you can for your leg of the relay. And on a couple of occasions I've actually been in a relay with my kids where I would do a swim and then they would do a run. And we were able to form a team for that. Now, in Wisconsin, it's great to be able to have something you can do indoors because the winters are pretty long. Like, for example, one of my patients, I said, "Well, what do you do for exercise?" "Well, I'm a kite flyer." "Okay, well, you know." (laughter) Okay, that's all right, but there's a lot of times when kite flying is not a recommended activity, let's put it that way, based on the weather. Although, hey, this year, who knows? Maybe we'll have open water on Lake Mendota all year long, as far as that goes. But for swimming, it's not just strength. It's not endurance, but it's technique. And that, maybe it's 75%, 80% technique. And that's great because, okay, if I swim at the natatorium, sometimes you get the kids showing up. They're freshman. You know, maybe they don't have a swimming background, but they start to swim. And I can beat them, and it's so wonderful. To be able to beat somebody who's 18 years old. But let me tell, though, what happens. And this is the sad part. Okay, if they keep swimming, then they learn how to swim, then they've got the power of youth, the energy, on their side. Then they can swim faster than me, and that's really discouraging. But, look, I, you know, swimming fundamentally is so easy. It's easy. We, you know, we, as life forms on this planet, came out of the water many years ago. I think it was millions, I believe, anyway, but all you do, I mean, we don't swim like many of the marine animals, but here I'm going to show you how to swim. Okay. You reach out, way out in front of you, as far as you can, you lean into it, and then you grab as much water as you can. You grab it with your hand, you grab it with your forearm, with your arm, and you push the water down that way. Okay. Only, you're supposed to be in this posture here, although, the posture represented by that logo at the bottom of the slide is not exactly correct because that swimmer represented in that picture should be much more horizontal. See, there's too much water resistance. Yeah, some of you are nodding. I can tell. You know, there's other swimmers here. But then, okay, not only do you push the water down, you reach up with the other side, and it's a rotatory, or not, a reciprocating motion, which our bodies are somewhat designed to do. You lean in, grab the water, push it. This is the recovery arm, so-called recovery and here's the propulsion phase. Notice I'm not even talking about the kicking, but that's because I don't get much out of kicking anyway. But those who are really good at swimming can do that and add to their speed. And so I can live my life now with sports clichs. Where does the power come from to see the race to its end? From within. Okay, that's a quote from Eric Liddell in Chariots of Fire. Eric Liddell was one of the members of the successful British 1924 track and field team that went to the Olympics. And there's another quote from his arch rival, Harold Abrahams, "I'm forever in pursuit "and don't even know what I'm chasing." Sometimes I feel a little bit like that too. When you're in the pool, you look at the bottom, you're going back and forth, and I'm not thinking about prevention and preventing Alzheimer's or keeping my brain healthy. I'm swimming because I kind of have to swim, I can't not swim. So it's really, it's become part of my nature. But I think it's just, you know, if I'd bought that convertible when I was 50, that thing would just be a pile of junk right now. So, swimming is something I've been able to stick with and still has value. "A good body with a dull brain is as cheap as life itself." A quote from Spartacus. But physical activity is the one behavior consistently shown to benefit cognitive health. Okay, so let's see, what are some other things which can benefit cognitive health? Maybe education. And it is great that you are here. Believe it or not, this is somewhat education. I know that not with everything I say, of course, but it's also social. And social activity is important. Well, how do we know this? Well, there's actually pretty good evidence to support social activity as being important. But if you look at the contrary, look at people who are put in solitary confinement. I just heard something on the radio the other day. They'd interviewed someone who'd been in solitary confinement in a New York prison, and he said his thoughts deteriorated, his speech deteriorated. There was no feedback to the speech. So, social activity is, we appear to, not only are we fundamentally aquatic animals, but we are social animals as well, it's very important. A glass of wine per day, but the glass of wine can be overdone. Like with Rick. What is your nationality? Rick, "I'm a drunkard." That makes Rick a citizen of the world. Now, I'm not going to recommend that you start consuming any alcohol as a preventive. Alcohol has actually been somewhat devastating in my own family, and I have to be careful. In fact, I don't use it at all as any kind of preventive because it's too laden with consequences that have been very close to me in my family. But if you are someone who has a glass of wine per day and that's been your habit, there really is not a need to change that. But benefits of physical activity? How does it benefit the brain? It gives the brain a good environment. Good environment in terms of blood pressure control, cholesterol control, glucose, and weight control. So, in many ways, physical health is tantamount to brain health. "But what would you do with a brain if you had one?" "Why, anybody can have a brain. "That's a very mediocre commodity. "Every pusillanimous creature that crawls on the Earth "or slinks through the slimy seas has one." I had to practice that phrase quite a while to be able to get it correct like that. But, you know, and this is something I just realized as I was driving up here to Oakwood, not something I learned over the last 30 years, that is, swimming itself probably doesn't really make you that smart because when you're swimming you are looking down, you're supposed to be looking down at the bottom of the pool. And that's a little bit boring. I mean, what is there? Not much. There's tiles, there's maybe some junk on the bottom of the pool, but there's a lane line, you're supposed to follow that lane line, and that's how you keep yourself going straight with the pool. But I think swimming or physical activity can lead to a situation in which your brain has a healthy environment in which to thrive. But it's also good to put some things in it by learning and keeping active and interested. And I know that this group here, whether it be from Oakwood or Capitol Lakes or wherever you might have come to this session from, I know you're very good at keeping active, interested, and involved. But what about competition? And by competition, what I mean is, I line up on a block, which is 20-plus inches above the pool. Actually, I forgot how high the block is, but let's say it's 24 inches above the pool surface. And I line up with a bunch of people in my age group. Now, actually, that's what makes it easy. They're, I'm competing against people in my age group. So, anyway. But it's a little bit different than that. Sometimes I'm competing against somebody older. And, in fact, I was, you know, it's always 10 times worse to be beaten by somebody who's 10 to 15 years older than you are. By the same token, it's so great to beat somebody who's, you know, in a significantly younger age group. So I've had both experiences. I've been first place, and I've been last place. Believe me, first place is a lot more fun. Okay. And racing, just getting on those blocks, it's a thrill. And I think it's, I think it's a little bit like addictive, like a, you know, almost like a gambling type thing where you get a little bit of a rush. So that's been very helpful. "Are you not entertained?" Well, it turns out that's a quote from Maximus in Gladiator. And I actually, when I'm swimming, I can actually imagine that I am a great swimmer, I'm like Michael Phelps. I'm, you know, really good, and the people are actually watching me and they're being entertained. Actually, nobody's watching me. It's like watching paint dry. I mean, yeah, it's, but I can still have imaginings and still believe that maybe someone is being entertained. And, on occasion, there's nobody else to watch or maybe I'm neck and neck with somebody else in the pool. That actually kind of, that actually happened this month. There was a guy, I should have beat this guy really easily but, instead, you know, I was a little slaggered, I wasn't in great shape. We were like neck and neck for three lengths of the race, which was just 100 meters in that case, it was a meter pool. But at the last I was able to win and feel like, you know, like it was a great victory. And people kind of noticed that because we were sort of neck and neck and I was able to outlast this other guy who, like I said, I should have beaten him easily He was actually older than I am. And people actually kind of clapped. You could hear them clap, so that was great. Now, these are my times in the 100-yard freestyle over the last eight or nine years. You see my age listed there on the bottom. These are my best times. Okay? So you're kind of wondering, gee, am I bragging or complaining? Well, it's a little bit of both. The really good swimmers are way faster than this. They have a swimming background. Maybe they swam in college or even the Olympics, some of the Olympians are actually doing masters swimming now. But that's not me, I had to kind of learn it, you know, from scratch, age 50. I had to learn how to, you know, do a competitive dive. Had to learn how to, when I get to the wall, to do a somersault, flip turn, so the only part of my body which actually touches the wall is my feet, if I'm lucky. So, anyway. But, you know, I was, let's see, let's say at age 54 I was able to do one minute and three seconds, or a little bit over. And it looks like I was actually kind of holding my times there for a little while. And, in fact, age 57, I was under one minute, three seconds, just a little bit. And that was great, I was getting older but swimming a little bit faster. And wait a minute. Does that make sense? Does, what actually gets better with age? Has anybody ever heard of that before? Anyway, so I thought, oh, great. I really, you know, I've stopped the aging process in its tracks. But, unfortunately, that didn't last forever. And things have gotten worse. And last year I couldn't even break one minute, five seconds for the 100-meter, excuse me, 100-yard freestyle. And those are my best times, some of the ones that I didn't select were worse. Now, where did I get all this stuff? Where did I get these data? Well, it turns out, if you join US Masters Swimming and you show up at their meets, they've got all this stuff in a database. Hey, go ahead, look me up if you want. I mean, once again, that's even more boring than actually watching me swim. But the, so why is this? Why am I slowing down? And I've had to really think about this, as I'm not really sure what the answer is. Well, yes, I'm getting older. But, you know, is my motivation different? Is my training different? Is my technique a little off? And what about aging? What is that? Why do we slow down with aging? Well, I think one of the most obvious things is the musculoskeletal system, and particularly the joints. When I reach out, grab that water out ahead of me, my joints are pretty much at the maximum stretch that they can be. And so my joints don't seem to be quite as fluid or mobile as they used to be. And what about the muscles that move those joints? Well, they're not quite as strong as they used to be. And why is that? Well, it turns out, there are little energy factories inside all our muscle cells called mitochondria, and they generate energy. That's why the kids, that's why those 18-year-olds, once they learn to swim, they can swim right past me. So, exactly all the reasons for this, I'm not sure, but I'm still out there fighting, still trying to swim, trying to keep my times better, trying to still beat the other people in my age group. And, with Masters Swimming, they know that people tend to slow down because what they'll do is they'll take an average of some of the fastest swimmers in that age group and use a formula to make qualifying times for the national meets. And the qualifying times, as you might expect, tend to increase with age. So, yes, I'm aging, yes, I'm slowing down, at least according to these freestyle times, but still working and still trying to maintain as best as I possibly can within my abilities. Now, let's shift to a different topic. Does anybody remember Tom Harkin? -

Audience

Yes. You don't have to remember too long. He retired. He's no longer a senator. He retired earlier this year. In fact, right about the start of January. But he was from our neighboring state of Iowa. "Let's face it, in America today "we don't have a healthcare system; "we have a sick care system. "We wait until people become obese, "develop chronic diseases, or become disabled, "and then we spend untold hundreds of billions annually "to try to make them better." Does that sound true? Okay. I'm going to take that as a yes. I heard a pretty resounding yes on that. But let's, that brings us, perhaps, to Medicare. Medicare, inadequate reimbursement. Well, you know. Okay, let me explain what I mean by that. If I send a, if I submit a bill to Medicare for $100, they pay me $31. Okay? So, they, and so that's from, that's the physician perspective, at least the geriatrician perspective. They have some limitations on coverage, as you know. Everybody needs a supplement to cover what Medicare doesn't. Medicare has some pretty complicated rules, especially they can be complicated and disappointing where it comes for the coverage of long-term care stays. Has anybody here run into an observation stay? Or anybody, or know anybody who has? What that means is that if you go to the emergency room and you have fallen and you've damaged your pelvis, let's say, or broken a bone in your spine, maybe you can't go home, maybe you're not in good enough shape to look after yourself like you had been doing before, but you don't need to be admitted for an orthopedic surgery. If you went to the ER and you had broken your hip, Medicare can handle that, and it can cover your stay, it can cover your surgery, and your rehabilitation. But if you break a bone in your spine, not so much. There's no surgery. It's kind of a matter of having some pain and limitation and getting better sort of on your own. And, yet, even though Medicare, it doesn't cover you well enough and it doesn't pay me enough, the financial outlook is guarded. "You despise me, don't you?" Rick, "If I gave you any thought, I probably would." Medicare is a program that, in a way, is very popular. We all are very dependent on it, geriatricians certainly are. We live on it. But we also love to hate it when it doesn't meet our needs. And there's, I just saw a patient yesterday at a different facility, and that individual had, unfortunately, broken the wrong bone. She had broken a bone in her leg, she was in a cast. Because of that, she was immobilized, and she was not able to even bear weight because the fracture was of such a type that she could not bear weight as yet. So she couldn't rehabilitate. So she's in sort of Medicare catch-22. Had to be in a skilled facility because she needed the care, and yet she couldn't rehabilitate because she couldn't bear weight on the recently broken leg. Medicare coverage, therefore, was absent, and she's, therefore, stuck. Probably didn't have a qualifying stay in the hospital. Anyway, just went here, maybe to the ER, maybe a brief hospitalization at best. So there are many problems with Medicare, and yet it does cover a very important part of long-term care, the rehabilitation of orthopedic fractures, for example, aside from the one I mentioned. Just a few words about electronic records. I started practice, as we've learned, many years ago, before there were electronic records. And I remember writing in the chart and trying to find things in the chart, both of which are somewhat difficult. Electronic records, we are actually kind of the, you could say, almost a national headquarters of electronic records here with Epic in Verona and all the hospital systems, UW, Meriter, and St. Mary's, using Epic. And this is a great system for data collecting and billings. Anybody have any trouble getting a bill after you go to the doctor? Probably not because Epic was developed as a billing system, and it's grown into something much more so that now there's data entry in the form of information about all of us who, you know, who see doctors or healthcare providers now and also order entry to manage the care if we're in clinic or hospital settings. But there's a computer in the room, and physicians role has become somewhat that of data entry. So that's changed things. It's changed the dynamic very much. I think some physicians can deal with this perhaps better than others. But, you know, we all have the computer on. I think you've probably all noticed that, that there's a computer in the room when you're with your physician. "What in heaven's name brought you to Casablanca?" Rick, "My health. "I came to Casablanca for the waters." "The waters? "What waters? We're in the desert?" -

Rick

"I was misinformed." (laughter) I think there is misinformation about medical information systems, electronic records. And I think with the advent of the Affordable Care Act, it was thought that electronic records would save money. They don't. If you, all you have to do is drive out to Verona and see the cranes. These are cranes which are, The construction type of cranes is what I'm talking about, building the vast complex out there. Yeah, there's a lot of money being generated going to Verona. But in terms of cost savings in healthcare or cost savings for you, I would say, I'm still waiting to see that. What about safety? Patient safety? Well, you know, look, you know, when I went to medical school, I didn't learn to type, I learned to scrawl, I think. But anyway, so there were problems with that, problems with readability or legibility of information in the charts or medical orders. But the trouble with the electronic system is with a computer, you can really foul things up. You know, you get a menu of choices, and, you know, you have to sort of pick the right one with a click. And if that is wrong, there can be possibilities for error. So I'm not saying that the systems are inherently dangerous. I mean, they're probably no more risky than what we had before but, in some ways, no less. Well, let's just move to a slightly different topic of pharmaceutical advertising. Has anybody ever seen a pharmaceutical ad on television? (laughter) Okay, look. You know, I often watch the national news, like, you know,

at 5

30. It's nothing but pharmaceutical ads. And, you know, we at UW really, we used to have direct marketing by pharmaceutical representatives to us. And that's gone away. And I think most of the medical systems, certainly at UW, it's pretty much a thing of the past. But what's replaced the marketing efforts on the part of the pharmaceutical companies is this direct to consumer advertising. So you can fix your pain, your sleep, intestinal symptoms, sexual dysfunction, urinary symptoms, depression, memory loss, I'm sure there's many things I've forgotten here that can be fixed. Now, in fact, look, you know, when we had pharmaceutical representatives actually, you know, directly interacting with us, that was, I must admit, that was pretty sleazy. And I actually believed that I was smarter, I was smart enough that I was not going to be affected or swayed by this aspect of marketing. But, actually, I don't think that anymore. I think the pharmaceutical companies are extraordinarily smart. They've got the best minds in the country. They've got the money to, you know, to do what they're doing, and they're not spending money ill-advisedly. They're spending money on direct advertising because it works for them. The FDA oversees the drugs ads, but it has never imposed a fine for misleading content. The AMA, to its credit, I believe, favors a ban on direct to consumer marketing because, in the AMA's view, the demand for more expensive drugs is thereby inflated. And I've never been to New Zealand, but maybe some of you have. Apparently, they have pharmaceutical ads in direct to consumer as well. But we are the only two advanced countries that do. I just have this one slide, but I think it's perhaps important. That over the years that I've been in practice, happening all around me, there's been a biotechnology revolution. And there are drugs now called monoclonal antibody drugs, and they have a suffix at the end, "MAB", monoclonal antibody. They're made by fusing myeloma cells, myeloma are essentially cancer cells, like multiple myeloma. Myeloma cells are spleen cells from a mouse that had been immunized. So we employ our friends, in this case mice are our friends, in the animal world, to help us make drugs, and they're monoclonal, they're from a single clone of cells, and they're antibody directed, so they have a specific target in our bodies. And these drugs are actually out there and available and, in fact, has anybody ever heard an advertisement for a drug called Opdivo? -

Audience

at 5

Yeah. - Yes. It turns out it's advertised quite heavily, it's a drug for lung cancer. And just to refresh other people's memory, there's a guy, I guess, who has lung cancer, and he's shown, I think, throwing a baseball, you know, to his grandchildren or maybe catching it in the mitt or something like that. So he's gotten some extra survival from using a drug made in this specialized manner. Now, one thing they don't have to tell you on that drug ad is how much it costs. Does anybody have an estimate? Let's say, a one-year therapy with Opdivo, a monoclonal antibody drug for lung cancer. What's it cost? -

Audience

at 5

100,000. 100,000. I'm going to have you go up from there. Anybody gonna give me more than 100,000? -

Audience

at 5

200. 200. I'm going to have you go up from there. Anybody gonna go higher than 200,000? -

Audience

at 5

Five. That's too much, too much. Okay, it turns out $256,000 for a year of Opdivo. And, now, you have to, in all fairness, I think it's combined with something else, but, you know, that's pretty expensive therapy. You would kind of wonder why the Medicare system is in trouble. But, look, these drugs are amazing and, you know, it is a biotechnology revolution. What about another drug that they commonly advertise? I see almost every day,

if I can catch the 5

30 news. Humira? Anybody ever heard of that? Sure. Okay, it turns out, what does Humira treat? Well, it treats a lot of different things. It treats rheumatoid arthritis. It treats psoriasis. It treats Crohn's disease. How does it do it? It works with the body's own immune system because all of these are immune system based diseases. But how does it do it? How do they make it? Look, aside from showing you this mouse peering into a beaker glass, you know,I'm not going to go into the details of how they because honestly it would be beyond what I could reliably tell you about how these drugs are made. But it is amazing. We are in the biotechnology revolution. What about drugs for the kinds of diseases which occur with aging? Well, you know, any of those diseases I mentioned, especially rheumatoid arthritis or lung cancer, those can be diseases associated with aging somewhat. What about Alzheimer's disease? Do we have a monoclonal antibody drug for that? Well, not yet. But they're trying it out. And they're trying it out right here in Madison, among other centers. And what, how could that work? Is Alzheimer's disease an immunologic disease? Maybe not but the monoclonal antibody approach is designed to get rid of amyloid. And the drugs are actually somewhat successful in doing that. So you tie an antibody directed against amyloid to a drug and help it to help get rid of amyloid, which builds up as a waste product in the brains of people with Alzheimer type dementia and the amyloid can go away. Unfortunately, we don't know if the drugs actually work to treat the dementia. And it's not, It doesn't always, it doesn't seem like it's linear progression, linear connection that we're going to get rid of the amyloid and cure the dementia. It doesn't necessarily, it may actually work in mice. I think they might have had some success there, but who cares about Alzheimer's disease in mice? I mean, but the point, I guess one point is that these drugs are out there. Yes, they're expensive. They may someday work against some of the fundamental mechanisms and diseases and scourges of aging. Now, I actually, I don't just swim, I read a book, and that's pretty remarkable in itself. But that book is listed on this slide. The Emperor of All Maladies. And I think it's kind of written by a genius, Siddhartha Mukherjee. I think, I believe he's from India, but he is an oncology practitioner in this country at this time. He wrote this beautiful book talking about the biotechnology revolution as it has related to cancer. But I think many of the same points in this book are very relevant to diseases of aging, such as Alzheimer's, such as Parkinson's, and I think we will be hearing much more about the biotechnology revolution over coming years. And I'm actually kind of miffed that he stole the moniker "emperor of all maladies" for cancer because I think, really, you could say the emperor of all maladies could be more appropriately a description of Alzheimer-type dementia. But this, it's a brilliant book, and actually, there's a public television series based on the book. But the public television series can be a little depressing, they show some kids, not all of whom survive. But the book is surprisingly uplifting and more optimistic than the television series, at least that's what I found. "Everyone takes them. "Lawyers, musicians, people going to interviews "for big jobs. "It doesn't make you anything you're not. "It just makes it easier for you to be who you are." There was a movie a few years ago, Side Effects, and it was, anyway, it talked about some of the, it talked about some of the pharmaceutical advertising techniques and the effects on both those who are in the pharmaceutical industry and also physicians. Now, at the bottom of this slide on your screen is a guy you might be familiar with, Jimmy Carter. Now, you know, I actually never voted for Mr. Carter. Okay? But, you know, I think he has been the greatest ex-president we've ever had. Okay? If he could have just gone, I've heard the statement somewhere else, if he could have just gone straight to being an ex-president, he'd be a great guy. Look, he's building Habitats for Humanity, he's speaking out for women's rights, he's standing for world peace. What isn't this guy doing? I don't know. But, anyway. But here's the thing, he had cancer. Did you all hear about that? He had cancer. What kind of cancer did he have? Melanoma. Melanoma with several brain lesions. Four. Four of them. Well, what happened? Is he dead? No. He's not dead. In fact, he went to his church, I believe in his town of Plain, Georgia, I think, and he has told the congregation he's cured. Well, how did Jimmy Carter get cured? He took a drug. What drug? I'm not actually sure. But it turns out it's a monoclonal antibody drug. He took a monoclonal antibody drug, and he got cured to this point. Now, look, is he cured for long term? Is he going to live forever? I don't know, maybe not. He's, but, you know, the tumors have apparently gone away. Now, melanoma is a funny condition, it's always been a little bit responsive to immunologic types of interventions. I mean, some people have responding to a BCG, an injection which treats tuberculosis. It kind of cranks up the immune system so every once in a while somebody will get cured by that. But Jimmy Carter took a monoclonal antibody drug, and right now they can't find any, apparently, can't find any tumors in his brain. So it's, now, how much did Jimmy Carter's drug cost? I don't know. I didn't have the heart to ask. As far as I'm concerned, he's worth it. He's worth it. I hope he has many years out there left. But, you know, I was actually ready to say goodbye to Jimmy Carter. I figured melanoma, brain, you know? And he said things like "I've had a great life, "a charmed life, a wonderful life." I believe he was a nuclear sub captain, I think. and he was in the Navy. And then, you know, presidency, governor of Georgia, then president. But I think he prepared us, you could say, for the end, for his end. Just as Maximus, when he was leading his men into battle in Gladiator, prepared them for the fact that some of them might not make it. "If you find yourself alone, "riding in green fields with the sun in your face, "do not be troubled for you are in Elysium, "and you are already dead!" Okay, well, his men laughed, but they rode into battle following Maximus in Gladiator. You probably think I get all my philosophy from lines in movies, and probably just about two-thirds of it. Not all of it. "But life is full of misery, loneliness, and suffering, "and it's all over much too soon." A quote by Woody Allen. You could say this is emblematic of my career. As Marje indicated, I am going to be retiring July 1. And, yes, some of you have heard this rumor, and I'm here to verify, that this is true. And I've made some preparations for this transition in my own life, and some preparation for the end of life may ease the transition there too. I think you had a session here in this context on advanced care planning. Is that right, Marje? Okay. Very good. Okay. So, but we need not perhaps dwell on that so much because here's a quote from Buddha, "The secret of health for both mind and body "is not to mourn the past nor to worry about the future, "but to live the present moment wisely and earnestly." I think maybe that's something, if it took me 30 years to learn that, I guess I could say better late than never. Rick, "Don't you sometimes wonder if it's worth all this? "I mean, what you're fighting for." Laszlo, "You might as well question why we breathe. "If we stop breathing, we'll die. "If we stop fighting our enemies, the world will die." I believe Rick said, "Well, that will put it out of its misery." And one last quote from Maximus. "There is no one left to fight, sire," after Maximus had just defeated apparently the last remaining barbarian hoard at the northern end of the Roman empire, but Marcus Aurelius, the emperor, said, "There is always someone left to fight, Maximus." And I think I know that many in this room have battles which you too are fighting as you go forward in your daily lives. But I do want to wish you good luck and may fortune smile upon most of you. Thanks very much. I'm here to take any questions. Thank you. (applause)