Don’t Cry For Me Argentina

I don’t know how many muscleheads, heart patients and readers are fans of musical theater and opera, but I am. I know, my wife thinks it’s strange too.

Now what the heck does Andrew Lloyd Webber’s song have to do with heart disease? Well this: I am a lucky guy, and share this much with Evita; I don’t need any sympathy for getting to do what I do.

But you do. You see, we live in a media world where the most improbable things, actually silly things, become ‘scientific fact’, ‘conventional wisdom’, ‘the standard of practice.’ I am not talking about Anthropogenic Global Warming or politics; I am talking about a world where a physician is afraid for his job if he does not prescribe statins and other drugs for every single patient with normal cholesterol levels.

Why should you care if such facts dominate conventional health care? After all you don’t have to take a drug if you don’t want to; right? Well, actually, you do. Let me explain. And then let me suggest something you can do to keep this Orwellian world from becoming even more oppressive. Put another way let me suggest some things you can do to help your physician and our society become better and less medication dependant.

The explanation, the story behind a doc’s fear of losing his job if he doesn’t prescribe certain drugs even if they are not wanted by the patient goes something like this; two examples:

  1. You have a patient who decides to take charge of his diabetes and has radically altered his diet, his level of exercise capacity, his basic markers of disease and is no longer, statistically, at anywhere near his prior risk for the known and real complications of his underlying diabetes. Now this near miraculous transformation does not keep his insurance company from reviewing the medications his physician prescribes for him. With knowledge only of his diagnosis, and no facts about his overall health, his doctor will receive, and he must sign for the letter, notice that the patient in question has the diagnosis of diabetes and is found not to be on Lipitor. The doctor is instructed to both rectify and explain this circumstance and to fax back immediately the way in which the mistake was addressed. Hmmmm…drug companies, insurance companies, registered letters, fax forms, lawyers, malpractice…pretty scary…the sequence of worries rushes through the doc’s mind. What do you think he will do?
  2. You are a doc in a large multi-specialty medical/surgical group and you know that your patients who have a cardiologist and cholesterol levels even close to normal (see graph) are supposed to be on Lipitor; all large groups have such guidelines. But the guy standing right in front of you says that he does not want to take the drug because he has no family history of that kind of heart disease, though he does have Mitral Valve Prolapse which is why he sees the cardiologist. Group says, treatment guidelines say: he must take Lipitor. Guy does not want it. Many patients wind up getting ‘fired’ from such settings and must find another doctor. Alternatively if the doc too routinely avoids writing such prescriptions he can lose his job in the group.

Soft coercion, but coercion nevertheless. It adds up, examples could be multiplied many, many times over. You are losing control of your healthcare by the dominance of the pharmaceutical model of healthcare. Now keep in mind that I have patients on statins, sometimes they are just the thing! The fact that they help less than 1 in 100 people is not in dispute. That they can cause cataracts, kidney disease, increase the incidence of certain bone fractures, decrease testosterone, cause liver failure, depression, muscle aches and fatigue is not in dispute; even in the medical literature. The only thing in dispute is whether anyone is exempt. Respected journals have carried editorials advocating their administration to entire populations.

By increasing your VO2 one MET you save 1 of 6 people’s lives and don’t cause cataracts or anything else but fun. Here is the rub: there is no accepted calculus that says you get to trade off a 1 in 6 benefit for a 1 in 100 benefit. Just take the drug. You can increase your HDL by a factor known to reduce your heart attack risk by 60%- better than 1 in 2 benefit- and that does not buy you exemption from the ‘take the drug mantra’ that helps fewer than 1 in 100. Organized medicine has no calculus for this, and if leading medical journals are any indication, and they are, no such calculus is coming anytime soon. Pity you, pity your poor doc! This is no longer a rational process. The ones who are harmed by this crazy rush to judgment are you and the good old mainline doc doing his best to help you, feed his family, and to keep up to date in his practice; for he cares too, he cares very much. But who can swim against such a tide?

Well it turns out you as a patient, you as a consumer can swim against this mighty tide better than your doc can. That poor guy is trapped from many sides: paperwork to fight the insurance company, threats from his medical group, powerful legal forces that try, often very successfully, to define the standard of care by degree of drug prescribing compliance behavior. God forbid something ever happens to a patient not on every new drug on the market; he is sued. Terrible side effects from taking every new drug and that is just the cost of ‘the standard of care.’ No harm even if there is a foul; at least legally.

The next time you go in for your ‘annual physical’- tradition is a good thing but this is actually silly too- and the doc says your cholesterol is high, just press him a little. What does he mean by ‘high?’ Why does that matter? Relate to him that you have heard, thank God for the Internet, that statins are not all beer and skittles. Etc. Talk to your friends at the Gym, at work, your wife at home. If the doc’s eyes glaze over and he starts his ‘high cholesterol is dangerous’ mantra you needed to find out he wasn’t your man anyway. Help change the climate. Be honest about your own real behavior issues of diet and exercise and relaxation behavior. Above all inform yourself because more than you would like, more than I would like, you are in this on your own. Your doc can’t help you; you need to help him.

Give him courage. He is trapped by near superstition and organized medicine’s conviction, by the way well based in experience, that most, they assume all, that most will not make the changes that would exempt them from needing even the very modest benefits of drugs.

Examine your own fear on this issue. You are 30; you don’t care! You are 40; it begins to get interesting. You are 50 and the doc says you have borderline diabetes, high cholesterol, and it scares you but, let’s face it, you need to close that new account to keep your boss happy, you employed and the kids sheltered, fed and schooled. OK, 55 and you have no choice; time to take the drugs! Don’t do this; help yourself, but in this article I am asking you to help organized medicine, your local doc and your society to start the climb-down from this goofy scenario.

Have Fun, Smile, God Speed,

Dr. Mike

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