Tell Me What You Want

I am asking readers to tell me what you want.  Not in general, but at a health or wellness talk.  A few weeks ago I was asked to speak at a wellness seminar given at a company for its employees about heart health.  The talk was well received, and we had a good discussion after my presentation.

What struck me was how willing people were, in a room full of co-workers, to ask questions about their personal health.  In the office, we have safeguards to protect privacy at check-in, in the waiting room and at check out.  Yet in this conference room, with people they know listening, I was told about cholesterol results and other tests, treatments they were given, etc.  Granted, we were talking about heart disease, which may not seem as socially or professionally awkward as some other topics, but it still surprised me.

It also made me wonder – what did they want?  My professional interpretation and opinion of their situation, or validation that the choices they had made in their own care were “good choices”?

I did my best based on the information people gave me to address their concerns, while encouraging them to speak to their doctors.  Some had questions understanding what they were treating or how to interpret their results.  Others had decided to try a different therapy (often homeopathic) than what their doctor recommended and wanted my approval – so the answer to my initial question is “both”.

I found it to be a little uncomfortable being asked to approve someone’s decisions with limited information, especially if I didn’t “approve.”  However, the talk and Q&A are for the attendees, not me, so I did my best to give a recommendation and encourage discussion between the person and their doctor.

This is a copy of the talk I gave – I want to thank TheVisualMD for the image support in the talk.

My question to you – if you went to a talk like this what would you prefer?  A general Q&A or time at the end to make a mini-appointment to discuss your questions one on one with the speaker?  Tell me what you want!

The path to wellness begins with a proper diagnosis

Personalized Medicine – Back to the Future

Almost every day I get asked a similar question.  “Should I get…”  we fill in the blank with a test – mammogram, stress test, PSA, colonoscopy are common ones.  People are concerned about having a disease and want to know if they can do anything about it.  They are worried and a little scared of what they may find out.  In addition, people are presented with conflicting information – the cancer society recommends women get mammograms beginning at age 40, an advisory committee called the US Preventive Services Task Force (USPSTF) says 50.  The USPSTF says not to check PSA in men, the cancer groups disagree.  There are ads for home DNA tests, full body scans and “executive physicals” that claim to identify disease.  There are media stories of being able to use all this technology to tailor treatment to a persons genetic code – ushering in the age of “Personalized Medicine.”  

It is against this backdrop and expectation that people ask their doctors to be able to predict the future, or look at their blood tests and reassure them that they are safe.  When people purchase these tests or ask me about ordering a test, almost all are thinking that a normal result will reassure them they are ok – not about what a positive test means – or worse – an indeterminate test.

The result is we now have the ability to use technology to see what is normal or not – but our ability to find abnormalities is much greater than our ability to assign meaning to it.  Is that nodule on your full body scan something dangerous or is it an abnormality that likely has no clinical meaning or impact on health – what we call an “incidentaloma?”  What has happened as our ability to detect has exceeded our ability to interpret is the development of guidelines.

These guidelines evaluate a technology or test and give a recommendation on its use.  The recommendation is usually based on a review of published evidence or a review of selected evidence.  The review of evidence averages out differences in the population in an attempt to give a blanket recommendation.  These generalizations are then applied to individuals and often viewed as hard and fast rules instead of suggestions.  This non-discriminate application of guidelines is the exact opposite of what science is trying to accomplish with technology – resulting in depersonalized medicine.  

It is ironic that with all the technology we are developing to personalize care we have devalued the very thing that would allow its proper implementation – the doctor-patient relationship.  By coupling technology with a doctor’s knowledge of both an illness and the personal history of the patient in front of them an intelligent plan of how to apply technology can be developed.  Prior authorizations, approval requests and denials by insurance companies interfere with a doctor’s ability to do so.  These obstacles add more to the cost of care than the very tests a physician may be trying to order!  

I have spent the majority of my career advocating for the intelligent use of information technology and Electronic Health Records to enhance the care of the patient in front of the doctor.  Guidelines based on the “average person” can be applied to large populations with ease.  However, when you are discussing disease risks and testing with the individual sitting across from you, it becomes less clear-cut that they are the “average person” the guideline applies to.

So while a patient’s DNA may lead to personalized treatments to diagnose and cure illnesses the ability to deliver personalized medicine already exists – when a doctor and a patient take their history and intelligently apply technology to it – resulting in the best care for that person.

The path to wellness begins with a proper diagnosis

Advanced Lipid Testing – when “bad cholesterol” isn’t good enough

In an earlier post, I reviewed the new ACC/AHA guidelines for treating cholesterol.  These guidelines recommend basing treatment solely on LDL-c or the “bad cholesterol”, treating when it is high but not to a specific target.  Over the last several decades, lowering levels of LDL-c has resulted in a decreased rate of heart disease that combined with advances in treatment has also reduced the death rate from heart disease.

Despite these advances, heart disease remains the number one killer of Americans.  A 2009 study from ULCA demonstrated that half of people who have heart attacks have relatively “normal” levels of LDL-c cholesterol.  What are we missing in these people?  Is their another marker we could measure to more accurately predict risk?  

What is Cholesterol testing?

Low Density Lipoprotein is the “sticky stuff” that clogs arteries.  Cholesterol is a carrier for the lipoproteins that circulate in our blood.  The more lipoproteins in you blood, the greater your risk for heart disease.  Historically we have used the measurement of LDL cholesterol to act as a surrogate measure of these sticky proteins because it was the best we had.  We have had a tremendous impact on heart disease by treating cholesterol.

The problem with LDL-c measurement is that it is a calculation based on certain assumptions about how the sticky proteins are distributed in the system.  The model breaks down when triglycerides (another component of a cholesterol panel) are elevated.  When this occurs, the sticky proteins are not distributed evenly and you have a lower level of LDL-c than the true level of sticky proteins that cause plaque.  The result is that the traditional LDL-c reading will underestimate the risk of heart disease – helping to account for the “half of heart attack victims with normal cholesterol.”

What other markers are there for lipid testing?

Many measurements have been evaluated to see if there are better predictors of heart disease than LDL-c.  3 of the most promising are Non-HDL-c, Apo-B and LDL particle number (LDL-p).  

Non-HDL-c is a calculation that simply subtracts the HDL-c level from the Total Cholesterol level in a standard lipid panel.  For those at highest risk of heart disease, a non-HDL-c level over 130mg/dl is associated with increased risk of heart disease regardless of what the usual LDL-c is.  The advantage of this reading is that it can be determined at no additional cost from a standard lipid panel.  Disadvantages are variability based on fasting state and that it may not predict how well medication is reducing risk.

Apo-B is a protein that is deposited in the walls of arteries to create plaque.  It is carried through the system by cholesterol.  The more Apo-B in your system the greater your risk of heart disease.  Each particle of low density lipoprotein contains 1 molecule of APO-B.  Studies have shown that Apo-B levels can remain elevated even in setting of “normal” cholesterol levels.

LDL-p directly measures the particles of low density lipoprotein that account for the risk of heart disease.  Studies have shown that LDL-p can be elevated even when cholesterol levels are normal.  Information presented at the most recent American Cardiology Conference demonstrated that treating patients to a normal LDL-p had a 22-25% reduction in heart attacks than those treated to traditional goal cholesterol values.

How does this affect my practice?

I see patients at increased risk of heart disease on a daily basis.  I generally order a traditional cholesterol panel on all patients.  When their history indicates an increased risk of heart disease – due to family history, diabetes, hypertension or obesity, I will order an LDL-p as well.  I will also order an LDL-p if their traditional cholesterol panel shows high triglycerides.  I find this test to be one of the easiest to interpret as there are direct values that correlate with risk.  It also does not require fasting – making it a very convenient test indeed!

So while not everyone needs to have their LDL-p measured, it is important not to simply accept a cholesterol reading at face value.  Like all tests, it needs to be interpreted in the setting of your individual risk factors and other medical conditions.  Knowing your real risk of heart disease is a necessary initial step towards improving your health!

The path to wellness begins with a proper diagnosis. 

Test me for everything

An Annual Physical is one of my favorite visits. It’s an appointment specifically designated to review your health – both where you are now and where you are heading. It’s the body’s status update. It’s also where I feel I get to know a person a little better, more about your life in general, not just your blood pressure or back pain. Besides having a conversation about your health, a blood test is usually performed. Often, when we get to drawing blood at a physical exam, a patient will say, “Test me for everything.”  Obviously, everything is not possible – so a discussion of what “everything” entails is needed. 

Often, patients use “everything” as a signal for testing for sexually transmitted diseases (STDs).  It is important to know that HIV can not be tested for without your request – so do not assume it is being tested – ASK FOR IT!

Other STD tests usually include HIV, syphilis, gonorrhea, chlamydia and Hepatitis B & C.  Herpes can be tested for in the blood as well, but the test only shows whether a person has been exposed to the Herpes virus, it does not give information on contagiousness or disease activity.

HPV is tested for in women during a PAP smear.  It is a test done on cervical cells – it is not a blood or urine test.  There is no test for men for HPV, unless there is a lesion – usually a wart – that can be biopsied.

So what are the usual blood tests done at a physical?

It depends on your age and gender. The blood tests I order fairly universally:

  • blood count (CBC)
  • sugar (glucose)
  • liver function (AST, ALT)
  • kidney function (BUN, Cr)
  • lipid panel (cholesterol)
  • thyroid function (TSH, Free T4)
  • urinalysis

Often tested, but not “mandatory”

  • iron levels
  • vitamin B12
  • vitamin D

Other tests determined by age, gender or a medical condition

  • high sensitivity C-reactive protein (cardiovascular risk)
  • hemoglobin A1c (for further assessment of diabetes)
  • urine protein (for people with diabetes or hypertension)
  • prostate specific antigen (PSA) – this is ordered after a discussion about risk and benefits
  • other tests can be considered depending on individual risk – advanced lipid testing, imaging studies, stress tests – these depend on your specific medical needs and are not “one size fits all”

Do I have cancer?

One of the most common questions asked when we draw blood is can you tell if I have cancer? Blood tests for cancer or genetic information are not routinely done, with the exception of the PSA in men for prostate cancer.  While there are tests that exist for following some cancers, they have not improved diagnosis – especially the CA-125 test that is touted in many email chain letters for finding ovarian cancer – it is not a diagnostic test but rather a test for following someone with ovarian cancer. Using tests improperly leads to confusion, anxiety, more testing and misdiagnosis!

More cancers can be detected or screened for with specific tests other than blood tests. Colon cancer, breast cancer, cervical cancer and lung cancer all have screening tests (procedures) that improve detection. There are many guidelines as to when these tests should be done – the bottom line is that each person should discuss their individual risks with their doctor to determine what tests should be done, as well as when and how often!

This leads to the biggest issue of testing – interpreting the information in a meaningful way for you.  The FDA recently forced a home genetic testing company, 23 and Me, to stop marketing their kits due to quality and interpretation issues. As more tests are developed, our need to synthesize this information to make good decisions is becoming more apparent.

So, “everything” means different things to different people – so be specific if there is something you wish to have tested.  You can’t assume it is part of everything.  An Annual Physical gives you a snapshot of where you are, and serves as a guide for how to get to where you want to be. Have a conversation with your doctor about your health fears – an annual physical is the time to chart your path to health!

The path to wellness begins with a proper diagnosis