The Personal Touch: Doctors Who Think It's All About Me

The other night the phone rang and when I picked up I heard a friendly soft-spoken voice. "Hi, George," he said. Dan Marelli here."

"Hi, Dan."

"I got the lab tests you dropped off and your message. I see the cholesterol is still up, 228, and you have been talking with Dana and decided to go on a statin."

"Yeah, Zukor. You and I have been talking about it for a while and she thinks it's time and so do I. Tomorrow she's having me go in to get tested for liver function to make sure I can take a statin. We decided it would be best to get it through the VA, cheaper, and they mail it to you."

"I agree that it's time. What I'll do is have you come in three months to check on any side effects. If you feel any muscular pain, call me right away and we'll see what's going on. I also noticed that your blood sugar is up, 136."

"Yea, that's a first. Dana thinks it could be because I've put on some weight, probably from eating so much fruit. I eat a ton of it. She gave me a bit of a talking to about portion sizes."

"We'll start watching your blood sugar. Dana also suggested a colonoscopy?"

"Yes. She said it has been five years since I had a sigmoidoscopy and I have never had a colonoscopy. She said that because of VA scrictures, she could only offer me a sigmoid but thinks I should have a colonoscopy. She suggested that I go through you. She wants you to be fully involved in everything and so do I."

"That's good, thank you. I think the colonoscopy is a good idea. I'll have the office make the arrangements and get in touch with you."

"You know, Dan, I really appreciate your following up on this so quickly. Thank you so much."

"Not at all. My pleasure."

The next day I got a call from Dan's office manager explaining that she had made arrangements for the colonoscopy and I could pick up the information at the office or have it mailed to me. Not in any hurry, I asked that the info be mailed to me.

You must understand that what's going on here is something almost unheard of in health care today. A doctor in private practice, Dr. Dan Marelli (not his real name, out of respect for his privacy) calling a patient at home the very same day that he receives lab results and recommendations from a VA provider? When it's not an emergency?

What gives? Am I some kind of VIP? Do I have some kind of sweetheart deal -- you know, wink, wink -- with Dr. Marelli? No and no. In fact, as far as I know, Dr. Marelli did not make a dime from our unhurried 15-minute conversation. And he was not the one who wound down the conversation; I did, because I know how valuable his time is.

Believe it or not, what we have here is a young, early forties, doctor who practices old-fashioned, patient-centered medicine. He didn't have to respond so quickly. He didn't have to call me at home. He did so primarily because he cares about me as a patient and to hell with the insurance companies and all the other complications that come between doctors and patients today.

I have been seeing Dr. Marelli for about ten years and he knows me and I know him. We are a team. But it is all about me all the time. He goes over the latest lab results and health developments and explains options.

Unlike many doctors who do all the talking, Dr. Marelli wants to know what I think. He listens intently. In the end, I am the decider. I decided when it was time for me to have two total knee replacements. This time I decided that, after two years of talking about it, it was time for me to go on a statin. Once I decide, Dr. Marelli makes it happen.

There is something else unusual here. We also have two health-care providers, one from the VA and one in private practice, working as a team. I have been going to the VA for nearly twenty years and it consider it an essential component of my health care.

Despite what you read about the neglect of wounded veterans at Walter Reed in Washington, D.C, patient care throughout the VA system is excellent. (Walter Reed is run by the Defense Department; the VA System is entirely different). My provider at the VA, Dana (also not her real name) offers me preventive care, something that Dr. Marelli cannot always offer.

She is not a medical doctor but a nurse practitioner, though I want to call her "Doctor." As far as I am concerned, she is a superb doctor. But when it comes to the big things, such as total knee replacements, Dr. Marelli is the go-to guy. With him, I can choose my hospital and surgeon. At the VA, I cannot.

Now it so happens, that Dr. Marelli and Dr. Dana know each other. They know each other very well. Dr. Dana worked in Dr. Morelli's office for ten years as a medical assistant. He was the one who encouraged her to go for further medical training and to become a nurse practitioner. He was and is her mentor.

Yet their respect is clearly mutual. She is taking the lead in getting me on Zukor and getting me a colonoscopy and Dr. Marelli readily approves. They both want the other to know everything that is going on with me. For me, the patient, what that amounts to is a built-in second opinion and superb ongoing care.

I only recently starting going to Dr. Dana after going to the same VA doctor (an M.D.) for seven years. When this long-term provider left, she called me at home to tell me the news. I was shocked. I put down the phone and cried. This was a doctor who knew me -- she had read my novel and read posts on this blog -- and cared about me as a person.

The first time I walked into Dr. Dana's office, I told her I was in deep mourning for her predecessor. "Oh, I know, isn't she wonderful!" And I proceeded to talk about what a wonderful doctor she is. Dr. Morelli's name came up and we both sang his praises.

To me, Dr. Dana was a question mark. I was skeptical. How could she ever fill those big shoes of my longtime doctor that I still desperately missed?

A year later, at this most recent meeting with Dr. Dana, I left her office feeling that here was a nurse practitioner who was a doctor in every way that matters to a patient, and one who knew and cared about me as a person. I can never forget my old VA doctor, but by some miracle her big shoes had indeed been filled.

At the door, I paused and said, "You know, you are absolutely wonderful."

She smiled, warmly. "Thank you. Make sure Dr. Marelli gets everything."

"I will."

Given the state of health care today, how lucky can one guy be?

So long and keep moving.

Clogged Arteries: Why is Bill Clinton Bugging Me About My High Cholesterol?

For a couple of years now, Bill Clinton has been stalking me. Every time I forget that I have a mortal body and feel good about life, the former president pops into my head wagging a finger and saying, "So you think it can't happen to you? Better think again, my complacent friend."

Bill Clinton has reason to be nagging people like me. Nearly two years ago, he was happily going about his business of being a popular and much sought after former president, as well as indulging in his taste for fast food. He was young, only 58, and was at the top of his game jetting around the globe advising world leaders on the great issues of our time.
Impeachment and Monica Lewinsky were dim memories. Life was a dream; that is, until it suddenly became a nightmare; until one day, without warning, death knocked on his door. On September 2, 2004, while resting at his Chappaqua, N.Y. home, he experienced chest pains and shortness of breath.

He checked himself in at the Westchester County Medical Center where an angiogram showed that he had nearly complete blockage in four coronary arteries. He was quickly transferred to New York Presbyterian Hospital/Columbia where he had successful quadruple heart bypass surgery to reroute the blood flow to his heart.

During the highly invasive four-hour operation, the former President's chestbone was sawed open and his heart was stopped for 73 minutes. During this time, Mr. Clinton was put on a heart-lung machine which kept his blood flowing and his heart oxygenated. Surgeons led by Dr. Craig R. Smith took blood vessels from his chest and left leg and sewed them into arteries feeding his heart, bypassing the blockages.

Though he was relatively young, physically active, and had had the benefits of eight years of top-flight presidential medical care, he was, in coronary terms, on the edge of a cliff -- and about to plunge to his death.

His arrival there was not as sudden as it seemed. For the past several months, he had been experiencing chest pain and shortness of breath. He blamed them on acid reflux and irregular exercise grabbed between long flights, airports, and speaking engagements.

For years, he had cheerfully gone along indulging his love of fast food, jogging regularly, acing stress tests, and carrying extra weight. Leaving the White House in January, 2001, Mr. Clinton had a total cholesterol count of 233 and a “bad” cholesterol count of 177. He began his new life as a private citizen by taking a statin drug, Zocor from Merck, to lower his cholesterol. His cholesterol dropped to normal levels.

After awhile, feeling good and his mind on other things, such as writing a bestselling book, he stopped taking the drug. About six months before entering the hospital, he went on a modified low-carb, low-fat South Beach diet and had slimmed down. However, the better diet and weight loss “was not enough to reverse years and years of unhealthy living,”said Dr. Christopher Cannon of Brigham and Women's Hospital in Boston.

By the time the former President presented himself at the Westchester County Medical Center, four of five arteries to the heart were dangerously choked with plaque. Unknown to himself or his doctors, he was a medical time bomb. Dr. Allan Schwartz, chief of cardiology at Columbia-Presbyterian, said: “There was a substantial likelihood that he would have had a substantial heart attack in the near future.”

Mr. Clinton was lucky. He sought medical care literally in the nick of time. Many people are not so lucky. Heart disease is the number one killer in the U.S. Every year 1.6 million Americans have a heart attack and half die.

Heart disease is a silent and invisible scourge that does its deadly work over many years. Often there are no symptoms at all. The first symptom is frequently the last. Or if there are symptoms, they are attributed to things like heartburn or acid reflux, as was the case with Bill Clinton.

High cholesterol? It is easy to put it out of your mind when you feel great and you're eating the way you always have and you're doing everything you have always been doing. That's how it has been for me for years.

Sure my cholesterol was higher than my doctors said it should be. But so what? I felt great. Don't bother me with that cholesterol crap! It's important to note that I had that attitude while not being exactly sure what cholesterol is.

This is how the National Institutes of Health describes cholesterol:

Cholesterol is a waxy, fat-like substance that occurs naturally in all parts of the body and that your body needs to function normally. It is present in cell walls or membranes everywhere in the body, including the brain, nerves, muscle, skin, liver, intestines, and heart. Your body uses cholesterol to produce many hormones, vitamin D, and the bile acids that help to digest fat. It takes only a small amount of cholesterol in the blood to meet these needs. If you have too much cholesterol in your bloodstream, the excess is deposited in arteries, including the coronary arteries, where it contributes to the narrowing and blockages that cause the signs and symptoms of heart disease.

To learn more about cholesterol, a good place to start is the NIH Home Page.

Now that I know a little about cholesterol and this latest blood test has got my attention, Bill Clinton is really getting in my face. My total cholesterol was 233, exactly what his was when he left the White House and, on the advice of a top-flight medical team, went on Zocor. My doctors are saying that it's time I did the same. It would seem to be a no-brainer.

Many older folks, such as me, were middle-aged before they ever heard the word “cholesterol.” Some of us old fogies find it hard to take seriously something that we can't see or touch. There are so many other things to worry about, such as paying the bills and holding your own on the tennis court.

Because of this mindset, many people either don't worry enough about their high cholesterol to do anything about it, or, if they begin taking a cholesterol-lowering drug, they stop. Mr. Clinton stopped taking his Zocor and some heart specialists say that this was almost a fatal mistake. They say that if he had continued taking the drug, he might have been able to stop the disease from spreading.

Dr. Cannon said, “Had he been on a statin medication, with much lower cholesterol levels, that might have prevented his developing these severe blockages.”

Mr. Clinton has resumed taking a statin drug, though which one has not been disclosed. An endorsement contract in the works?

Meanwhile, Mr. Clinton recovered nicely and seven weeks after his bypass surgery he was back out on the campaign trail. A week before the 2004 election, he appeared with John Kerry in Love Park in downtown Philadelphia, looking thinner and sounding slightly hoarse.

But his spirits were buoyed by an enthusiastic welcome. “If this isn't good for my heart, I don't know what is,” he told the cheering crowd. Mr. Clinton went on to log thousands of miles campaigning for Mr. Kerry.

However, about a year ago, on March 10, 2005, Mr. Clinton was in the hospital again. This time, he had follow-up surgery to remove scar tissue and fluid from his left chest cavity, residual effects of his open-heart surgery.

In retrospect, Mr. Clinton was at high risk for a heart attack. He had high blood pressure, high cholesterol, a history of heart disease on his mother's side, and years of a fatty diet. His exercise and belated weight loss had served only to push these these risk factors into the background and to camouflage a massive build-up of plaque over many years, causing a 90% blockage in four coronary arteries and a virtual sentence of imminent death.

In view of Mr. Clinton's experience, should I -- eight years older, with the exact same total cholesterol, similarly asymptomatic -- learn from his experience and take the damn Zocor? Should I stop bashing the authors of the new cholesterol guidelines urging more aggressive use of statins and just take a proven medicine that could save my life?

So what if the authors of the guidelines are on the take from the drug companies? Why worry about something as pointy-headed as conflict of interest, when the statins are known to work? Why worry about possible longterm side effects when there is perhaps a better chance that taking a statin may avoid a heart attack now or in the very near future?
I called my sister, Marion, a retired nurse who was once Director of Nursing Care at a large Boston-area hospital and is today a hospice volunteer. I gave her my cholesterol numbers and my whole spiel about not wanting to go on a statin unless I absolutely have to.
First of all, she said that the "bad" cholesterol of 169 was "not good, not good at all" and that I had to get it down. "But I have already tried diet and exercise,"I said. "I can't eat any better, I don't need to lose any more weight, and I already exercise like a maniac; I can't exercise any more. No matter what I do, my cholesterol stays where it is -- high."
"About fifteen percent of the population have bodies that produce too much cholesterol, regardless of diet or lifestyle. No matter how much they exercise or how few fat colories they consume, the body still produces more cholesterol that it needs. You may be in that population. Which means that you don't have much choice but to go on a statin."
I gave her my spiel about side effects, conflict of interest among those pushing the statin drugs, the lack of longterm studies. "You know, George," she said. "You're an informed health-services consumer. That's good. But you don't want to be a foolish health-services consumer. Whether you have build-up now or not, you need to prevent future build-up. You need to think prevention and that's what a statin will help you do."

Marion's giving me a good talking-to, on top of the close call that Mr. Clinton had has me rethinking. Am I being pig-headed about avoiding a statin drug? What if my coronary arteries are already hopelessly clogged as Bill Clinton's were? What if the glogging is getting worse? There is no way to tell, short of an angiogram.

This was the test that Bill Clinton was given, in which a dye was inserted into the bloodstream from the groin to the heart, revealing blockages. The only trouble is that the angiogram is not given to people without symptoms. In fact, there is no good test for people without symptoms, though work is being done on using multidetecting CT scans for heart disease that yield much more detail and information than angiograms and are much cheaper, $700 instead of $4000. Unfortunately, these scans are unreliable and expose the patient to large doses of radiation.

If I asked for an angiogram, would Dr. Donna Santora or Dr. Marelli say “sure” and order one? The answer is no because neither the VA nor the private health care system work that way. You get the angiogram when you are in the hospital at death's door, as Bill Clinton was (and as I may be for all I know). Or you get it if you survive the heart attack.

So what I have decided to do is figure out a way to get myself tested for blockage, even though I do not have symptoms. All I know is that I have a total cholesterol count of 233 and, ask Bill Clinton and my sister Marion, this is not good. But I do not know if I have serious blockage as he did.

I also know that cholesterol-build-up is chronic, slowly progressing, and cumulative. It is associated with a narrowing of the arteries (stenosis) and blood clotting (thrombus) that rapidly slows or halts blood flow that carries life-sustaining oxygen.

With four of his five arteries to his heart blocked, Bill Clinton's heart was strangling from lack of oxygen. The same thing may be happening with me and I am now going to find out if it is. No more complacency for me.

I'll let you know what I find out.

Thank you, Bill Clinton. And now that I am getting off my duff and doing something about my cholesterol, would you please stop bothering me? And, yes, I'll consider Zocor.

So long and keep moving.

 E-Books by George Pollock

"State Kid: Hero of Literacy" is fiction based on his  real-life experiences  growing up in foster homes; "Last Laughs," is the true story of how five foster kids (he and four younger siblings) found their way in life and each other. "Killers: Surprises in a Maximum Security Prison," is the story of the author being locked up for 23 hours with killers in a maximum security prison;  "I, Cadaver" is about the author's postmortem adventures and mischief in the anatomy lab at UMass Medical School. “A Beautiful Story” demonstrates the art and process of creative writing as a 16-year-old boy goes all out to write a story good enough to get him into an exclusive college -- on full scholarship; and "A Long, Happy, Healthy Life," which is about how to live the title every single day.

Elevated Cholesterol: Take Zocor or Lipitor or Take Your Chances on Your Own?

One's health is not static.

After getting both knees replaced, after enduring months of rehab torture at the hands of pain-loving Iron Mike, after a week in the hospital with a misaligned pelvis followed by more brutal rehab, and after thumbing my nose at it all and taking up fiercely-fought singles tennis; after all that, you would think that the sinister forces trying to bring me (and everybody else) down would back off.

But no, after a battery of blood tests at the VA, I get the results with the following note from Dr. Donna Santora:

George, I am concerned with your elevated cholesterol levels. I looked back over the past nine years and they have always been elevated when checked at the VA. I do not have any labs from Dr. Marelli to compare these to. have you ever been on cholesterol-lowering medication? I feel you should be on medication at this point for cardiac protection. (The VA starts with Zocor.) Please discuss these lab results with Dr. Marelli and let me know what you decide. We look forward to seeing you at your next visit. Please remember to bring any outside labwork with you.

Total cholesterol was 233; she said it should be less than 200. Low density lipoprotein, the "bad" cholesterol, was 169; she said it should be under 130. This bad news was accompanied by some good news. High density lipoprotein, the "good" cholesterol was 53; this should be above 40. Triglycerides were 57; this was well under the upper limit of 150.

Everything else was fine. Liver function tests were normal. Electrolytes were normal. PSA was 2.78, unchanged from past tests and normal. Thyroid function was normal. Urinalysis was normal. The complete blood count was within normal range.

So, everything was normal except for the elevated cholesterol. This was not news to me. For eight years, my previous VA doctor, Dr. Susan Krantz, had been asking me to consider taking a cholesterol-lowering drug such as Zocor or Lipitor. I kept holding her off, saying that I wanted to "depend on the resources of my own body for as long as possible."

Over the same years, Dr. Marelli, knowing of my reluctance to go on a statin drug, took a "let's keep an eye on it" approach. But then, in 2004, he sent me a letter saying he was concerned about my elevated cholesterol. This was his letter:

Dear George,

Your recent results have been reviewed. I apologize for the delay. These were done at the later portion of April.

The results include a cholesterol of 237. The good cholesterol is 42. These numbers give you a ratio of 5:6, which is high. The ratio should be below 4.

I would like sit down and discuss your lipids in more detail. Please call the office and arrange a brief morning appointment in the next month or so to do so. I look forward to seeing you then.

Sincerely,

Daniel R. Marelli MD

Well, I thought at the time, at least he was looking at the calendar and not his watch in suggesting an appointment between annual visits. But in the seven years I had been seeing him, this was the first time he had suggested an additional visit to discuss a medical problem.

While the cholesterol problem was not news to me, Dr. Santora's note had an alarmed tone and sent me rethinking. Was I really at risk for a cardiac "event"? Other than age (68) and high cholesterol, as far as I knew I lacked the other major risk factors for coronary heart disease.

But I did know that of the major risk factors for heart disease, elevated cholesterol is considered a biggie. Both produced by the body and derived from what we eat, excess cholesterol leads to a clogging of the arteries and interferes with blood flow. Heart disease is the number one killer of both men and women in the U.S.

The other major risk factors for heart disease are:

Diabetes. Having this disease, an excess of sugar in the blood because of the failure of the pancreas to produce enough sugar-absorbing insulin, automatically puts you in the highest risk category for coronary heart disease. According to these last blood tests, I have glucose levels slightly above normal levels.

Heredity. For a male, a family history in which your father, brother, or son had coronary heart disease before age 55; for a female, the disease in your mother, sister, or daughter before age 65. My father died at 26 of rheumatic heart fever, an inflammatory disease of the pericardium and heart valves, which is not hereditary and rarely dangerous today. My mother, who was obese and a diabetic, died of heart failure at age 86. My four siblings, of which I am the oldest, are all in their sixties and in good health and with no heart disease.

Age – Male Over 45. The risk of heart disease for men is three to four times higher than for women in midlife. It is especially important for men as they age to reduce the risks they can control. At age 68, I have age risk up the gazoo. Even my oldest son, Greg, who is 42, will soon be saddled with this male risk factor.

Age – Post-Menopausal Female. Before menopause, women have lower cholesterol than men of the same age. After the age of menopause, women's LDL levels tend to rise. At age 62, my wife Barbara and ace patient advocate, has reached this stage. Her latest total cholesterol count was 218, with an LDL of 142 and an HDL of 59, for a TC/HDL ratio of 3.7. Both of her parents lived into their mid-eighties and there is no history of heart disease in her family.

Low HDL. (less than 40 mg/dl): We're okay here. Barbara's HDL is an excellent 59 while mine is 53, up from 42 two years ago.

High Blood Pressure. (above 140/90 mm Hg). No problem here, with both of us scoring consistently below this level. My blood pressure is always around 120/70-80.

Smoking. Neither of us have ever smoked. Let's amend that. At age 12, I found a few dollars in an alley and, along with some acting-out friends, blew the entire amount on a movie and a carton of cigarettes. (A few bucks went a long way then.) As a matter of honor, I smoked a whole pack in one afternoon of playing grown-up. I got sick to my stomach. I got a headache so bad I thought my head was going to explode. I never smoked another cigarette. All four of my siblings, however, became heavy smokers. Amazingly, given the significant known risks of smoking, all remain healthy.

Even though obesity and physical inactivity are not on the above list of standard risk factors for coronary heart disease, they probably should be. The two are often connected. Together, they place extraordinary burdens on the heart which increases the risk of diabetes, high blood pressure, elevated cholesterol, and artherosclerosis. By virtue of my authority as a patient, I hereby add obesity and physical inactivity to the list above.

I am not obese and neither is my wife Barbara, though both of us are 20 to 30 pounds above recommended weights. I am highly active physically, playing tennis three or four times a week. Barbara is less active physically but still active, walking two or three miles at least twice a week and working hard doing yard work and other home chores.

Of all the above risk factors, I have two: age – at 68 or 21 years beyond the 45 years that is the onset of this risk factor; and elevated cholesterol. The first I can't do anything about. That leaves me the second to deal with: a cholesterol count considered of enough concern for Dr. Marelli to request a sit-down discussion.

Federal health officials have sharply raised the cholesterol bar for Americans at moderate to high risk for heart disease. Moderate risk is defined as having one of the risk factors cited above. High risk is defined as having established heart disease along with another condition such as diabetes or high blood pressure, or smoking or a recent heart attack. My age and cholesterol level classifies me as high risk.

New standards would seem to make me a medical person of interest, to say the least. I'm expected to reduce LDL (bad cholesterol) to under 130. These new standards carry recommendations for more aggressive use of cholesterol-reducing drugs, including higher doses, to meet them.

With an LDL of 169, I would seem to be walking into Dr. Marelli's office as a cardiac event waiting to happen. As is Dr. Santora and as was Dr. Krantz before her, Dr. Marelli would be under pressure to recommend that I start taking a cholesterol-lowering drug.

Despite my fervent wish to lead a drug-free life, despite the risk of side effects of muscle weakening and liver complications (small but there nevertheless), despite the fact that once you go on statins you're on them for life, going on a cholesterol-reducing drug would seem the rational thing to do.

And, anyway, what do I know compared to new information published in the journal Circulation and endorsed by the U.S. Centers for Disease Control and Prevention, the American Heart Association, and the American College of Cardiology? The new guidelines are backed by these organizations as written by nine of the country's top cholesterol experts and reviewed and endorsed by an additional 80 experts. They were based on five different clinical studies since 2001.

But just for the sake of discussion, let's step back for a moment. To start with, eight of the nine authors of the report received money from the makers of the most widely used cholesterol-lowering drugs, according to the Center for Science in the Public Interest. The money came in the form of consulting and speaking fees, research grants, support for clinical studies, and travel expenses to educational seminars sponsored by the companies.

These companies stand to gain financially, and in a big way, from increased cholesterol drug usage. An estimated 11 million Americans take statins. The new guidelines are likely to make that number go a lot higher and those already on statins are likely to have their doses increased.

Merrill Goozner of the Center for Science and the Public Interest said, “It's outrageous they didn't provide disclosure of the conflicts of interest.” He said it doesn't mean that their research is wrong but that doctors and the public have a need to know “that the people who are giving you this advice have their research funded by a party who has a self interest in the outcome of that research.”

After consumer groups like the Center for Science and the Public Interest attacked the report as tainted with conflicts of interest, the authors of the study, as well as the National Institutes of Health, conceded the ties to the drug industry. But the authors defended the new guidelines as based on sound science.

Dr. James Cleeland, coordinator of the National Cholesterol Education Program, which oversaw the recommendations, said: “If you excluded all the people who have any financial connections to industry, you'd exclude all the people who are most expert.. The recommendations passed muster as they went through layers and layers of review.”

Dr. Gary Palmer, a vice president of the cardiovascular medical group at Pfizer, which makes Lipitor – the number one statin seller – also dismissed the criticism. He said, “We have over 70 million patient-years of experience worldwide, so we're able to comment on our efficacy and safety profile with confidence.”

That may be so, but statins have also gained wide usage in a relatively short time. They have come into use too recently for longitudinal studies to have been completed on possible longterm side effects. The science on which statin use – and now recommendations for increased usage – is based might more accurately be described not as sound but as on probation pending longterm clinical confirmation.

It is also a science in which the interests of patients are not necessarily the main driving force. Clinical studies on new and existing drugs are routinely funded by their manufacturers, as were the studies that led to this most recent recommendation for more aggressive LDL cholesterol standards.

Finally, it is not science based on my body. It is based on studying the reactions of large numbers of other bodies under controlled conditions, taking great pains to see that some are given a certain treatment and some a placebo. Patient reactions are observed and the results are then quantified in percentages. In medicine, new knowledge marches to the steady drumbeat of dry statistics.

But I am not a statistic. My body -- though it has a head, arms, legs, internal organs, and the same basic operating system of every human body – is not exactly like the bodies used in these studies. Not only is it not exactly the same, but it may be unique in important ways.

In my case, 68 years of individualized living, food choices, environmental exposure, physical and emotional experiences, and wear and tear are reflected in my physical plant – for good or for ill. And the sum total of all this customized living makes me different, perhaps very different, from the people in those studies.

Bottom line: the clinical studies on which doctors must rely to treat the patient do not reflect these individual differences. Therefore drugs introduced as a result of these studies are not necessarily a good idea for everybody, especially when longterm effects are unknown.

Dr. Marelli was thirty minutes late for his appointment to discuss my cholesterol level. He has a very busy practrice and for years has not accepted new patients. He came into the examination room carrying his trusty manila folder and apologizing for being late.

“Thank you for your letter about my cholesterol,” I said. “It was a wake-up call. There's nothing like seeing it in writing to make you realize that something is serious.”

“What do you think?”

Dr. Marelli is patient-centered and a listener.

“I think I would like to avoid the statins if at all possible. The only risk factors I have for coronary disease are my age and high cholesterol. I don't smoke. I'm not a diabetic. I'm not obese. My blood pressure is good. I'm physically active. There's no heart disease in my family history. I have four healthy younger siblings, all in their sixties and no heart disease."

Dr. Marelli nodded.

“In fact, thanks to your letter, I have made diet changes. I've stopped drinking coffee. I used to drink seven or eight cups a day, with cream in each. Now I drink green tea. Every morning I used to have two English muffins slathered with butter and jelly. Now I have one slice of whole wheat toast with a brush of butter and no jelly. At night I used to have pie or cookies with my coffee. Now I have green tree and a little nonfat yogurt with blueberries or strawberries.”

“I see that your weight is down.”

“Yes. I've lost ten pounds, from 198 to 188. Little changes in something you eat every day make a big difference.”

“Good, very good.”

“The other thing that bothers me about the statins are the side effects. They are so new that there hasn't been enough time for any longterm studies on these side effects. Who knows what the side effects will turn out to be.”

“That's true. The statins are only about ten years old.”

“Also, these new aggressive cholesterol guidelines are riddled with conflicts of interest. I did a little research and found out that eight of the nine authors of the new guidelines are being paid by the drug manufacturers who will benefit from increased statin usage. It gives me a queasy feeling in my stomach.”

“I don't disagree with anything you said. If I did, I would say so. I think your position is perfectly reasonable. I also think that making changes in your diet and getting your weight down are important and can help get your cholesterol down. I would suggest that you keep working on that and we'll test you again in December and see where we are. You feel okay about that?”

“Yes, perfect.”

That discussion took place two years ago. Since then I have lost ten more pounds (yea!) and cut down on donuts, candy, and ice cream, though I went back to drinking coffee. But a funny thing happened. My cholesterol count remained almost exactly the same.

So last week, ( May 24, 2006)I was back in Dr. Marelli's office and showed him the VA lab results and Dr. Santora's note. "She thinks the time has come for me to go on a statin. At the VA, it is Zocor."

“What do you think?” he said, looking over the VA lab results.

As always, Dr. Marelli lets the patient take the lead.

"I have to tell you, I still feel the same. All those tests I had in Seattle a year ago (following a near-fainting incident) showed no blockage. The scan of the carotids was clear. The echocardiogram showed no blockage or obstruction of blood flow to the heart. The brain scan was completely normal. I just think my body produces more cholesterol than it needs."

"That is possible."

"I mean I have always had a healthy diet but in the last year I ate super healthy, just about cutting out anything fatty, and lost almost twenty pounds. And what happens? My cholesterol remains the same. Plus it's not super high. If it were, I might go for a statin."

"Also, I see that although your glucose is slightly high it is more than offset by your jump in HDL, or good cholesterol, from 42 to 53. This brings your ratio of down to 4.5. The ratio was 5.3 last time, a significant improvement."

"What if we hold off on the statin and retest in the fall? That'll give me a change to focus on it and we can look at it again then. Would you mind letting Dr. Santora know what we're doing?"

"Yes, I'll be talking to her. Maybe I'll write her an old-fashioned letter."

Finally, Dr. Marelli asked me to get up on the examination table. He listened to my heart. He took my pulse. It was 70. He took my blood pressure. It was 120/78.

"Good."

He did a rectal exam. "No blood. Have a great Memorial Day weekend."

And, with a smile, he was out the door.

So long and keep moving.