Acquitted of cholesterol guideline insubordination

A family physician in the northernmost part of the United States was acquitted last week of charges stemming from years of guideline insubordination.

Interviewed this weekend by members of the local press while he was cleaning the stall of his favorite horse, the silver-haired doctor declined making comparisons between the manure he was shoveling and the now-abandoned numeric cholesterol guidelines, and would not comment on his former accusers’ fall from their pedestals.

He made no reference to “Cholesterol Guidelines and the Bachelor with Platform Shoes,” the very first post on his anonymous blog: A Country Doctor Writes.

Instead, he turned philosophical.

“I remember the first cholesterol medication, Atromid,” he said. “It lowered cholesterol but still increased the risk of death by almost 50%. We should all have paid attention to that when it was taken off the market more than ten years ago. You could have satisfied the requirement to reach specific lipid targets with a dangerous drug like that, but not have helped a single patient by prescribing it. Right now, almost the same thing is happening with drugs like Zetia, Tricor and niacin.”

Opening a bag of clean pine shavings for the stall floor, the Swedish-born physician continued:

“Health care has changed from a profession to an industry, and the founding principles for physicians, like ‘First, do no harm,’ have lost their central place.”

“In Sweden,” he continued, “the oldest laws regulating the practice of medicine state that it is the physician’s duty to practice in accordance with ’science and time-tested experience.’ Cholesterol treatment is a good example of a practice that drifted into the realm of speculation instead of staying on firm scientific ground. Instead of waiting for outcomes data such as heart attack rates, doctors were more or less willingly jumping on the bandwagon, prescribing unproven and sometimes unsafe medications because pseudoscience extrapolated from surrogate endpoints like LDL and CRP levels.”

“So what did you do when that was the guideline you were working under?” asked one of the reporters.

“I told my patients what the science told us and what the guidelines recommended, and I had the patient make an informed decision, which is pretty much what our new marching orders are.”

“So, you are pleased with the new guidelines?”

The bespectacled 60-year-old physician sighed.

“I am relieved and saddened at the same time,” he answered. “I am relieved we aren’t told to do things that have no basis in science, but I am sad that there has to be guidelines that essentially say ’help the patient understand what we know about heart disease prevention and help them make an informed decision’ — I mean, do we really need a guideline for something as basic as that? Isn’t that the way we are supposed to work anyway?”

He hesitated, then added: “Sometimes clinical guidelines remind me of overly basic consumer information. There is a Swedish joke about one of their neighboring countries. Supposedly glass bottles there are inscribed on the bottom with the words, ‘open at other end.’ But of course Norwegians aren’t really that silly, and doctors aren’t either. We’re supposed to be critically thinking professionals, aren’t we?”

With that, he hoisted the last bags of horse manure over his shoulders and brought them down to the dumpster to be hauled off the property.

“Fly and odor control — keep the manure away from the barn,” he explained.

On the side of the green four square yard dumpster was a warning sign: Do not play on or in.

“I guess everybody has guidelines these days” were his parting words to the reporters before he walked off with a spring in his step and disappeared behind the door of his little red farmhouse.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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  • Suzi Q 38

    He’s got my “vote.”

  • Ron Smith

    Hi, Country Doc.

    Thanks for a great article.Here is a general response to guidelines as a result.

    Re: “He hesitated, then added: “Sometimes clinical guidelines remind me of overly basic consumer information. There is a Swedish joke about one of their neighboring countries. Supposedly glass bottles there are inscribed on the bottom with the words, ‘open at other end.’ But of course Norwegians aren’t really that silly, and doctors aren’t either. We’re supposed to be critically thinking professionals, aren’t we?”

    This reminds me of the sleeping guidelines for newborns based on 5 studies, none of which were done here in the US, some dozen or more years ago.

    The purpose of the guidelines were to once and for all stop Sudden Infant Death Syndrome. Of course it didn’t stop SIDS. And I have to give the history about the studies and my strong suspicion that sleeping position has nothing to do with SIDS.

    What the guidelines have managed to do is create a new medical industry to treat the plagiocephaly that has become rampant in the first six months. The orthotic and medical costs of correcting that condition could have been better spent on more significant studies such as the possibility that SIDS is the result of Long QT Syndrome, or something akin to it.

    Does anyone remember the same thing we went through with the fluoridated vitamin recommendations some 25+ years ago? Now what’s making the rounds is the recommendation for extra Vitamin D in children over two months. Recently it was determined that the way we measure Vitamin D gives different results for blacks and whites because of a genetic difference. Does this alter the results of the study from whence that recommendation arose?

    But I also wonder about that when I think of my own experience after I replaced my small $3000 hemoglobin instrument with a full $18,000 CBC analyzer. Since then I’ve realized how that we have over treated children at 9 months for a factitiously low hemoglobin and hematocrit.

    The latest one I heard at a conference was the recommendation that children not be given antipyretics before or 24 hours or so after vaccination because it reduces the immunologic take rate. This was based on one study in 2009 that I don’t think as been repeated.

    What I’ve learned over time is that just because things are published in print or otherwise, doesn’t make them true. Think of the MMR and autism debacle for which its author has been completely discredited and from which the medical community received a resounding retraction from the Lancet.

    Listen, colleagues, if it sounds a little too good or a little too simple then a healthy dose of skepticism may well be in order. That’s why we have repeat studies to back up medical claims of ‘discovery.’

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • drjoekosterich

    Great article. Very astute observations and comments

  • http://briarcroft.wordpress.com/ Emily Gibson

    So much wisdom here, my country colleague. There are days when cleaning the barn of accumulations of horse manure makes so much more sense than the nonsense the health care industry wants us to perpetrate on our unsuspecting patients. Give me a pitchfork any day…