Guidelines are Not Commandments
My recent astronaut physical at Johnson Space Center is an excellent starting point for this article. I have no problem with the concept of periodic health checkups but I often have a huge problem with how doctors interpret the results. Somewhere in my past I read, "Beware the counsel of someone who stands to profit from it".
Been there and done that pretty well describes my past in medicine. For ten years I was a USAF flight surgeon dispensing care to flyers and their dependents, a slice of humanity remarkably close in age distribution to what I would experience later with my 23 years of civilian family practice.
Almost all military air bases are also retirement centers giving me the full age spectrum from children to seniors. I say this only to support that I might know what I am talking about. I am also board certified in Preventive Medicine so if anyone should be supportive of the concept of finding and treating problems early, it should be me.
It was 1999 when my cholesterol finally had climbed to the point where the NASA physicians finally found something to treat. I had this new disease called hypercholesterolemia.
For decades doctors had been brainwashed about how bad cholesterol was. The Framingham data appeared to prove conclusively that for every 2 points you lowered your cholesterol you gained a year of life. In my practice I had aggressively treated only the really high cases but the guidelines were changing every year.
Now I was retired from medicine and it was my turn to be the patient. I have to admit I was reasonably enthusiastic about finally treating my slowly rising cholesterol, 270 was high enough for my NASA Docs and high enough for me then.
Within a few weeks I had an incredible amnesia episode called transient global amnesia for 6 hours and the following year when I was rechallenged with only half the previous dose of the same statin I became a 13 year old high school student for a harrowing 12 hours.
Most of you have heard all this before but those episodes are what started off my research on this new disease called hypercholesterolemia and the statin drugs used to treat it. Along the way I have picked up some different thoughts about glucose and blood pressure treatment as well.
This trend for close cholesterol control has many causes. In addition to Ancel Keyes' 'selective presentation' of cholesterol data, they include economic gain from the drug industry, food establishment and medical community, over-enthusiastic and uncritical interpretation of various guidelines and the relentless pressure from the drug companies.
We wondered about the validity of cholesterol causation when some 50% of new myocardial infarctions were occurring in people having perfectly 'normal' cholesterol values. And we wondered when longitudinal studies showed statin benefit even when the cholesterol values failed to be lower and sometimes even increased. Then we learned that statins work by inhibition of inflammation and cholesterol appears irrelevant to the atherosclerotic process. Our 40 years of blind advocacy to cholesterol causation was wrong.
And what about type 2 diabetics? I know now that some 90% of these can be treated by aggressive dietary means alone, the so-called protein augmented diet - basically eradicate all simple carbohydrates. Most of these people have more weight than they need and would gain additional benefit from slow weight reduction. I see no need for expensive glucose monitoring equipment in this group and the use of oral agents. We are wasting time and money treating these people as if they are really sick when all they need is dietary adherance, nothing more. If despite all this, repeat office visits show they still have grossly abnormal sugars, then they are type one diabetics, not two and should be on insulin.
And the present emphasis on blood pressure is a disgraceful exhibition of patient recruitment. Generally your blood pressure is taken while sitting with no consideration of state of mind. If you remind them that your mental state can cause a greater blood pressure response than the 240/125 of a cold pressure test, your words are unheard.
And the blood pressure guidelines have been reset downward every few years with huge Big Pharma posters on the walls depicting damage to your arteries from an 88 diastolic compared with 80 or of a systolic above 130, with no regard for normal age changes dictated by physiologic changes in the character of your blood vessel walls or capillary beds.
If one questions the accuracy of such a blood pressure value, the immediate reaction is to schedule you for a 24 hour blood pressure monitoring and likely a screening blood test battery and routine ECG as well. Never will they simply place you in a recumbent position and get your pressure after a 5 or 10 minute rest period. That simply is not (can I say this?) cost-effective - they might have to send 80% of their patients home, as normal.
Once the data is collected you will be placed on the MD's favorite medicine and checked again in one month. During this interval no one knows what response you have had, if any. That will come at your one month check, when adjustments will be made and you will be scheduled for another one month check.
With any luck your blood pressure will be brought down to the new guidelines within 6 months or so but then, so what? What benefit has this new pressure level really given you. Your 92 diastolic is now 82. Your systolic is now 135 not 145 and you don't feel nearly as well with chronic fatigue and serious ED and a few other things you would rather not talk about and you or your insurance company have already spent some unholy amount of money and will continue to do so until the end.
I have many problems with my personal experience in this regard and if I had a chance to replay my 23 years of family medicine, I would do it much differently.
Duane Graveline MD MPH
Former USAF Flight Surgeon
Former NASA Astronaut
Retired Family Doctor