Is Marcus Welby, MD Resuscitatable?

Over the last decade or so doctors have felt their stature steadily slip away. Their significance has of course remained; without doctors healthcare would come to a screeching halt. Newly named “physician extenders” cannot do what most physicians can. They are simply not trained for the task. As important and passionate as they are in healthcare delivery, physician assistants and nurse practitioners possess just a small portion of the training required to become practicing MDs. Doctors often spend more than a decade after college training to a level required to deliver the most sophisticated and complex care. Many laypeople seem oblivious to this fact; some likely have intentionally blinded themselves to it. Physicians are “where the buck stops”. We are the CEOs of our practices, the generals if you will. Yet, the insidious degradation of doctors has led to a variety of deleterious and likely unintended forms of fallout. Most obvious is our title. Once called nothing but “doctor”, we are now dubbed, “health care practitioners”, “health care providers”, and most recently, “EPs, or eligible providers”. This fact may seem trivial, but its reverberations run deep. We have been equated to all others who treat patients – nurses, advanced nurse practitioners, physician assistants, medical assistants, and physical therapists…  Our distinction as leaders in patient care is being eroded. Imagine if the same were true in the military – no more generals, colonels, sergeants or the like. Just “military personnel.” Or, what if we applied the same rule to government – no more senators, congressmen, mayors, governors, or even presidents. Simply “public servants.” There is no doubt such an arrangement would be justifiably unacceptable to those involved. These two systems, like the medical system, would crumble absent titular distinctions. But the damage to medicine dives far deeper than this.

We have just witnessed the release of Medicare payment information for each doctor in the US. Soon the “Sunshine Act” will also become a reality. The amount of money paid to highly specialized doctors to deliver educational talks will become fodder for the public to muse. The lunches, coffee, or even requested medical articles brought to offices by pharmaceutical representatives will soon be open for public scrutiny. Total transparency is a beautiful concept for an ideal world. In such a world everyone would love and respect each other; no one would compete with another; and all would be subject to the same laws and regulations. Such is not the case of course. Do you know what your attorney earned last year, or how much money your grocery store pays for its eggs?  Of course not! We live in a land that purportedly permits freedom to compete. Competition requires a high degree of privacy. Our country was in fact built upon such a premise. How can one dermatologist fairly compete with another if confidential internal financial records become open access? There are far too many financial ramifications to explore in this short blog, but the adverse fallout from such transparency will be pervasive. And it will most certainly include a drastic decline in the education of practicing doctors. That of course will translate into deteriorating quality of care.

The most consequential outcome of medicine’s recent evolution will undoubtedly be decay in heath care delivery. Marcus Welby, MD was an excellent television show because it depicted a dedicated, diligent, assiduous, committed physician. Dr. Welby captured the hearts of viewers because he loved his patients and they loved him. He was honored, respected, appreciated, and yes, even well compensated. The reality, for better or for worse, is that doctors are human beings. They crave recognition and appreciation for their sacrifices. Absent such recognition, and assuming a continued decline in reimbursement as well as the massive increase in federal regulations, the Marcus Welby, MDs of this nation will become extinct. At times this augury feels inevitable. At other times there is hope. Unfortunately however, until the general population recognizes the physician resource it is rapidly losing, I believe the more pessimistic outlook will prevail. Marcus Welby, MD may truly be unresuscitatable.

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ConsumerLab Approval: A Brief Boast about VitalOils1000

couple bike riding

I make it my practice not to blog about VitalRemedyMD or any of its products, but this week demands a self-promoting shout-out. VitalRemedyMD is a company I started over ten years ago. It is now owned and operated by my wife (Laura Baum – also an MD). VitalOils1000 was created about six years back as the first and only enteric-coated fish oil pill to contain a full 1,000 mg of combined DHA and EPA. Thus, VitalOils1000 was the first omega-3 fish oil to meet the American Heart Association recommendation for individuals with cardiovascular disease in just one pill. This fact holds true even when considering prescription fish oil.

Yesterday we made the grade again. On April 6th, the preeminent watchdog of the nutritional supplement world, released their every-other-year study of omega-3 fish oil products. Once again VitalOils1000 was “approved.” This year, in addition to “proving” our purification, concentration, and quality of enteric coating, we were also tested for PCBs and Dioxins. We were one of only two products tested in this comprehensive fashion, and we “passed” this important criterion as well. Our purification process of supercritical fluid technology enables us to achieve these exceptionally high standards for safety and purity.  There is so much confusion about omega-3 products that I felt compelled to write about our continued success with VitalOils1000. Needless to say, I am very proud. Thank you for permitting me a moment to boast.

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The Emory Symposium on Coronary Atherosclerosis Prevention & Education

Here’s a shoutout to my friend and colleague, Dr. Larry Sperling.

The renowned Emory Heart Center of the Emory University School of Medicine will be holding its 13th annual Emory Symposium on Coronary Atherosclerosis Prevention & Education June 4-8, 2014. This year’s event, which is titled “Emory Escape 2014“, will be held at the OMNI Amelia Plantation on lovely Amelia Island, Florida..

The challenge
Cardiovascular disease remains the number one cause of death of men and women in the United States, and is a major cause of disability. The American Heart Association has a stated goal to reduce deaths from cardiovascular disease and stroke by 20% by 2020. In order to achieve this goal, physicians and clinicians must gain the knowledge, skill and resources to integrate the latest research and clinical guidelines in the context of their own practice.

The event
At ESCAPE attendees will hear nationally renowned speakers discuss the recently released, 2013 ACC/AHA guidelines on hypertension, blood cholesterol, obesity, healthy living and risk assessment. In addition, there will be one day dedicated to lectures on CV prevention in “special population” patients, including patients with HIV, PCOS, breast cancer, connective tissue disease and post renal transplant. There will also be lectures on electrophysiology, interventional cardiology, heart failure, tobacco cessation, and women’s heart health. This conference will close the knowledge gaps between national guideline goals, practice, and research. Physicians and clinicians will have the opportunity to discuss with the speakers and other attendees how these principles can be applied to patient care in the context of their own practice in order to decrease cardiovascular disease risk.

In addition to the extensive educational curriculum, events will include pre-meeting workshops,  an attendee and spouse session and a family social and cookout.

Who should attend
Cardiologists, internists, family practitioners, emergency medical personnel, primary care physicians and nurses can all benefit from this conference.

Register online at – registration deadline May 4th

Call 1-800-THE-OMNI to make room reservations.

Hosted by: Emory University School of Medicine Department of Medicine Division of Cardiology.

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The Great FH Debate: Reinforcing the fact that “Time is Plaque”

Currently a debate rages in the world of Familial Hypercholesterolemia (FH).  Old school thinking is that this lipid disorder – typically caused by a mutation in one of three genes – is exceedingly rare. The initial teaching stated that the homozygous form (two mutations – one from mother and one from father, HoFH) occurs at a rate of one in a million, while the heterozygous form (one mutation from just one parent, HeFH) occurs at a rate of one in 500. Recent explosions in not only genetics, but also the acquisition of large volumes of patient data have put this prior supposition in question. Now, a recent study published in the European Heart Journal by Sjouke et al truly proves that we have grossly underestimated the prevalence of FH. Examining over 100,000 patients who were referred for genetic analysis, the authors found 74 patients with clinically significant mutations consistent with the homozygous form of FH (HoFH). Being abundantly cautious in their interpretation of data, the authors pared the number down to just 45, from which they conducted a mathematical calculation of the prevalence of FH. (Their minimalist rationale is beyond the scope of this blog, but suffice it to say that had they included all patients, the disease prevalence would be far greater). Their restrained assessment revealed the prevalence of HoFH in an unselected population to be 1 in about 300,000 while the prevalence of HeFH, 1 in 244.

Perhaps more striking and even earthshattering is what the authors discovered about the wide range of HoFH LDL-C levels. Older belief systems had maintained that the LDL-C in untreated HoFH should always exceed about 450 mg/dL. In their comprehensive and novel analysis however, the authors discovered untreated HoFH patients with LDL-C levels as low as 170 mg/dL. 170 mg/dL overlaps not only the HeFH population, but the non-FH population as well. The bottom line here once again is that as in diagnosing all other diseases, clinicians must maintain open minds when diagnosing FH. When considering FH, we must always look for a family history of premature vascular disease, very high LDL-C levels, signs of the disorder on physical examination, and the presence of aggressive coronary artery or cerebro-vascular disease in the patient we are evaluating. Most important is for all clinicians to keep FH on the tips of our tongues. Without considering the diagnosis, we will never make it. And without making the diagnosis, we will never treat it. Early treatment can be life saving so early diagnosis is of course paramount. In no other lipid disorder is the concept that “Time is Plaque” more apparent. FH patients bathe in their own LDL-C in utero and beyond. The longer they remain untreated the worse they do. So let’s think of FH and treat it when we see it. By doing so we can hope to prolong the lives of more than a million people right here in the USA.

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LDL Cholesterol: Sometimes the Simple Questions are the Most Revealing

Recently, after participating in a meeting attended by a few high-powered CVD researchers I returned home plagued by a most simplistic question: What is the purpose of LDL cholesterol? Please refrain from bursting into uncontrollable spasms of laughter; I am well aware that as a clinical lipidologist I never imagined such a question would have the capacity to keep me up at night. And yet it did. And so I called my faithful counsel, upon whom I can always rely to extricate me from any lipid conundrum. Tom Dayspring responded to my query unflustered, promptly sending me articles to help me find my way. I read them and this is what I realized. LDL cholesterol is essentially garbage. The story goes something like this.

Our livers manufacture triglyceride – (TG) and cholesterol – containing lipoprotein particles called VLDLs. This is old news. VLDL contains about 80% TG and 20% cholesterol. Its purpose is to nourish our organs. As these particles pass through the tiny capillaries of our various organs, enzymes called Lipoprotein Lipase (LPL) snip the fatty acids from their TG backbone, Glycerol. This too is old news. These released fatty acids are either used for energy or stored by our organs for future needs. The shrunken down VLDL particles, devoid of most of their TG energy content, are now re-dubbed. They have become LDL particles. They are cholesterol-rich. Their content represents what most people speak about after visiting their doctors – LDL-C or LDL cholesterol. Here’s where it gets intriguing. Although any lipid specialist can tell you that every single cell in our body has the capacity to make cholesterol, most believe that the cholesterol contained in LDL particles has some greater purpose. Our cells however do not need the cholesterol contained in LDL particles; nonetheless, most of us believe they use it. This belief is untrue. LDL-C is actually not utilized to any significant degree by any organ systems in human beings. Other animals may use some of it here and there, but not us. We just don’t need it. In fact, the goal of LDL particles is to get to the liver ASAP for disposal. Otherwise, these particles tend to land in places where we do not want or need them, our blood vessel walls to be more specific. You know how that story goes – plaque forms; plaque ruptures; heart attacks or strokes ensue…

So when people tell you not to worry about your high LDL-C levels, please reconsider abandoning your doctor’s LDL-C-lowering advice. And definitely don’t worry that low LDL-C levels will deprive your cells of their much-needed cholesterol. It won’t. Your cells are quite capable of making their own supply of cholesterol. On a somewhat esoteric note, it is true that the surface of LDL particles transports some vital nutrients around the body (vitamin E for one). This fact however does not imply that more LDL is better than less. We need just a tiny bit for non-cholesterol purposes. Excess does us no good, and in truth it does us a good deal of harm.

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Two Recent Supplement Studies Merit Mentioning – Vitamin D and Glucosamine Sulfate

Two recent trials addressing commonly used supplements are worth noting as they exemplify pertinent and prevalent issues facing physicians and patients every day. One deals with vitamin D, the other with Glucosamine Sulfate.

The vitamin D study, published out of the University of California San Diego in Anticancer Research, is entitled “Meta-analysis of Vitamin D Sufficiency for Improving Survival of Patients with Breast Cancer.” In the trial, patients with the highest vitamin D levels had the best outcomes. This group had an average 25, OH-Vitamin D level of 30 ng/ml. The initiated should instantly recognize that this number lies on the lowest edge of a normal range for vitamin D. Yet, the press reported the following, “High vitamin D levels may increase breast cancer survival.” So what might an uninformed reader assume? Take large quantities of vitamin D to shield you from breast cancer, of course. This clearly is not at all what the study concluded. A more appropriate title for the press might have been, “Very low vitamin D levels associated with worse breast cancer outcomes.” Our takeaway message is probably to avoid very low levels of D. But, we should in no way infer that very high D levels protect us from cancer (or anything else for that matter). Some trials even suggest that very high D levels might be dangerous. Once again the ideal reaction to this single piece of evidence is simply to speak with your doctor. Have your vitamin D tested. If your level is very low, supplementation is likely in order. If your level is normal, probably no further action need be taken. The key though is not to act alone. This type of discussion is another opportunity to engage your physician and help develop your own brand of personalized medicine.

The second trial evaluated what was described by the press as a “new form of Glucosamine” – Glucosamine Sulfate. First, please understand that Glucosamine Sulfate has been available for decades. Being more costly than its counterpart, Glucosamine HCL, it is typically found in only superior products. For me the interesting aspect of this trial (published in The Annals of Rheumatologic Disease) is that in a double blind placebo controlled fashion (the purported king of clinical trials) Glucosamine Sulfate was shown to statistically significantly decrease joint space narrowing over a two-year follow-up period. Older studies had similar findings, and consequently for the past ten years I’ve recommended a Glucosamine Sulfate-containing joint product that I formulated for VitalRemedyMD called JointFormula (catchy name I know). I’ve received nearly universal patient reports of improvement in joint discomfort. Anecdotally, results have been most dramatic in the hands and knees. Many of those who take JointFormula have written notes of gratitude, thanking us for helping them avoid knee replacement surgery. Yet, some trials other than the above-mentioned have “proved” the worthlessness of Glucosamine. How do we explain this to our grateful patients? Placebo effect is surely a possibility. It is also possible that what works in one person might fail in another. And, we must always acknowledge that clinical trials are not the final word. We see enough discordance of conclusions among the trials; so by this observation alone we should know that trials are hardly ever truly “conclusive.” The lesson from this study is that there will always be conflicting results among clinical trials. The ultimate decisions regarding patient care always reside between patient and doctor. Trial results help guide doctors; they should not shackle them. And, patients should not be made to feel foolish for their beliefs, nor should doctors be made to feel unscientific for theirs. Instead, doctors need to continue “practicing” medicine as best as they can, and patients must remain their own most potent advocates for health and wellness.

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Omega-3 Fish Oils – Misleading and Erroneous Interpretations of Scientific Studies Can Cause Harm

Recent statistics demonstrate a small but pervasive decline in national sales of fish oil supplements. Before I continue, let me make it clear that I have a bias here. In 2007 I formulated VitalOils1000, the first omega-3 fish oil carefully and uncompromisingly concentrated and purified so as to enable the American Heart Association’s recommended 1,000 mg of combined EPA and DHA to be placed in a single enteric coated soft gel.

Now, seven years later, VitalOils1000 still stands alone among a sea of fish oil choices (sorry; I couldn’t resist). Needless to say, I am very proud of that accomplishment. So my conflict is clear; I want people to take VitalOils1000. I believe it’s good for them. In fact – that’s why I designed it. So I am disturbed by the decline in people’s consumption of fish oils. Though the “business” ramification of this decline bothers me, I am far more disturbed by its root cause. Falsely frightened people have crumbled under the illusory conclusions of a few poorly constructed trials and the even-more-poorly constructed conclusions derived by “critics” of these trials.

Consider first the fact that four decades of research spanning bedside to bench and back again have demonstrated the sweeping benefits of the omega-3 fatty acids DHA and EPA – fish oil’s “active ingredients”. That’s forty years of thousands of brilliant minds examining the omega-3 issue from a multitude of vantage points. Forty years of overwhelmingly positive conclusions! Then come a few – and I mean a few – poorly designed studies with at times truly ridiculous conclusions. As with most other aspects of news reporting, the negative draws more readers and listeners than the positive. And so the media ran with the story. Some doctors even jumped on the bandwagon. “Fish oil is not what we thought it was,” they concluded. In response, omega-3 experts from around the world voiced their discontent. But their voices were muted as they failed to resonate with fear. The scientists and doctors spoke with authority and knowledge, devoid of histrionics. And so their side of the story didn’t sell newspapers or airtime. The outcome we now witness is that some people prematurely “drank the media cool aide”. They stopped their fish oils.

The problem is that I and many others in this field are left with the great concern that these individuals have left themselves less well protected against a host of disorders than they had been while taking fish oils. Unless they’ve dramatically increased their fatty fish consumption, they have certainly placed themselves in a relative omega-3 deficient state. Think of this: the average American consumes about 100 mg of combined EPA and DHA daily while the average Japanese consumes eight times this amount. And the Japanese have far lower rates of heart disease and prostate cancer than do Americans. Yet, the scant research behind the omega-3 fear mongering cited concerns about the ineffectiveness of omega-3s in cardiovascular disease as well as the possibility of omega-3s predisposing to prostate cancer.

There are many other plausible explanations for these inconclusive trials (see my blog Throwing the fish out with the fish water is however not called for. And so my conclusion here is once again to read the primary research. Do you own homework – though it may be hard – and decide for yourself what you think is best. If you need help evaluating the literature, look for the opinions of those who are true leaders in this field – William Harris, PhD, Bruce Holub, PhD, Tom Brenna, PhD, Susan Carlson, PhD (not the owner of the supplement company), and Kevin Maki, PhD for starters. There are plenty of others but be sure to listen to the experts.

Sadly we can no longer rely upon the media’s “Medical Experts” to be our source of scientific veracity. They are too busy, and often forced to weigh in on disciplines far removed from their particular areas of expertise. They cannot possibly be expected to know everything about every medical field. I am sorry to leave you with the task of “doing your own homework”, but nowadays it is something we must all become accustomed to do.

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February 28 is “Rare Disease Day” – FH is a Rare Disease That’s Just Not That Rare

Familial Hypercholesterolemia (FH) is a genetic disorder of LDL cholesterol handling which can lead to heart attack and stroke at very young ages. You may be shocked to learn that afflicted children as young as four years old have required bypass surgery or even perished from heart attacks. More surprising still is the fact that we now recognize that FH is far more common than previously believed. Some studies indicate that one in 200 people has a “milder” form of the disease, while one in 160,000 suffers from its most severe variant. It’s all FH though, and even in mild cases the risk of heart attack can be 20 times that of a “normal” individual.cholesterol meter Heart attacks in such cases occur much earlier in life than would ordinarily be anticipated. Here’s an example to which everyone can relate. 20% of patients who have heart attacks under the age of 45 have FH. Consider all the young people you know who’ve had heart attacks. One fifth of them probably have this genetic disorder. That is a huge number. The most recent estimate puts the number of FH patients in the US at 1 to 2 million. So that is certainly not rare! The number of extraordinarily severe cases is probably between 2 and 3 thousand, qualifying for the definition of a rare disease – being fewer than 200,000 in the US. Distressingly, only about 10% of FH patients have been identified as having the disease. That leaves 90% unrecognized, undertreated, and at great risk. We must change this pattern.

It is imperative on this Rare Disease Day that we all do our part to spread the word about FH. If you or someone you love has an LDL-C greater than 190 mg/dL you very likely bear this genetic malady. That means every one of your first-degree relatives – parents, siblings, and yes, even your children – has at least a 50% chance of also having the disease. Early treatment is key to improving outcomes. That’s why we recommend all children with a family history of premature heart disease or very high LDL cholesterol have their initial cholesterol level checked at the age of 2. By identifying family members with FH we can then treat them accordingly. Early recognition saves lives, sparing families the agony of losing a young, vibrant relative in the prime of her life. The good news is that there is much we can offer patients with FH. Novel medications and procedures such as LDL apheresis can dramatically lower LDL levels.

To learn more about such treatment strategies, please visit the FH Foundation at  If you believe you might have FH, please join our National Registry, the CASCADE FH Registry and become one of the many people who will help us curtail the terrible toll FH often takes. We look forward to hearing from you!

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The Truth about Truth in Medicine

I have read one too many blogs that speak about the “Truth” in one area of medicine or another. As long as such blogs and news reports and even scientific journals perpetuate the notion that in Medicine we have the capacity to know the “Truth” we will continue to have unhappy patients and argumentative doctors. Sadly I have not yet met a man or woman in the sciences who has conversed with god about medical issues (or any other issues, for that matter). Until such time as we actually do find a way to communicate with “the big guy” we must refrain from bolstering our beliefs and contentions into the realm of the absolute. I have stated this before but I believe it requires repeating: Medicine is a process. We are continually learning, creating novel theories and abandoning old beliefs. One day we might be sure of something and the next day we laugh to ourselves as we learn how wrong we were. On a personal note, I spend a great deal of time exploring a variety of health-related issues. My studies often take me to the depths of cell biology and molecular biology. I even find myself immersed in the swamps of genetics. Each time I explore these spheres I gain greater knowledge about that which I am studying. I also reinforce my understanding about how little we (and I) actually know. Even discoveries from our Nobel Laureates become démodé as new Nobel Laureates pave different pathways. This is simply the nature of science and medicine. And it is wonderful. So I implore you to help eradicate the misperception that in Science and Medicine we have access to truth. By so doing, you will help bring a tranquility to the practice of Medicine that will in turn make doctors and patients far more comfortable in their respective roles as teachers and students. We are not and should not be considered members of the clergy.

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Caramelized Brussel Sprouts

brussel sprouts12 ounces Brussels sprouts, halved
Course salt
Ground pepper
2 T Olive oil
1 T fresh lemon juice

In a large skillet, combine sprouts and 1/2 cup water. Bring to a simmer over medium heat. Cover; cook, stirring occasionally, until most of the water has evaporated and sprouts are crisp tender, about 5 minutes (add more water if skillet becomes dry before sprouts are done).

Increase heat to medium-high; add olive oil to pan. Continue to cook, uncovered, without stirring, until sprouts are golden brown on underside, about 5 minutes. Remove from heat. Stir in lemon juice; season with salt and pepper.

Brussels sprouts are delicious, high in fiber and like other vegetables in the cruciferous family, are rich in a wide variety of nutrients and antioxidants. You will know when Brussels sprouts are in season when they are readily available in the market; look for nice green, small-medium sized sprouts. To prepare for cooking, rinse in cold water and remove the ends with a paring knife. For maximum health benefits, do not overcook.

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