Shared Decision Making

In an era where there are so many options in the medical field, having the opportunity for shared decision making is more important than ever. Shared decision making is when a doctor and patient decide together on what needs to be done next. This contrasts with the more traditional practice of medicine in the 19th and 20th centuries, where the health care providers had the knowledge and dictated to the patients and their families of what needed to be done. Shared decision making is important when more than one option is being presented and it’s not 100% clear on what needs to be done. In a more “clear cut” situation, the role of shared decision making is less pronounced. For example, a young person comes in with acute appendicitis. We know that if we don’t operate and remove the appendix quickly, it can burst, cause peritonitis and ultimately lead to death. We wouldn’t converse about it for an hour with the patient and his family; we would say that this is what needs to be done and this is what we are going to do. Another common case (that I have often experienced as a cardiologist) is when someone is having a heart attack. We know that it’s important to move quickly and take care of the situation, and giving a variety of options is not the best use of time. 

In instances that have more than one option and are not as acute (or urgent), shared decision making is a very ethical option and practice with most physicians. Here’s an example of how this tends to play out: say we have a patient who comes in for an appointment. She feels fine, and has no symptoms of an impending heart attack or stroke, but is considered high risk. As a doctor, I offer the option of prescribing a statin (which lowers cholesterol). These medications have been widely used since the 1980s and have been credited for cutting the number of heart attacks in half. They have been very powerful and useful, but they need to be taken on a daily basis. While they are generally safe to use, it’s important to remember that there are no medications without side effects. Statins are not “muscle friendly”, and approximately 1 in 5 patients develops muscle aches while taking this medication. This is not life-threatening, but it can inhibit daily activities. It becomes a back and forth discussion that takes time and effort from both the patient and the doctor. Of course, it is much easier for a doctor to say “here is your prescription, take this daily and come back in two months so I can check your cholesterol levels”. But the approach where the physician invites the patient to make decisions together based on the patient’s comfort level can be extremely beneficial. On one hand, we want to educate the patient on what we think is best; but on the other hand, we want him to be able to follow through with that decision. 

Shared decision making is a wonderful thing. It’s what patients deserve, but it takes time and a good attitude from both the patient and the physician. It takes the realization from the patient that there are no easy fixes in medicine and that prevention is the first line of defense. Does your doctor practice shared decision making? If you’re not sure, have a discussion with her and find what fits your needs the best.

To your health!
Dr. Anthony

If YOU know how your body works then…

“Know thyself “

• An ancient Greek aphorism that appeared in the Temple of Apollo in Delphi and was also inscribed-in Latin- over the Oracle’s door in the 1999 film “Matrix”.
• A maxim that has been attributed to ancient philosophers.
• Benjamin Franklin wrote: "There are three things extremely hard: steel, a diamond, and to know one's self."

Understanding our self, our feelings, our emotions, and what motivates our behavior is or should be an important goal in life. But what does it practically mean in the areas of health, wellness and prevention?

Knowing how our body works helps us understand what is important in keeping it healthy. In order to keep our arteries healthy and avoid heart attacks and stroke, for example, we should care about what we put into our mouth (diet), as this stuff is absorbed by our gut and enters the arteries and heart circulation, with potential salutary (fruits and vegetables filled with antioxidants) or destructive effects (frequent intake of red meat, fast food or cold cuts, filled with unhealthy fats). A healthy metabolism supports healthy arteries and its pillars are a combination of healthy diet and near-daily exercise, including both cardio- and muscle building through light weights. As another example, knowing that one of our immediate family members has type 2 diabetes means that our own pancreas cells that produce insulin are probably not very durable, so we better watch it and avoid becoming obese or eating too many cookies and desserts, or else!

Listen to your body -- once you know it well enough, you can pick up on its cues.

As it is true that no one can know our feelings or emotions better than ourselves, we can also be the best barometers of our physical health. Many times we know when something is “out of whack”, without being able to pinpoint to the exact, precise cause or details. Such knowledge or “gut feeling” may prompt us to make changes in our lifestyle or even visit our doctor.  Speaking about doctors, there must be the right “chemistry” between us and our health care provider.

There are several ways to advocate for yourself.

1. Ask question’s - It is ok to arrive at your doctor’s office with a list of questions.  The better organized you are they better it will be for you and your health care provider.

2. Second opinion - It may be appropriate to get a second opinion. That is why when it comes to YOUR health, you are allowed to talk to several medical professionals about the concerns you have.

3. Be honest - Feel comfortable telling the truth without hiding anything or fearing that will be chastised for doing so.  The old saying Honesty is the best Policy certainly applies here.

4. Not the Right Match - In case we sense that our doctor is not the right match, we should not hesitate to find another provider.

Knowing our body will help us shape and keep our healthiest version of ourselves. Whereas the general principles of a healthy lifestyle may be, more or less, the same for all of us, the details of how to get there are different. This should come as no surprise as no two individuals are the same, not even monozygotic twins.  We have recently spoken to a woman who joined a gym and felt pressured to take a yoga class, as her friends raved about it and she, herself read about its benefits. However, after trying it, she found that yoga was not for her. She did not enjoy it; she felt it was something like a chore she had to attend. As she was not getting the most out of it, she tried something else. She found that a toning class using light weights was more her style. What works for one person does not work for all.

We need not worry if we do not look like the supermodels in the magazines or that bodybuilder at the gym. Actually, this may be a good thing. Some supermodels smoke like a chimney, in order to control their appetite and eat less (smoking is worse than obesity) and many bodybuilders use anabolic steroid drugs that seriously undermine their health. Keep in mind that the weight we carry around our hips is not nearly as bad for our metabolism as our belly weight. In pursuit of a healthy diet, some may be able to follow a strict program and count calories, while others find it easier to just eat healthy. Remember that a diet is good only if we keep it in the long run. And that is okay to be different! If everyone was exactly the same - wouldn’t that make for a boring world?

Listen to your body and watch your body. If you see or notice changes, take action. In today’s busy society it is easy to put everyone else first: kids, spouse, job, even your pet! But YOU have to take care of YOU. Also, do not forget to reward yourself from time to time. Embrace your differences, and work to be the healthiest version of YOU that you can be!

Here’s to your Health!!

Dr. Anthony

Do you know what Statins are? If not, you should ….

Statins: the Pros and Cons of a Heavyweight

Statins are life saving medications, literally. In the fight against heart disease, they are credited with reversing the tide of rising heart attacks. Of course, the decline in smoking and better use of blood pressure medications has helped with the reduced rate of heart attacks. The good news is that, since 1996, for the first time in over a century, we have seen a decline in heart attacks by 40-percent.

Statins are a group of medications that lower the bad (LDL) cholesterol and reduce inflammation in our arteries. They help stabilize cholesterol plaques that frequently (and permanently) reside in our heart and brain arteries. Statins keep the blood flowing and reduce heart attacks and strokes by 30 to 40 percent.

Since statins are a true heavyweight champion of modern medicine, they are among the most widely prescribed medications in the US (almost 20 million patients use them). Although they generally have a very good safety track record, statins also have a dark side.

The greatest problem with statins is that they are not muscle friendly. About one in five statin users develops muscle aches, pains or stiffness that, although not life-threatening, can cause discomfort and suffering. To many affected statin users, these symptoms make the expected benefits not worthwhile. Other negative aspects of statin use are much more rare and include severe liver damage (one in a million), kidney failure (one in ten thousand), or type 2 diabetes (one in a thousand).

For some individuals healthy choices may include statins, on top of a  healthy lifestyle. The decision to start statins (and continue them for the rest of your life) should be based on your particular risk for developing heart attack or stroke. Individuals with the highest risk include (but are not limited to) those who have:

• already suffered a heart attack, a stroke or mini stroke
• undergone bypass surgery or stent placement
• either type 1 or type 2 diabetes
• an LDL cholesterol above 190 mg/dl.

As you discuss with your doctor whether statins are right for you, you need to weigh the good and the bad when it comes to the side effects of statins. You must consider how statins can help your arteries and prevent life-threatening conditions that may be points of no return, like heart attacks and strokes.

Keep in mind that doctors routinely check (through a simple blood test) for severe liver or muscle damage. They may also recommend over the counter supplements (like Coenzyme Q-10 or Vitamin D) that can protect against muscle aches. Doctors also warn their patients that, in case of severe muscle aches or dark-color urine, they should promptly stop taking statins.

The list of the currently available statin medications includes:

• Crestor (rosuvastatin)
• Lescol (fluvastatin)
• Lipitor (atorvastatin)
• Livalo (pitavastatin)
• Mevacor (lovastatin)
• Pravachol (pravastatin)
• Zocor (simvastatin).
• Advicor (lovastatin/niacin extended-release)
• Simcor (simvastatin/niacin extended-release)
• Vytorin (simvastatin/ezetimibe).

Good health to you!

Anthony Pothoulakis, MD, FACC