"My personal and professional journey to prevention took longer than my 3-year cardiology fellowship more than 25 years ago, but it changed the way I practice cardiology. Prevention is the missing component of cardiac care."  Rolando L. deGoma, MD

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Mentoring Others - Sharing and Passing On What Works

Practical Tips for Practicing Lipidologists and Preventive Cardiologists

Click the links below to quickly navigate to each section.

1. Getting yourself known in your community as a board certified lipidologist - putting all the pieces together.

2. EZ Daily LDL Chart Audit

3. EZ Cardiovascular Risk Assessment

4. How to use Cyber Dietitian.

5. CholesterolClinic.net listing

To go to NLA Interactive Forum, please click here.

 

Note: The downloads are intended for the personal use of NLA members only. If you are not a member yet, please visit www.lipid.org to find out more.

1. Getting yourself known in your community as a board certified lipidologist - putting all the pieces together.

There are several obstacles the all board certified practicing clinical lipidologists face and need to overcome. Patients have never heard of the word lipidology, much less, clinical lipidologist. For the very few who may know about lipidology and lipidologist, they have no idea where to find one close to or in their community. Another obstacle is that your colleagues believe that they can manage and get to goal their dyslipidemic patients as well as a board certified lipidologist. This may or may not be true in some cases. You need to find out yourself that you are, in fact, providing better care. How can non-specialists convince asymptomatic dyslipidemic patients to take medications that they think will cause liver and muscle damage? With much difficulty. If non-specialists can't convince these patients to take statin, can you?

 

Here are a few things you can do:

a. Door signage

Your door gives you free publicity, so make good use of it. It should convey your message to your existing patients, new patients and your colleagues in your building. I used the term "Cholesterol Clinic" instead of "Lipid Clinic" because it is self explanatory. "Preventive Cardiology" is also included in the name. Below my name is a descriptive phrase "Prevention, Diagnosis & Treatment of Heart Disease". I want and enjoy providing the whole spectrum of care - from prevention to diagnosis to treatment of heart disease. Because I have diagnosed and treated thousands of patients with heart disease before I got into aggressive prevention, I witnessed how heart attack and stroke impacted people's lives and families. Once I decided to pursue prevention, acquired the needed skills, developed a clinical management (ACCEPT) system and treated most patients to goal, the magnitude of combined event reduction in just 4 years surprised me. And after 9 years, events seemed to have essentially stopped, almost. You can cure a respiratory tract infection, not heart disease. But you can fight it and win in most cases. These experiences have made me even more determined to prevent as many as I can; and what can't be prevented, delay it for as long as possible.

b. New business card

Create a logo for your business card. Add your website and general e-mail address.  My card is busy for several reasons. Preventive Cardiology and Cholesterol Clinic are not synonymous and represent two different services. Some of my established patients expressed concern that I might abandon them as I become busier with prevention. My card needs to communicate that the new services are in addition, not in place of.

c. Waiting room posters or brochures

 

Use your waiting room to showcase what you do. Patients know very little about prevention. For the 15 minutes that patients are waiting to see you, they can look at these posters. If one catches their attention, they will get up from their seats and read it. Some might even ask you questions about what they just read. Your waiting room should give them a positive feeling that they came to the right place for prevention.

d. Community lecture program

 

Develop a portfolio of lectures for your community. Contact local civic groups and businesses. Learn to use powerpoint masterfully to create your own slides. Your lecture should educate as well as tell a story - the message you want to convey. Half of the slides I use for community lectures are the same slides I use for physician lectures. You will find some of them scattered in my website, especially in the Patient Mentoring section. It is a mistake not to include scientific data and clinical trials in your presentation. Explain it well using customized powerpoint slides - simply but accurately. Make it fun. Enjoy the interaction with your audience.

e. Website

 

It is 2010. An online presence is becoming more and more important. If you are perusing this webpage, then you can appreciate the power of a website to communicate ideas and connect people, anytime, any place. Some patients who found me through Google were willing to travel 100 miles to see me. I discouraged some and referred them to other NLA members who were closer.

f. Deliver superior treatment results and improved clinical outcomes for your patients compared to non-specialists.

I am a firm believer in self audit. The way I practice cardiology changed after participating in a physician compliance study in 2000. I thought that we (my group) treated all our CHD patients to LDL goal of less than 100. However, to my big surprise, the intention to treat every CHD patients to LDL goal did not always translate to actually doing so. In fact, that was true in 75% of cases! Only 25% were at goal. So, do not assume that are doing what you think you are doing until you confirm it by self audit.

 

Elevate the NCEP ATP III guidelines from mere suggestions from a panel of experts to your minimum standard of care. You can do more, but not less, depending on the particular case. I believe in treating residual risk. But if only 25% of your high risk patients are at LDL goal, why start going after residual risk? You still have plenty to do - go after to the primary goals first where patients get the greatest benefits. You need to prioritize since your resources are limited - time and personnel. After getting most patients to LDL goal, then, on a case by case basis, go beyond the guidelines - check for LDL-P, etc. If needed, I do not hesitate to share my risk and lipid profile with my patients especially those that need combination drug therapy. Click here.

g. Do not become discouraged. There is a great need for what you do. There is a void in cardiovascular disease prevention that is literally begging to be filled. Over 40 million Americans are eligible for preventive lipid therapy. The magnitude of what optimal lipid therapy does in changing plaque morphology and altering the normal progressive course of the disease is unmatched by any other single form of therapy. Everyday, thousands die or become disabled needlessly of a disease that started many years (even decades) before. There was plenty of time to identify these patients and intervene effectively to halt normal disease progression and change the outcomes. You can succeed. Once you begin to see real clinical benefits, it will become your passion too.

The natural course of atherosclerotic cardiovascular disease is a recurring cycle of cardiovascular events. A large cardiovascular healthcare industry has grown and prospered treating and catering to these events. In 1994, the 4S study ushered the modern era of cardiovascular disease prevention. The science of prevention has grown by leaps and bounds since. But cardiovascular disease prevention has not taken foothold in clinical practice. There are many reasons why this is so - outdated public health policies, lack of a cost effective delivery system for CV preventive care to a large at-risk US population, reimbursement issues, lack of an effective clinical management system, fear of loss of income from fewer events, fewer hospitalizations, fewer procedures, etc. I hope change will come soon. The total economic burden of cardiovascular disease was estimated at $500 billion and growing with the aging population. There is much that need and can be done. With me in the lower photo is my son, Emil. He is a promising cardiologist, graduated from Harvard College (magna cum laude) and Harvard Medical School, currently a third year Stanford cardiology fellow and already lipid board certified. All medical schools should include cardiovascular disease prevention in their curriculum and training. According to the Institute of Medicine, it takes 17 years for advances in medicine to become widely implemented in clinical practice. Why? There should be a training in the art of medicine - how to apply the advances in the science of medicine into clinical practice without waiting for 17 years to pass.

Joining  SELA in 2001, years before NLA and NELA existed, helped me get started on prevention. But in 2004, I was feeling very discouraged. I was starting to have doubts. Was I on the wrong track? No one seemed to share the same vision - that the future of cardiovascular disease management is prevention. Dr. Wolk's message was inspirational to me and came just at the right time. Someone who is well established in my field is posing the same question. I was on the right track! Persevere. I did.

Keep your focus. It is a worthwhile endeavor even if currently, the reimbursement is disproportionately inadequate for the value of your work. An important plus - it reduces cardiovascular healthcare cost. The combined event reduction reported at the end of most clinical trials is about 40% after 4 to 5 years. Unlike clinical trials, there is no constraint of time limit in clinical practice and after 9 years of aggressive lipid therapy, combined event reduction far exceeds those reported in clinical trials. Preventive cardiology involves not just improved lipid management, but better blood pressure control and lifestyle changes as well. From 2001 to 2009, my patients' consumption of expensive cardiovascular healthcare resources dropped substantially. Reduced risk translates to much fewer events and much fewer hospitalizations and procedures.

The title above is from an article about a recently published study. To read more, please visit http://m.theheart.org/article/1044939.do. For the WHO Bulletin article, click here. The ever widening treatment gap has many serious consequences - unnecessary deaths, disabilities, increased consumption of expensive cardiovascular healthcare resources and rising already huge total economic burden.

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2. EZ Daily LDL Chart Audit

The first lesson that I learned from all the retrospective physician compliance studies including the one we participated, is that the physicians' intent to treat all high risk patients to LDL goal less than 100, does not translate to actually doing so in many cases. Performing a self audit is the only way for you to find out. Doing it prospectively, instead of retrospectively, is less time-consuming, especially if you have a system. Here is a component of the ACCEPT system that I am sharing with you.

Instructions:

1. Download EZ Daily LDL-c Chart Audit template. Click here. For both LDL-c and LDL-P chart audit, click here.

2. Time Saver: Copy the template on colored papers (yellow paper stands out in the chart) for daily use.

3.Time saver: Your office staff fills up the columns 1,2 and3 when the patients come into the waiting room for their appointments.

4. The third column LabDate is for the date of the last lipid profile. This addresses the problem of not having at least one lipid profile in the chart within the previous 12 months.

5. You fill up columns 4 and 5 by just simply checking or encircling the appropriate selection at the end of each visit. Column 6 is for Comments, specifically, why a high risk patient is not at LDL goal - such as noncompliance, side effects, new patient 1st visit, new patient 2nd visit, etc.

6. At the end of the day, spend 5 minutes or less examining your data.

7. Compile your data and examine them weekly or monthly.

8. In your performance analysis, include all consecutive high risk patients with at least two previous visits, regardless of how high their baseline LDL or proven statin-intolerance. Every practice has a few of them. No exclusion criteria.

9. Time saver: For routine labs, ask patients to go to the lab 2 to 3 weeks before their next visit. This helps reduce routine phone calls. One of the problems noted in compliance studies is that there is no lipid profile in the chart within the past 12 months. 

Note: The downloads are intended for the personal use of NLA members only. If you are not a member yet, please visit www.lipid.org to find out more.

 

Defining statin intolerance due to muscle symptoms in high and very high risk patients

1. Most patients who claim that they can't take statin are not really statin intolerant. For the high and very high patients, the potential benefits are such that you want to challenge this claim. Your first step is to make your patient understand that the reason for taking statin is not just to lower LDL but more importantly, to reduce the risk of serious events such as stroke, heart attack and sudden cardiac death. It will require your time, patience and mentoring tools. It is easy to give up and just prescribe a cholesterol absorption inhibitor or sequestrant but don't. Most patients will agree to try another statin, and then what next? You need to develop your own strategy in resolving this issue. The sequence of which statin to try next is up to you but save fluvastatin for last since it has the fewest and least impressive clinical trial data.

2. For my practice, statin intolerance due to muscle symptoms is present when a patient is unable to tolerate the lowest daily dose of all six statins, and even at modified dosing schedule of the "best tolerated" statin (On, Monday to Friday, Off Saturday and Sunday; or every other day dosing schedule) with Co Q10 200 mg daily.

3. You can't win them all. About 5% of high and very risk patients can't or won't take statin. Then, try red yeast rice with cholesterol absorption inhibitor and/or sequestrant.

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3. EZ Cardiovascular Risk Assessment

The second lesson is that patients who do not have CV risk assessment documented in the chart are less likely to be treated to goal. Here is another component of the ACCEPT system that I am sharing with you.

Instructions:

1. Download EZ Cardiovascular Risk Assessment. Click here.

2. Time Saver: Copy the template on colored papers (yellow paper stands out in the chart) for daily use.

3. For Framingham Risk Score, click here.

4. In the Comments section, there is room for your notes and for Reynolds Risk Score if you decide to use it for some intermediate risk patients.

Note: The downloads are intended for the personal use of NLA members only. If you are not a member yet, please visit www.lipid.org to find out more.

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4. How to use Cyber Dietitian.

For most patients, changing their eating habits is harder than quitting smoking. Diet counseling is time-consuming and frustrating. There is no one approach that works for most cases. Asking the question "Are you following a healthier diet most of the time?" during every patient visit is an important reminder. At the start, just keep it simple - cut down portions by 1/3, eat more fruits, vegetables and nuts, reduce red meat by half, more fish and chicken instead, etc. Telling patients to switch completely to Mediterranean Diet rarely works. Most patients are not familiar with it and Mediterranean diet can be expensive. They may have a Mediterranean meal when they go out to eat but they will not have it everyday like my Greek patients. My usual next step - South Beach Diet, NutriSystem, Weight Watchers, Hospital Dietitian or Cyber Dietitian, depending upon the patient.

 

Cyber Dietitian is an etool that anyone can access. Some patients can use it by themselves, but ideally, it should be used by a dietitian, NP or PA with the patient. Click here for a sample printout diet analysis at baseline and 6 months later. Ask the patient what he/she eats most  of the time (or 50% of the time) for breakfast, lunch, etc. After the initial diet analysis, ask the patient to choose from among the healthier choices available (or something equivalent).

 

Another approach to using Cyber Dietitian, especially for a patient whose taste for food is mixture of healthy and unhealthy varieties. Perform two sets of analysis. First, what is your unhealthy breakfast, etc. like? Second, what is your health breakfast, etc. like? Compare both printouts with the patient. How can you help the patient choose the familiar healthier diet more often? Different variations of the dish? Ask the patient to choose the healthy diet more often, at least 50% of the time for a start.   

 

Remember that risk factors are divided into three categories: non-modifiable, patient-modifiable and physician-modifiable. Dietary habit is patient-modifiable, not physician-modifiable. Physician's role is that of a mentor and coach, but the patient is in charge. Over time, the cumulative benefits of even small changes in patient's eating habit will add up. 

 

To go to Cyber Dietitian, click Healthier Lifestyle on the left menu, then click on "Meet Your Personal Cyber Dietitian".

 

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5. CholesterolClinic.net Directory (under development)

If you are a board certified lipidologist and want to develop your practice, you might be interested in applying for free listing at www.CholesterolClinic.net. Visit the site and click on listing application. Please follow application instructions carefully - send one copy as Word document via email and a second signed copy send via fax or regular mail. We are compiling applications but completion will depend on availability of funding. Having an online presence helps patients find you. The ultimate goal is to close the wide treatment gap by developing a network of dedicated board certified lipidologists who share knowledge, vision and ideas to provide high standard of care to a large at-risk US population.

Which lipid clinic model is right for your practice? Click here for more about PaKS and ACCEPT.

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Rolando L. deGoma, MD, FACC, FNLA                            Emil M. deGoma, MD

Medical Director, NJ Preventive Cardiology                                       Senior Cardiology Fellow, Stanford University

rdegomamd@gmail.com                                                                emdegoma@gmail.com