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Hypercholesterolemia: Shared Decision-Making
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Howard Weintraub, MD: I couldn’t agree more with what you’ve said. I’m going to go 1 step further. Along with caring, it’s also listening. I’ve seen a lot of individuals in their 30s and early 40s who were summarily told by their primary care doctor, “Your LDL [low-density lipoprotein] is X, and you need a statin.” Many of these people, as you already pointed out, want to be “natural,” so they immediately run to the internet. They decide that the doctor is an agent of big pharma and trying to do all kinds of dastardly things to them, because when you google the word statin, glowing reports don’t immediately show up on your doorstep. I invariably listen to them. We talk at length about their diet. We talk about their expectations. I let them know specifically what I anticipate might happen. I let them know that in my approach of aggressively, thoroughly approaching risk factors, I don’t grade on a curve, but I also would like very much for them to have the best possible outcome. In doing that I am giving in to get my own way when I encourage them to follow an enlightened diet or nutritional pattern, to stop smoking, to lose weight, and to exercise. We set realistic goals, and I give them several months to do this. I give them enough time for them to figure out whether they can tolerate the diet, whether they feel put in some culinary hell by what I’m asking them to do, or whether they find that it’s a lifestyle that’s entirely livable. Then we reconvene in 4 months, which is enough time for them to get all this information together and also to be able to see a reasonable impact, if there is 1.
I agree with you. Getting 10% reductions at the end of the year is probably a very realistic number, not what patients believe they should be able to get. They hear about the fantastic stories of people like Dean Ornish and others. They don’t really know what Ornish’s diet and lifestyle are like. They’re not quite ready to give up booze, red meat, and oils, or to have to exercise and meditate, but this is what it is. I find, interestingly, that people come back. If I just tell them, “Here’s a pill,” these are the people who take the medicine for a month and don’t refill it again. These statistics are everywhere. This is something I agree with you about, and by listening, you show that you care and that ultimately, your concern is to improve their cardiovascular outcome. I also tell them, “I can do this with your help or without it. I’d love your cooperation with this, because it means that if you do need medicine, you’ll be on fewer medicines. That means we’ll be able to do this in a way that is more acceptable to you.” I tell them “But if you look at me and say, ‘My life is not going to be worth living unless I have a cheeseburger every week.’ ” I tell them, “Fine. Then understand that you’re going to need to get your LDL down a certain degree, whatever it is, and that we might need to use more medicine.” If I need to do more of the heavy lifting, I’m prepared to do it, but this is part of our agreement. I don’t want to say contract, but this is the agreement that I forge with patients. All these things involve listening and having the patient feel that you care. They must feel that they are not being summarily given a judgment that they don’t have a chance to discuss and don’t completely understand, that they feel might be somewhat arbitrary and is contrary to what they’d like. As you put it, they’d like to be natural. That’s completely correct.
Transcript Edited for Clarity
