To prescribe or not to prescribe: that is the question. Is it in the best interests of patients to try to lower their cholesterol via lifestyle modifications, or are statins always the answer?
In May 2004, Ms. C, 35, had been a nurse practitioner in Dr. X’s family practice for six years. One day, Mr. D came into the office to go over the results of a recent blood panel. A few days earlier, he and his wife had been at a local auto race. During a break in the action, Mrs. D had noticed a booth that was offering cholesterol screening.
“Let’s get our cholesterol checked,” she urged her 31-year-old husband. “The test is free, and it wouldn’t hurt to get tested.”
Despite having gorged on hot dogs and a few beers, the couple went into the booth and submitted to finger-stick tests. Mrs. D, 27, was told that her cholesterol was fine, but the technician looked worriedly at Mr. D and suggested that he go to his primary-care provider for a complete fasting lipid panel. The next day, Mr. D made appointments for the lipid test and the evaluation.
Ms. C noted in the chart that the patient was 6 ft tall and 220 lb, with a BMI of 29.8. His BP was elevated at 140/90 mm Hg. The laboratory results showed normal glucose levels but elevated cholesterol: Total cholesterol was 287 mg/dL, with LDL 160 mg/dL, HDL 42 mg/dL, and triglycerides 148 mg/dL.
Asked about his lifestyle and family history, Mr. D acknowledged that he did not exercise regularly and ate a diet rich in red meat and fried foods. Both his parents were still alive, with no history of cardiovascular events. No first-degree relative had diabetes. Mr. D said he was a nonsmoker, but he did enjoy beer on a regular basis.
“You’re going to need to make some significant changes to your lifestyle in order to bring your cholesterol numbers down to a healthier level,” Ms. C told him. “These changes should improve your BP as well.”
She then gave him a brochure outlining a diet plan low in fat and sodium and high in fruits and vegetables, as well as an exercise program. Ms. C spent 30 minutes counseling Mr. D and noted in the chart that he was receptive and attentive. They scheduled follow-up testing in six months to assess whether changing his diet and increasing his exercise were having any effect.
Ms. C saw no reason to discuss the visit with Dr. X, nor did Dr. X have any reason to review the file.
Six months later, Mr. D’s wife accompanied him to the follow-up appointment. She was very anxious about her husband’s cholesterol numbers. Ms. C reported that the patient’s total cholesterol was now 267—still high, but a 20-point drop from baseline. His LDL was 150, HDL was 44, and triglycerides were 142. At 140/80, his BP had followed the pattern his cholesterol had taken—improved but still elevated.
Although Mr. D had lost 10 lb since the previous appointment, his BMI was still a troubling 28.5. When Ms. C asked Mr. D whether he had been following the diet and exercising, he said he was trying his best but could perhaps exercise more.
“Shouldn’t you prescribe a medication?” Mrs. D asked. “I’ve heard that people with high cholesterol should be on something—it was on TV.”
“Your husband is making progress with the lifestyle changes, and we’ve seen improvements in his numbers,” the NP replied. “Mr. D is very young; I’d hate to prescribe medication for him at this point because he’ll most likely be on it the rest of his life. Let’s wait another several months and do another blood test. If there still hasn’t been enough improvement, we can discuss medication then.”
The couple left after scheduling an appointment for six months later. But Mr. D never appeared for that May 2005 follow-up. He died of an acute MI in April.
Ms. C was distraught at the sudden loss of such a young patient, but she was shocked when Mrs. D accused her and Dr. X of malpractice. Defense attorneys assigned by their insurance company assured both clinicians that the widow’s case was weak. But it was certainly dramatic. When Mrs. D testified at trial, she tearfully talked about losing her young husband.
“I told her to give my husband medicine,” she shrieked, pointing to Ms. C. “She didn’t listen, and now my husband is dead.”
The defense attorneys jumped to their feet to object, and the judge told the jurors to disregard the widow’s outburst.
The plaintiffs’ attorney then introduced an expert primary-care physician who described recent changes to the Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program. These updates meant that more people with hyper-cholesterolemia should be on medication, particularly those with other risk factors, such as hypertension. In her opinion, the expert said, Mr. D should have been prescribed medication, which in all likelihood would have saved his life.
Testifying on her own behalf, Ms. C defended her decision not to prescribe in this case. Mr. D’s response to dietary changes and exercise led her to conclude medication was premature, she said. But on cross-examination, she was forced to admit that she was not familiar with the updated guidelines and that she had not consulted her supervising physician.
When Dr. X took the stand, he praised Ms. C’s competence and affirmed his confidence in her judgment. Had he been treating Mr. D, he declared, he would have followed the same clinical course. On cross-examination, Dr. X said he was familiar with the new guidelines but admitted he had not discussed them with Ms. C nor called them to her attention.
The jury deliberated for two hours before awarding Mrs. D $5.9 million.
Ms. C and Dr. X were not blatantly negligent in this case; they exercised clinical judgment. So what swayed the jury? Perhaps it was Mrs. D’s tearful outburst.
During a trial, a lawyer can object to an inappropriate or irrelevant question or to an unresponsive answer. If the judge overrules the objection, the question gets answered or the answer stands. If he sustains it, he tells the jury to ignore the question (or answer). Of course, in reality, jurors may be swayed by emotional outbursts despite being told to forget them.
Ms. C would have been better off if she had been aware of the new guidelines, even if she ultimately decided against prescribing a statin in this case. Her ignorance made her appear unprofessional or, at the very least, not up to speed. Similarly, Dr. X should have discussed the updates with his NP. Practice guidelines may change frequently, and it is essential for all clinicians to be aware of the latest recommendations for diagnosis and treatment.
Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.