A Country Doctor Writes:

A Family Physician in the northernmost part of the United States was acquitted last week of charges stemming from years of guideline insubordination.

Interviewed this weekend by members of the local press while he was cleaning the stall of his favorite horse, the silver-haired doctor declined making comparisons between the manure he was shoveling and the now-abandoned numeric cholesterol guidelines, and would not comment on his former accusers’ fall from their pedestals. He made no reference to “Cholesterol Guidelines and the Bachelor with Platform Shoes”, the very first post on his anonymous blog, “A Country Doctor Writes”.

Instead, he turned philosophical.

“I remember the first cholesterol medication, Atromid”, he said. “It lowered cholesterol but still increased the risk of death by almost 50%. We should all have paid attention to that when it was taken off the market more than ten years ago. You could have satisfied the requirement to reach specific lipid targets with a dangerous drug like that, but not have helped a single patient by prescribing it. Right now, almost the same thing is happening with drugs like Zetia, Tricor and niacin”

Opening a bag of clean pine shavings for the stall floor, the Swedish-born physician continued:

“Health care has changed from a profession to an industry, and the founding principles for physicians, like ’First, do no harm’, have lost their central place.”

“In Sweden”, he continued, “the oldest laws regulating the practice of medicine state that it is the physician’s duty to practice in accordance with ’science and time-tested experience’. Cholesterol treatment is a good example of a practice that drifted into the realm of speculation instead of staying on firm scientific ground. Instead of waiting for outcomes data such as heart attack rates, doctors were more or less willingly jumping on the bandwagon, prescribing unproven and sometimes unsafe medications because pseudoscience extrapolated from surrogate endpoints like LDL and CRP levels.”

“So what did you do when that was the guideline you were working under”, asked one of the reporters.

“I told my patients what the science told us and what the guidelines recommended, and I had the patient make an informed decision, which is pretty much what our new marching orders are.”

“So, you are pleased with the new guidelines?”

The bespectacled sixty-year old physician sighed.

“I am relieved and saddened at the same time”, he answered. “I am relieved we aren’t told to do things that have no basis in science, but I am sad that there has to be guidelines that essentially say ’help the patient understand what we know about heart disease prevention and help them make an informed decision’ – I mean, do we really need a guideline for something as basic as that? Isn’t that the way we are supposed to work anyway?”

He hesitated, then added: “Sometimes clinical guidelines remind me of overly basic consumer information. There is a Swedish joke about one of their neighboring countries. Supposedly glass bottles there are inscribed on the bottom with the words Open at Other End. But of course Norwegians aren’t really that silly, and doctors aren’t either. We’re supposed to be critically thinking professionals, aren’t we?”

With that, he hoisted the last bags of horse manure over his shoulders and brought them down to the dumpster to be hauled off the property. “Fly and odor control – keep the manure away from the barn”, he explained.

On the side of the green four cubic yard dumpster was a warning sign: Do not play on or in.

“I guess everybody has guidelines these days” were his parting words to the reporters before he walked off with a spring in his step and disappeared behind the door of his little red farmhouse.