Hearts in Maine #140

Dr. Peter Shaw:

One of the important things about medicine I've always felt, is good communication and communicating not only with your patients, but also with other practitioners and also the public. And communication is central to the fundamental meaning of doctor, which is a Latin word meaning teacher. I think that that has been the principle by which I've lived and practiced, and I felt very gratified to be able to do that here.

Dr. Dervilla McCann:

Lifestyle modification remains the mainstay of therapy for cholesterol treatment, and that means smoking cessation, exercise, achievement of your ideal body weight, and a healthy diet.

Dr. Lisa Belisle:

This is Dr. Lisa Belisle and you are listening to the Dr. Lisa Radio Hour and podcast show number 140, Hearts in Maine, airing for the first time on Sunday, May 18, 2014. Heart disease is the leading cause of death among American adults. Thus it generates much discussion in the fields of medicine and public health. Today we speak with two physicians who have had many years of experience in cardiology, yet continue to understand heart health in innovative ways. Join our conversations with Dr. Peter Shah and Dr. Durvala McCann and learn how our doctors are using their heads to gain important insights into Maine hearts. Thank you for joining us. Any good doctor will tell you that

Dr. Lisa Belisle:

the foundation of their own medical career is having good teachers, good physician teachers, good other healthcare provider teachers. And among my really basic foundational great teachers is Dr. Peter Shah, who actually is in the studio with us today. Dr. Peter Shah is a cardiologist in Portland at Martin's Point Healthcare. He's been practicing medicine for 36 years and has been affiliated with Maine Medical

Dr. Lisa Belisle:

center and Mercy Hospital throughout his career in Portland.

Dr. Lisa Belisle:

There's really so much more behind that short bio, but I just wanted to thank you for taking time out of your patient schedule and coming in and talking to us today.

Dr. Peter Shaw:

Well thanks for asking me, Dr. Shah.

Dr. Lisa Belisle:

It's really interesting me to have you here because it's not just me that you have a relationship with. You've known my father as Dr. Charlie Belisle. You've been around sort of the same length of time practicing medicine in the Portland area.

Dr. Peter Shaw:

Yeah, I have. When I came here, there were just a few of us cardiologists and several of us were covering each other at night. And the large groups ultimately becoming the hospital owned practice evolved over many years. One of the great things about this city is the resources that it has. And among those were the opportunities to practice and teach at two very great hospitals, both of which had training programs that allowed me to do what I really have always felt my mission was. And that is to take care of people and to pass on what I know to others. One of the important things about medicine I've always felt is good communication and communicating not only with your patients, but also with other practitioners and also the public. And communication is central to the fundamental meaning of doctor, which is a Latin word meaning teacher. So I think that that has been the principle by which I've lived and practiced and I've felt very gratified to be able to do that here.

Dr. Lisa Belisle:

When I was starting my medical training, we were really right in the age of technology where it was about we were taught how to order tests, we were taught how to make diagnoses based on testing. I know as a cardiologist you use tests yourself, but one of the things that I remember quite vividly was the time spent with you at the bedside of patients using one simple piece of equipment, and that was the stethoscope. And I remember it so clearly that you would, first of all, it would be important that the doctor patient relationship was very strong. And it was never assumed that this was, okay, you know, we're just going to stick our stethoscope on you. There was always that, the sense that it was important to bring the patient in as a teacher as well. But then the learning of murmurs, the learning of abnormal pulse presentations, the physical diagnosis stuff, which is something that I think gets lost in today's medicine that was so strong in your teaching. Is that something that you still count on, rely on yourself?

Dr. Peter Shaw:

Well, I don't only count on it, I teach it. We have at Maine Medical Center a beautiful facility for teaching that is called the Simulation Center. It's sponsored by Hannaford and it's a state of the art structure that allows experience in the operating room, at the bedside and doing instrumentation like endoscopy so the bedside teaching, which is, I think, irreplaceable, has been greatly augmented by having idealized mechanical subjects that we can really demonstrate very clearly what a particular feeling or sound or observation is. And then that could be taken by the interns and residents who are alerting it to the bedside, where they're free to make observations on live patients. One of the things that we try to do is get them to understand that they're not just listening at a patient's heart, but they're listening for particular findings that will give them clues as to what diagnoses to then explore.

Dr. Lisa Belisle:

You have a background in public health. You spent two years at the Centers for Disease Control, and not everybody would understand the link between cardiology and internal medicine and public health. It's pretty clear to you and I. But tell us what it was about public health that caused you to go in that direction first.

Dr. Peter Shaw:

My first introduction to public health was actually in fourth year medical school when I was at Columbia Medical School in New York. And at least a third of our class went abroad for a couple of months to do tropical medicine. So I did the last two months of medical school in Liberia, where it was a very different country at that point, but where I was stationed at a place called Zaw Zaw, which is up country several hours. My wife and I lived in a house there that was occupied by a nurse who had been there for probably 30 years and had made a huge impact bringing childbirth from the jungle into the hospital. And when we arrived at Zaza, we arrived exactly at the same time as she died suddenly from Lhasa fever, which was an epidemic disease at the time. And in the other half of the house where we were living, CDC had sent investigators to explore the reasons for this epidemic and to dissect animals and take samples. That really fascinated me. Even though I knew I wanted to be a cardiologist, I thought, hey, this is cool. So when I was given the opportunity to join the army in Vietnam, I took even a better opportunity to go through the court program into the cdc, where I had seen this fascinating investigation go on. My area was, believe it or not, parasitic diseases, and they still are important. And as a matter of fact, I probably knew more when I got to Maine about amebiasis or malaria than anybody else. So it was really kind of a sideline, but I didn't. I just concentrated on cardiology. But the CDC really opened my eyes to a number of things. First of all, I learned how to interpret and read journal articles and know what was believable and what perhaps was not. I learned more about biostatistics than I had learned in medical school. I'm told I learned about biostatistics in medical school. I have no memory of that at all, but I certainly do at cdc, and then that kept me aware of the larger picture. So I just have been very much aware of that throughout my practice too. As a matter of fact, even though I was a clinical cardiologist and also on the faculty, I helped establish the cardiac Rehabilitation program at University of Southern Maine. It was called Lifeline. And then in later years helped establish upbeat, which was at mercy. And that ultimately transformed into Turning Point at Maine Medical center, which continues to be an extremely important, not only personal health, but public health facility. So I think that that's been a nice additional interest that I've pursued throughout my career.

Dr. Lisa Belisle:

You also took time not too long ago to go to Botswana where you thought that you were going to be just doing standard internal medicine, primary care, but it turned out that you were able to marry your love of public health and your use of echocardiogram. So modern technology and your knowledge of infectious diseases and really provide some interesting, really learn some interesting things and provide some help.

Dr. Peter Shaw:

The University of Pennsylvania where I trained was inquiring among its trainees, former trainees, anyone who could give time to their bup. There was the Botswana University of Pennsylvania partnership aimed at diagnosing, treating and managing HIV AIDS and TB in Botswana. Additionally, Baylor has a similar program involving pediatric patients, and Harvard provided all the laboratory services there. I had a year of freedom. So I signed up to go for three months. And knowing what I did about Africa, I inquired, am I going to be involved just in teaching medical residents and house officers about how to be a doctor or how to treat HIV aids? Or is there any cardiology there which I could actually help with? I was told no, there's not much cardiology, so you'll just. You can teach them how to be a doctor. So knowing what I knew about heart health in Africa, I arranged with one of the echo corporations to provide me a loaner echocardiogram machine for three months. I spent time before I went learning how to do a study, and then after I went, the machine arrived on time. It was sent down from Nairobi to Haberoni, which is the capital of Botswana, where I was working. Within a day or two, I was making these unbelievable discoveries of pathology that guided appropriate management. Anybody who appeared with swelling in their legs and trouble breathing was called ccf, Chronic Congestive Failure and Everybody was treated the same, but with the help of diagnostic skills that I had and the echocardiogram to document what pathology was there, I was able to define how to refine the management of these patients to treat exactly what they had. Some had stiff hearts that were not dilated and swollen and unable to function properly. Others had huge fluid collections around the heart, something called a pericardial effusion. Some had severe valvular disease. And in fact, the TBAIDS population had frequent presentations with large pericardial effusions. And the echo machine helped me do guided pericardiocentesis, which is a technique by which a needle is placed into the chamber, into the space around the heart and the fluid is drained. I had to make my own equipment. I used an intravenous catheter for the catheter to enter the space around the heart. I used IV tubing to drain the fluid, and I used a urine bag to collect the fluid. But it worked out beautifully. I did six of those while I was there. I found intracardiac tumors. I found two patients who had severe heart valve infections. The echo helped me see how serious these were and led to my sending them by plane to Johannesburg for heart surgery. And they came back six weeks later with they came back three weeks later with their intravenous catheters, ready to get antibiotics for the next six weeks. New heart valves and feeling well again. So that echo machine saved lives. And it also made me able to be a much more effective practitioner and teacher.

Dr. Lisa Belisle:

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[Unidentified voice]:

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Dr. Lisa Belisle:

If you are a health care provider and listener of the Dr. Lisa Radio RM podcast, we invite you to the second lecture in our Apothecary By Design lecture series to be held at 75 Market street here in Portland. Our second lecture is with Dr. Kristin McKelvin, a Dr. Lisa Radio RM podcast guest and expert in the field of Lyme disease.

Dr. Lisa Belisle:

She will be holding a discussion of

Dr. Lisa Belisle:

Lyme disease and her naturopathic medical view on the disease on May 28 at 5pm at her talk, Dr. McKelvin will review general tick borne illness information including diagnosis and testing and treatment options using both conventional and complementary therapies. This is a great opportunity for practitioners to gather reputable resources for use in their clinical practice. Visit apothecarybydesign.com for more information. I hope to see you there.

Dr. Lisa Belisle:

You also saw something that we see often in the United States which was hypertension. But you saw some really severe and untreated hypertension which you showed me a picture of on your iPhone. I love this that you were able to show me pictures of CAT scans and echo results on your iPhone. Why do you think that that is that we that they aren't able to treat something as basic as high blood pressure?

Dr. Peter Shaw:

Several reasons I think number one, it's Africans and African Americans are very susceptible to hypertension and its prevalence is high. Second, the drug management of hypertension is not quite as persistent in a place like southern Africa as it is among a middle class population in the United States. I think it's certainly frequent in America that we've got populations that are no better served than people in rural southern Africa and probably have the same incidence of complications of untreated disease. The most common cause of stroke in southern Africa is really intracranial hemorrhage, and that's usually a hypertensive complication. The last reason is also the inconsistency of drugs. So people are treated with whatever drugs around for that few months, and then when those drugs are used up, then other drugs replace them. And so trying to maintain a consistent antihypertensive schedule is not that easy.

Dr. Lisa Belisle:

We actually have some similar problems, even as you've said here in the United States, where there is a popular segment of the population that doesn't have access to medication, not because it's not right there and right available at their drugstore, but because they don't have health insurance or they don't have prescription coverage or they don't have the funds to cover the co payment. How does that feel to you that you can go from this country that's underdeveloped to a country that is theoretically very well developed and we still have some of the same issues?

Dr. Peter Shaw:

Well, you know, I view medical care as a right. I view it as I view this whole question of why Does America have 50 million people without health insurance. A moral issue. It's not an economic issue, it's a moral issue. This is a horrible situation and I think there's no excuse for it. I think that whatever we need to do in order to provide people the health care they need is essential. And whether it's through the Affordable Care act or whether it's through a universal payment system or some way to provide health care to anyone who needs it is, I think, a responsibility of a society. So I really feel it's too bad and we got to do something to fix it.

Dr. Lisa Belisle:

It's interesting to hear you say that because not all doctors are behind the Affordable Care act, for example, not all doctors are behind single payer systems or some of the legislation necessary. But I would say that most doctors

Dr. Lisa Belisle:

understand that there's something about the system

Dr. Lisa Belisle:

that's not, that's not quite right.

Dr. Peter Shaw:

Oh, absolutely. I mean, I think that the Affordable Care act is not perfect. It's several thousand pages long. Because like every other legislation, a lot of different interest groups need to be assuaged in order to reach consensus. And in the case of providing health care, we live in America by health insurance. It's not, I think that it's idealized if we could provide universal health care by single payer. But on the other hand, it's Just not the way America has worked. And you can't change this place in an instant. So we have to work with what we have. I think that the. I'm puzzled by the different messages I'm getting about the reasons to be concerned about Medicaid expansion. I recognize that Medicaid is not a panacea in that it doesn't pay very well. It also is something that was a technique for trying to expand the number of people with some form of insurance. But from the point of view of taking care, of expanding medical expenses, it will in itself cause issues of disagreement and discord. So I think that there's a lot of evolution that we have to undergo to bring medicine into the 21st century and beyond and to make it available to as many people as possible. I think we have to work together to determine what's acceptable in this society and what's not. But in the end, I think that since health care is a right, we have to find a way to provide it. And it's not just through free care. The hospital shouldn't take the burden of that, and it's not through having different levels of quality of care. I think that that's not acceptable either. So there's a lot of work to be done.

Dr. Lisa Belisle:

What I'm noticing about medicine is that there aren't as many people who are staying in long enough to have a historical perspective about it. I mean, I know. I think about you. I think about my father who's been practicing. I think he finished Medical School in 1971, and there are a few other doctors who are of that ilk who have been around long enough. I mean, you've been practicing for 36 years.

Dr. Peter Shaw:

Yeah, I graduated in 72.

Dr. Lisa Belisle:

So how do we.

Dr. Lisa Belisle:

I guess, how do we capture that

Dr. Lisa Belisle:

historical perspective if there aren't as many people who actually have been around long enough to have seen all of these shifts take place?

Dr. Peter Shaw:

You know, there are a lot of people who have been around long enough to participate in that. For example, the chief of medicine at Penn, Arnold Relman, when I was in training, went on to other positions, including being a professor at Harvard and also editing the New England Journal. There are so many different things to do in medicine or around medicine. Just as you're doing that, if you're awake and alert and at all conscious of the evolution of society as well as medicine specifically, these awarenesses can happen. All I can say is that medicine is in constant evolution. I have changed how I practice basically every five years for my entire career, and I've concentrated primarily on a single laboratory entity that is echocardiography, and always had that as ancillary to my practice as opposed to the thing I did. And as echo has evolved and the treatment of patients has evolved and the management of illnesses has evolved, it's been like riding a surfboard. It's just been remarkable. I can't think of a better career for me. And I think your example and your son who's about to go into medicine, I think that those who want to be doctors really find that this is a wonderful profession, no matter what we're paid. And the fact that a number of the smartest graduates of Ivy League colleges were going off into money management instead of professions like medicine. You know what, they probably weren't going to be in medicine for long anyway, or good doctors. And I think that those who want to go into medicine are going to continue going into medicine and they're going to continue having experiences just like I've had for the last decades.

Dr. Lisa Belisle:

As you've mentioned, my son is thinking about going into medicine. Actually. He's applied to school. And I think I've felt the same way that you're describing. I mean, a lot of, I've talked to a lot of doctors who would say, oh, I would never encourage my child to be a doctor, and I don't feel that way. I think the important thing is you just know somewhat what you're getting into right now and then realize that you're probably going to have to have some nimbleness of intellect and emotion and some perseverance in order to just keep riding the wave as you've described. So it's a funny thing. If you go into medicine expecting one thing, then you'll probably, it's going to change by the time you graduate from medical school, and certainly in 35 years, is 36 years, it's going change as

Dr. Lisa Belisle:

long as you know that's right.

Dr. Peter Shaw:

And all I can say is that, you know, make sure that you get enough rest, enjoy what you're doing, never stop learning, and it will continue to be a fulfilling career.

Dr. Lisa Belisle:

Well, Dr. Shah, it's been a pleasure to have you here today. And I know with your very busy schedule, we're really privileged that you took the time to come in and talk with us. People who are interested in finding out more about your practice, they can go to the Martin's Point Healthcare website. And I really, I appreciate your, I appreciate all that you've done and thank you for making me a better doctor. I got a new stethoscope recently and I thought, you know, Dr. Shah would really like the stethoscope. So you've made a big difference in my life and I'm sure you've made the same big difference in the lives of medical students and residents really around the state.

Dr. Peter Shaw:

Well, thank you, Lisa. And I will say this, as long as I've been in practicing, I still needed to buy a new stethoscope, which I am about to receive in the mail this week. So it's an ongoing process and I think it's been a thrilling career.

Dr. Lisa Belisle:

Well, we've been speaking with Dr. Peter Shaw, who is a cardiologist with Martin's Point Healthcare and keep doing the good work.

Dr. Peter Shaw:

Thank you.

Dr. Lisa Belisle:

As a physician and small business owner, I rely on Marcy Booth from Booth Main to help me with my own business and to help me live my own life fully. Here are a few thoughts from Marcy

[Unidentified voice]:

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Dr. Lisa Belisle:

we all know that Maine is a small state and especially when it comes to things like public health. I was privileged to work with Dr.

Dr. Lisa Belisle:

Dervilla McCann on a public health project

Dr. Lisa Belisle:

through Maine Health several years ago and

Dr. Lisa Belisle:

today we have her with us again. Dr. McCann is formally the director of the cardiology division at St. Mary's Regional

Dr. Lisa Belisle:

Medical center and is on the medical staff and is a full time cardiologist with Central Maine Medical center in Lewiston. Thanks for coming in.

Dr. Dervilla McCann:

Thank you for having me, Lisa.

Dr. Lisa Belisle:

Dr. McCann, you have a very interesting background.

Dr. Lisa Belisle:

You spent some time out of the state before you chose to come to Maine. Tell me a little bit about what brought you here and your background.

Dr. Dervilla McCann:

My first real full time exposure to Maine was when I came here as a freshman at Bates College and I fell in love with the state at that time. I left after graduation, but I had planted a little seed. I talked my parents into moving to Portland. So they moved while I was still in college, and I left, went to medical school, joined the Navy, got married, and came back eventually to the state in 96, drawn both by the fact that my parents were still here and I wanted my kids to get to know them a little bit. I had a job, so that was another pull. But basically I'd always loved the state and had always been looking for a way to get back here.

Dr. Lisa Belisle:

And your family's originally from Ireland?

Dr. Dervilla McCann:

My parents are both Irish. They met in medical school and emigrated initially to Newfoundland, Canada, and then to New England, eventually settling in Portland.

Dr. Lisa Belisle:

What type of physicians are they?

Dr. Dervilla McCann:

Both my parents are physiatrists, which is a specialty focused on rehabilitation medicine. And my dad was really one of the founding members of the Wheelchair Sports association and was a real pioneer, as was my mom, really. They both were very interested in sports for the disabled and were part of that early movement and have remained very active in that element of sports ever since they started.

Dr. Lisa Belisle:

So was the fact that your parents were physicians and in basically what is a public health related field, did that influence your decision to go into cardiology?

Dr. Dervilla McCann:

You know, I think I decided to be a doctor when I was about 7. And I really feel that you select your profession in part because you're selecting a peer group. You know, you. You want to continue to grow intellectually, you want to be challenged, and you want to help people, and medicine was a really great way to do that. I was an internist for a number of years, but I found that my personality really matched my better with cardiology. There was pretty immediate return on an intervention with cardiology. Of course, when I became a cardiologist, cardiac catheterization was relatively new and intervention was in its infancy. So many technologies have advanced dramatically since I started. It's been really challenging to stay current and to stay as well informed as you can be for your patients. But that's part of the beauty of it, I suppose.

Dr. Lisa Belisle:

Do you ever speak with your parents about the Irish medical school system or the Irish medical system? And how it differs from the American system and where we are today.

Dr. Dervilla McCann:

Yeah, we talked about it a lot, especially at the beginning of my American medical training. And actually I went to Ireland to experience it with my husband. I was married at the time, and we did a rotation in Dublin. And that was really an interesting experience. The focus was quite different. The Irish medical students relied far less on labs and technology. They really focused on physical diagnosis and the history, the bedside examination. I couldn't believe the stuff they memorized. It was really impressive. Very, very bright also, when I was there, and this was years ago. But the medical system was also very informed by religion, you know, Catholic, Ireland. So there were some social differences that we observed. My husband and I observed when we were there, regarding the communication with the patient, the communication with the family. So it was. But it was a really good thing to experience and see up close and personally, so that I understood much better how my parents had been trained and what their focus had been.

Dr. Lisa Belisle:

Why did you choose to go into the Navy and how did that shape your ritual?

Dr. Dervilla McCann:

Had none. Was married, wanted to be independent. Seemed like a good idea at the time. You know, the uniforms were definitely a pull because they. They look great. No, seriously. Medical school at the time that I entered was during the Reagan administration. I went to Tufts. The tuition doubled the year before I got there because federal subsidies were removed. So private medical schools around the country were suddenly seeing a very dramatic acceleration in cost. And my husband and I both had to find a way to get through this. And so we applied for a Navy scholarship. He got his the very first year. I got mine our second year. So I worked as an audiovisual tech during my whole first year of medical school to pay the bills. I have no regrets about this at all. It really turned out to be a fantastic experience, a great adventure. And believe it or not, it turns out that after Tufts Medical School, I applied to Bellevue Hospital and was accepted there for my residency at the height of the AIDS epidemic. And we had no idea what was in store for us during those three very difficult years. 50% of my patients had AIDS or AIDS related illness, and 50% of the ones who had AIDS died while I was caring for them. So it was an inundation with one type of disease. And it was a very sad time with very little that I could do. After I got done with my residency, that was the time that I started my Navy payback. And I learned more internal medicine in the Navy because they specifically excluded HIV positivity. So it was really helpful for me to have had those two experiences, one very much based in a public health crisis with intensive care medicine emphasis and very poor outcomes. So I became really. I really understood the critical care elements of medical care. The Navy taught me a completely different side, the outpatient side, taking care of people who are essentially well, but who have chronic medical problems as they age. So it was a really terrific double teaching track, so to speak.

Dr. Lisa Belisle:

You've had to be somewhat nimble as you've gone through because you've dealt with different demographic groups, you've been to different places, and now you find yourself in Lewiston and you have this interest in what's going on with the Franco American, the French Canadian, formerly French Canadian population. Tell me about that.

Dr. Dervilla McCann:

Well, there's no question my life has zigged and zagged. I have not been. Been sort of a shooting star with a linear arc. That has not happened. But that's the great thing about America, I suppose, and about the opportunities that we can all take if we want to. So I've been exposed to a lot of different ethnic groups. On the West Coast, I met a lot of Pacific Islanders in the Navy, I met a number of Cuban refugees. In Boston, I met, you know, my. The Irish Americans. That, you know, sort of certainly informed my understanding of that group. But definitely in Lewiston we have a high population of Franco Americans. I believe it's 29% of the city, which is more than the state as a whole. And the state has a very high percentage of Franco Americans. And that is fine with me. I find the, my patients of Franco descent, particularly the ones who speak French as a first language, to be a really interesting and wonderful group of people to take care of. I really enjoy them, I can remember. And I speak a little bit of French, which is helpful when you go to, for example, the emergency room sometimes, especially at the beginning when I first got there, I can recall the French speaking nuns would be behind the curtains speaking French to the patients. It was almost. It was a lovely thing, sort of a spiritual thing. And that continues to inform the community. Although Lewiston is rapidly changing and becoming far more cosmopolitan. And unfortunately that French culture is not, you know, completely successful, sustainable. Although some wonderful leaders in the community are really trying to hang on to the history and the culture and the language.

Dr. Lisa Belisle:

As you've been taking care of this particular population, you've noticed some things about them medically that have been noticed before, but it just has caught your interest as a cardiologist.

Dr. Dervilla McCann:

When I first arrived in Lewiston and started seeing really young people with Heart attacks. It was a bit of a surprise. Often these folks, young heart attack victims, would often have a whole lot of risk factors. They would have diabetes, or they would smoke, or they would have high cholesterol or high blood pressure. You know, many different risk factors. But what I kept finding was very young people with very high cholesterols. And I started looking into this subtype of patient called people with familial hypercholesterolemia. When you look at cholesterol, we divide it up into all sorts of subgroups, and there's this one genetic tendency that gives people very high LDL cholesterol. That's the bad, you know, what we used to call the bad cholesterol. Individuals with familial hypercholesterolemia inherit this from their parents. If they get both genes, one from the dad, one from the mom, they're called homozygotes. And those types are very sick at a very early age. They typically have strokes or heart attacks, sometimes in their teens. And they often don't survive past the age of 30. But if you get just one copy of the gene from either one of your parents, you're called a heterozygote. And heterozygotes do have very high LDL cholesterols, but they're less likely to have that very early childhood form of heart disease. But they succumb to coronary artery problems. That's arteries of the heart in their 30s and 40s, much, much earlier than normal.

Dr. Lisa Belisle:

The goal of the Dr. Lisa Radio Hour is to help make connections between the health of the individual and the health of the community. The goal of Ted Carter Inspired Landscapes is to deepen our appreciation for the natural world. Here to speak with us today is Ted Carter.

[Unidentified voice]:

Some mornings I lie in bed exhausted, thinking, wow, did I really sign up for all this? I think we've all sort of been there where life just is a struggle sometimes. And it's long, it's hard, it's arduous. But I also think that that's how the human spirit is tested. And I think that sometimes when we're pushed up against a wall, that's when our best forms of creation come out. And in looking back at the most difficult projects I've been on, something came out of those projects that wouldn't have otherwise come out if it was easy, I guess you might say. And I think in reflecting back on life in general, we look at. We look at life and we say, you know, those were really difficult times, but I got through it and I got to the other side and I was able to create something that was really meaningful and it even has greater meaning and depth because of the struggle. So I guess we have to say in life we have to bless our struggles and bless the journey and make the most of everything we have and be grateful for it. I'm Ted Carter and if you'd like to contact me, I can be reached@tedcarterdesign.com

Dr. Lisa Belisle:

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[Unidentified voice]:

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Dr. Lisa Belisle:

so you wanted to learn more about why this was happening?

Dr. Dervilla McCann:

Exactly.

Dr. Lisa Belisle:

You having taken a very kind of, I guess we'll call it holistic and family based approach to the way that you practice medicine, you started digging into the history of this group, right?

Dr. Dervilla McCann:

It turns out that familial hypercholesterolemia is a gene that is seen ubiquitously. It's all over the world. Every group, you know, every country, every ethnic group has some expression of this gene. But there are subgroups, you know, sub populations that seem to have a higher risk and the Franco American population is one such. This appears to be secondary to what we call the founder effect. And this is where the story got very interesting for me. It turns out that there were probably four to six founding families from France who went to Quebec and became the early settlers of that area really founding Quebec. And because of language, culture, religion, they intermarried. And it turns out historically, apparently the French government gave them subsidies and additional monies if they reproduced and had lots of kids. And so these founding families appear to have carried the gene with them and appear to be the source for this higher than usual expression of this gene in this population. So now go to the Industrial Revolution, with mills being built around the New England area and a railroad that went directly from Quebec to Portland. And the people of Lewiston built a railroad so spur so people could get on the train in Quebec and make a change and get off in Lewiston. And thousands of Franco Americans ended up coming to Lewiston to work in the mills where they were able to make a much better living there than as subsistence farmers in Quebec. But the same culture, the same language, the same shared heritage tended to create a situation where people continued to intermarry and they had lots and lots of kids. So the end result of this is the gene became sort of concentrated and amplified in this particular population. So if you claim Franco American descent, you are more likely than the average person to carry the gene for familial hypercholesterolemia.

Dr. Lisa Belisle:

So what does this mean for you as a cardiologist? Obviously, cholesterol is still confusing us. I mean, I'm a primary care doctor and we're uncertain as to how we're supposed to deal with this. But we know that there is a problem with cholesterol in the heart. So how does this change the way that you work within your practice?

Dr. Dervilla McCann:

You're absolutely right. Cholesterol is confusing. Believe it or not, it's still confusing to cardiologists too. We've just received some new guidelines. Last November, the American Heart Association, American College of Cardiology published some new guidelines that have been quite controversial, actually. But one thing that has continued to be the mantra is that LDL cholesterols that are really high need to be very aggressively treated. Unfortunately, patients with familial hypercholesterolemia have LDL cholesterols. We like to see them under 100. Their LDL cholesterols are typically 190 or greater. So they're really very, very high. And lifestyle modification remains the mainstay of therapy for cholesterol treatment. And that means smoking, cessation, exercise, achievement of your ideal body weight, and a healthy diet which is not high in trans fats or hopefully is very balanced with lots of fruits for vegetables, whole grains. I often will talk about the Mediterranean diet to my Patients, which really has some good evidence behind it as a very healthy way to eat. But with familial hypercholesterolemia, even aggressive lifestyle modification typically isn't enough. And so we have to treat these people with some pharmacologic agent and the one that seems to be coming after all these years, and lots of other tries with lots of different, different things. Statin therapy appears to be the safest and most effective therapy for them. And in fact, it can really do wonders for these patients and markedly reduce their risk of heart disease. But we frequently, as physicians, work in sort of silos, and we have not got strong links to community programs, facilities for dietary modifications, smoking cessation, exercise. Those are sort of all different packets of talent that are scattered around our communities. And we're very busy. We're all under a lot of pressure to just get through the patients of the day. So with the support of Central Maine Medical center and St. Mary's I've been working with both hospitals in Lewiston because we've recognized that this is a community problem. We are working now on a pilot project to link all of those things to make sure that when we identify high risk patients, we do a couple of things. We sit down and talk with them, explain the genetics, and try to screen their first degree relatives. That's called cascade screening. It's very cost effective and we're very likely to identify other individuals who are at high risk using that approach. Just mother, father, brothers, sisters, kids. If we screen them, we're likely to find additional family members with high cholesterol. And then we really work on the lifestyle stuff, give them the support that they need to quit smoking if they smoke. Diet is focused on a healthy diet. We've gotten some support from St. Mary's Nutrition Center. We think we're going to be using them as part of our process to, to educate. And we've got all sorts of exercise groups in the area that would like to be part of this. And we're going to try to create links for our patients. But we're going to try to maintain the primary care provider as the central link and the central connection for that patient. We are going to be in the background trying to add quality to what the primary care provider is going to provide. But this program today is very helpful because I want to make sure that we get the word out to the public, not just to the medical community, but to the public, that this is a unique, not isolated to Franco Americans, but particularly important to Franco Americans in the state of Maine and the Real reason that I got started on all this is we've got this brand new electronic medical record and you can do all sorts of fun things with it like ask it questions. So I asked the question, how many patients do we have in our system? And the answer is 80,000. And how many of them have ever had an LDL cholesterol of greater than 190? And that's a sort of a standard starting point to identify individuals with familial hypercholesterolemia. And within a population of 80,000, you would anticipate about 160 patients. That's 0.02%. That is 1 in 500 people are typically expected to have this gene. We got 4,000 patients. My jaw dropped when I saw that number. And that was really the impetus behind all of the activity that we've been engaging in over the last several months.

Dr. Lisa Belisle:

Can people contact you through the Central Maine Medical center website or switchboard?

Dr. Dervilla McCann:

They absolutely can. And I would encourage them to keep an eye out because we are going to try to spread the word both publicly. They don't have to come to me personally. They can continue to work with their primary care providers. Their primary care providers. We'll be probably publishing our results. I intend to try to perhaps get together a brochure to help patients educate themselves about what they need to do. I would love to get some money to distribute that. So anybody out there who'd like to give me some money to get this really jump started, that'd be great. Thanks in advance. But we're starting small. We're gonna do a pilot, we're gonna build, and hopefully we'll grow it.

Dr. Lisa Belisle:

Well, thank you for the work that you continue to do for patients is in the Lewiston area and the state of Maine. And thank you for really making an effort to embrace medicine where it is right now, because it is an exciting time to be in medicine and there are a lot of things we can offer patients now that we weren't able to offer them 10, 15 years ago, before the age of electronic medical records. So we've been speaking with Dr. Dervilla McCann. He was a cardiologist with Central Maine Medical center in Lewiston. Thanks for coming in.

Dr. Dervilla McCann:

Thanks so much for having me, Lisa. I really appreciate you giving me this time.

Dr. Lisa Belisle:

You've been listening to the Dr. Lisa Radio Hour and podcast show number 140, Hearts in Mame. Our guests have included Dr. Peter Shaw and Dr. Dervilla McCann. For more information on our guests and extended interviews, visit drlisabelisle.com the Dr. Lisa Radio Hour and Podcast is downloadable for free on itunes. For a preview of each week's show, sign up for our e. Newsletter and like our Dr. Lisa Facebook page. Follow me on Twitter and as bountiful one on Instagram. We love to hear from you, so please let us know what you think of the Dr. Lisa Radio Hour. We welcome your suggestions for future shows. Also let our sponsors know that you have heard about them here. We are privileged that they enable us to bring the Dr. Lisa Radio Hour to you each week. This is Dr. Lisa Belisle. I hope that you have enjoyed our Hearts in Maine show. Thank you for allowing me to be a part of your day. May you have a bountiful life.

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