Maine Wellness 2015 #173

Dr. Lisa Ryan:

At the end of the day, we have to remember we're there to really take care of our patients and give them the best quality care and make them as healthy as we can be. And we can't get too wrapped up and too focused in clicking the right boxes and get disengaged from that.

Dr. Craig Brett:

I think people need to really understand what the effect of chronic stress is on their body because I think that's a little underappreciated. Everybody knows stress is bad, but I think the actual effects of that chronic activation and how that promotes clotting and how that may promote atherosclerosis. I think if people know what that's doing to their body, then they may be a little bit more proactive in trying to manage that as best they can.

Dr. Lisa Belisle:

This is Dr. Lisa Belisle and you are listening to Love Maine radio show

Dr. Lisa Belisle:

number 173, airing for the first time

Dr. Lisa Belisle:

on Sunday, July, January 4, 2015. Today's theme is Maine Wellness 2015. Maine Magazine begins each new year with a focus on wellness. We know that health and happiness are interwoven and we wish both for our readers. Today we speak with Dr. Lisa Ryan, pediatrician and President of the Maine Medical association and Mercy hospital head cardiologist Dr. Craig Brett about the ways in which they approach wellness with patients. Jumpstart your health in 2015 by listening in to our inspiring conversations. Thank you so much for joining us.

Dr. Lisa Belisle:

It's fun for me to spend time Talking with other Dr. Lisa's as Dr. Lisa Belisle, I get to interview today Dr. Lisa Ryan, who is a pediatrician at Bridgeton Hospital, which is part of the Central Maine Medical Central Maine Healthcare Family, but also she is the president of the Maine Medical association and the mother of two children. So she's a busy woman, but we're really privileged to have her to talk to us today about some of the issues that I know that she and I both find fascinating and important as to the state of medicine today. Thanks for coming in.

Dr. Lisa Ryan:

Thank you for having me.

Dr. Lisa Belisle:

Lisa. You've been doing a lot of work with what we call organized medicine for quite a while. And organized medicine is kind of going beyond clinical practice where you're seeing patients, and it is spending time meeting with other doctors, meeting with administrators, trying to understand what patient needs are, trying to really reach out into the community and into the medical system at large and influence change.

Dr. Lisa Ryan:

When I was in my residency, I got interested in working with the American Academy of Pediatrics and was able to take a leadership role within our state chapter and then within our district area, which was all of New England. And I really got to see a little bit more about how organized medicine works. And it was a great experience. I loved it. I made a lot of connections in New England. So after my residency I moved to New Hampshire. I did my residency in Burlington, Vermont, and in. In New Hampshire was able to really get involved with New Hampshire Pediatric Society with doing some legislative work and sitting on their legislative committee, was there for a few years and then sort of migrated to Maine and once again continued to be involved with the state chapter of the American Academy of Pediatrics and then became involved with the Maine Medical Association. So it's been a continuum really since residency training. And I find it fascinating and interesting and really an important part of medicine aside from just patients care. So it's been a wonderful experience and it takes time and it's worthwhile. It's definitely worth it.

Dr. Lisa Belisle:

Having gone from the specialty organized medicine, which is the American Academy of Pediatrics, to the Maine Medical association, which is basically the American Medical association, which is more generalized, representing physicians and healthcare providers. What are you seeing as the differences?

Dr. Lisa Ryan:

There's not really a lot of difference. I think in general, a lot of these organizations, both on a state level or on a national level, really have the same goals in terms of supporting physicians, supporting their members, improving quality and improving health of patients. I think I find the similarities are much more common than the dissimilarities, really.

Dr. Lisa Belisle:

As a doctor, I understand why it would be important to have these groups as a patient. Why is it important to know that our doctors are working in an organized way towards bettering medicine?

Dr. Lisa Ryan:

Well, I think that the organizations hold a certain level of accountability for the profession and most of the Organizations look to policy, look at research, really try to guide medicine in terms of best principles and best practices. And I think it's important for physicians to be involved with organized medicine. It's sort of the mothership, if you will, that really is out there for our profession. And I think as an individual, and I hear this a lot in my experience with organized medicine, individuals will say, well, what do they do for me? How do they know what I want? And I think it's important that. My sense is that the leaders in these organizations really want to know what the individual physicians are struggling with and dealing with and how the organizations can help them. So I see it really as a two way street and I see it important to really make those connections. And there are people in every community that are involved in some degree with organized medicine. And I would encourage physicians to really think about touching base with those physicians that are involved to get their word known.

Dr. Lisa Belisle:

So patients benefit from having providers part of organized medicine because it creates a higher quality of care. It creates sort of an oversight of the profession. And it really, and I guess the term organized, it really is a good one because I think for many years doctors were able to all act independently as they cared for their communities. And increasingly we are connected and to have some sense that what you call best practices or best principles. So if I come in to see you as a pediatrician and my child has some sort of a respiratory illness, you can say to me, well, your child probably doesn't need antibiotics. The best practices are that we actually give your child some supportive care and not go to antibiotics. So it's that sort of thing that we're actually paying attention on a bigger level to the types of things that influence not only our patients and our families, but also the communities and public health. Definitely it's been an interesting thing to see how physicians respond to what has happened in medicine. And I think it would have been easy for you as a doctor to just sort of hunker down, do your work. You know, you have children who are in high school now, so you know, get your job done, put them through college, it's just a job. But instead you've really continued to look at this as a profession and one that you have a lot of. You're very gratified by what keeps you excited and motivated to be in medicine and to work at things in this higher level.

Dr. Lisa Ryan:

I think that's a great point and something I've really thought about as I assume this role of president for the medical association, and I had mentioned I came across a document several months ago that really I've embraced. It's really influenced me in my thought process, and it's very along the lines of what you were talking about in terms of the profession and finding some excitement and some passion and some energy. My sense is, as I travel around, as I meet with fellow physicians, I am sensing a lot of dissatisfaction. I think a lot of physicians are frustrated by what's happening with health care and all the changes that are happening and the onus that they feel is put upon them, not only to take care of patients, which I think all of us feel like we've always done a good job at that, but now there's much more accountability along those lines. This document I came across was actually published in the Annals of internal medicine 12 years ago, and I find it so relevant today and wonder why I haven't seen it for the past 12 years. It's called Medical Professionalism. In the New a Physician Charter. It really looks to all of the changes and understanding the pressures that are going on right now with health care and trying to step back and remember three basic principles involved. The first principle is patient welfare. And that's really, I think, what we all went into medicine for is that we wanted to take good care of our patients. The second principle in the charter is looking at patient autonomy. And I think that's a relatively new phenomenon in medicine, away from the days of the doctor tells the patient what to do and the patient says, okay, and does it. I think we much more want to engage patients now in their health care. It's their health care. They need to be engaged. They need to be a part of that. We as healthcare providers need to talk to them about what their disease process is, how to maintain wellness, talk about options that are out there and really engage them to be partners in that health care. And the third principle of this charter is really social justice. And I think I hadn't necessarily thought about that a lot in the past, but it really is an obligation, I think, of our profession and of ourselves individually to make sure that there's equity in healthcare and that everyone is getting the same quality and the same level of healthcare. So this document has really, in essence, re energized me and my passion for medicine and made me take a step back and say, wait a second, this is why I'm doing what I'm doing. This is what brings me passion, and take that step back and say, okay, you know, refocus and re energize. Because we all fall under the Pressure sometimes when we're overtired and we're stressors in our lives and stressors in our work that it's hard to remember. So I found this. I carry it around with me everywhere.

Dr. Lisa Belisle:

Well, I think that's really important is to know what some of your core values are, because this is something that we can get very distracted away from. We can get so focused on. I have 20 patients to see today, 30 patients to see today. How do I just make it through the list to get everybody happy and try to move them towards health? But instead, if you can really be thinking in the bigger. In the grander scheme of things, is what I'm doing actually heading in the direction of social justice, making patients more autonomous. And the third one is basically just patient welfare and patient welfare, health and well being. Yeah. So if you can be thinking of all of those things, then it gives a sort of bigger purpose to the work that you're doing. And isn't that really what all of us need, is some bigger purpose to the work that we do in our lives? As a patient, what types of things can I do to create a better relationship with my physician? If I'm looking to change providers, for example, or establish care with a new doctor, or in your case, as a pediatrician, you interact a lot with parents. So what are some of the things that I can do to create a good relationship with my provider, who might be a nurse practitioner, who might be a physician assistant? What are some of the questions I can ask? How can patients, from their standpoint, foster that? All of those principles that you just mentioned.

Dr. Lisa Ryan:

I think it's really important for parents and for patients to feel that they can talk to their provider. As I've been around to different practices in different practice settings, I hear a lot from physicians that they don't feel like their patients talk to them and tell them about their concerns. But I think on the same flip side is we as physicians need to change our mindset and change our thoughts with how we walk into a practice and how we walk into an office visit. And I think, you know, for us to take the time and just say, which I've started to do even more so in my practice. What's. What's really. What are you worried about? What's really bothering you? We have to engage in those conversations. And I would hope that patients take more of that responsibility for themselves to feel that they can talk to their physician or their healthcare provider about what they're really worried about. And I get the sense that that's a different mind shift for a lot of patients. I think it's so important. I think it's so important to have a conversation, not somebody telling you what to do and what's going on. I think when you walk in to meet someone, you're interviewing someone as a patient. I really believe in that gut sense of your feeling and your gestalt for a person is really important. We've all had those experiences in different aspects where you reflect and say something just didn't sit well with me and I should have gone with that. And I think that's really important. Your level of comfort, your level of ease with not only the healthcare provider, but really the setting they're in, the environment they're in, how their staff seems. I think that's all important to say, is this a place I feel welcome? Is this a place I feel safe? Is this a place I feel comfortable?

Dr. Lisa Belisle:

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Dr. Lisa Belisle:

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Dr. Lisa Belisle:

What about cost? I know that quality has been an important piece for you and that you've done a project with Maine Quality Counts. And I believe Consumer Reports has somehow gotten involved in questions that we should be all patients should be asking their doctors, really, what's your take on these things?

Dr. Lisa Ryan:

There are five questions. Is the Is the Consumer Reports Quality Counts message about do you really need a test or procedure? Are there other alternatives, other options? What happens if I don't do that test or take that medicine or do that procedure? What are complications and side effects if I do? And how much does that cost? And I think cost is important. We've all sort of shied away from cost over the years, but we know in this country our healthcare costs are astronomical. It really can't continue the way it has. And I think it's important. Those are important questions. And I work for a system. It's difficult to get the answers. I know they're looking at finding the answers, and I'm hoping to at least get some of that paperwork to start to begin to look at it. And I don't have the answers all the time for patients when they come in the office right now, but I think it's my job to be able to guide them and steer them to the places that they could get the answers to those questions. And it's important. A lot of families have very high deductible insurance plans now, and cost is a huge issue.

Dr. Lisa Belisle:

I agree. And when I was in private practice, I knew how much I charged for a patient visit. I knew how much we would bill to the insurance. I knew how much we were likely to get back from an insurance plan. And I had a sense from having investigated this, how much it would cost to order a cholesterol test or an X ray or an mri. I think it's gotten more and more cloudy as time has gone on. And especially working within a healthcare system, it can be very confusing. There are different things called facility charges which are now added into patient visits. And the clearer we can be to ourselves as to how much things are going to cost, the better off everybody's going to be, because there's nothing worse than being a patient who gets a bill for a test that they really weren't sure they needed to have in the first place and have it be so high that they never want to go back and see their doctor again because that trust is broken. I'm thinking about all the changes in medicine that we've had to embrace and actually all the good things that have come out of things like technology and electronic medical records and really this idea of justice. And part of justice is public health. It's the ability to care for people as part of a population. You know, make sure that people are immunized against measles, mumps, and rubella, and make sure that people aren't being exposed to other infectious problems. So how about public health? Tell me how you feel about what we've been doing in public health over the last 10 to 15 years.

Dr. Lisa Ryan:

Well, I think I agree wholeheartedly, and I think the healthier an individual is, and you had mentioned communities. I think it's so important. You know, public health is so important. And I think that, you know, we as healthcare providers are really at the forefront to help educate our families and our patients about the importance of public health. And, I mean, we certainly can see over time the amazing advancements in things like infectious disease. For example, I think right now everyone's really worried about Ebola and worried about the enterovirus. And there are things like that that catch our awareness and our attention in a much more acute situation. And I think that I talk to patients in the office that there are hundreds of enteroviruses. When we talk about the risk and what we look for is not any different for this particular virus. It's the things that we always look for with respiratory infections and things that you're worried about and things that I'm worried about. So I think I've been involved with the school health program in my school district, and really looking at population health, I think we don't always think of that on an individual, provider level. I think we all probably contribute to it without really realizing how much we contribute to it. And I know the public Health committee of the Maine Medical association is probably one of the most active committees within our organization who really embrace public health and looking at all aspects and how that affects Maine citizens. So I think we all do it. I think we don't always consciously understand how much of a role we have in that.

Dr. Lisa Belisle:

We had Gordon Smith on the show, I think, a couple of years ago. Now he's the executive director of the Maine Medical Association. And I was impressed with how the medical association has needed to change its Focus change the way that it outreaches. What are some of the things that the medical association has asked you to champion as the president this next year?

Dr. Lisa Ryan:

Well, I think there's not the issue of championing anything that I get from the medical association and from the leadership. I think it's more on an individual basis, sort of what you're passionate about and what your vision and what your hope is for your term as president. I really feel strongly about physician wellness, physician burnout, physician dissatisfaction. And I think as a medical association, we really need to remember that what we do is taking care of our physicians and our healthcare providers and the quality piece and the patient improving the health of Maine citizens. And I think we have to remember my goal, my vision is to really hear from members to try to re energize members who are feeling dissatisfaction and frustration. I think part of that comes from education and looking at how we have to function now within all these changes in terms of quality documentation, in terms of accountability, in terms of continuing medical education. I think as an organization, we need to be able to support physicians and have answers and resources for them. We are trying to get out. We've done a couple of what we call listening sessions. We've done one in the Portland area and one in the Bangor area, where it's a social event and we invite physicians and healthcare providers in the community. I've been to the one in the Portland area. We have one coming up next week in the Lewiston, Auburn area. It's been great. We've just started this, but I see physicians that I would never see. They don't come to meetings. They're not on our committees. These are physicians out there in the trenches taking care of patients. And we really get to interact as leadership of the organization to see what concerns they have, what things they're worried about, what they're wondering about. And my hope is to really get out there and be out there for physicians to really get a handle on what's going on, what their concerns are, what their joys and what their satisfactions and what their and their accomplishments are also. And really sort of try to energize the healthcare providers. Because you had mentioned it, we're faced with an onslaught of requirements and boxes to check and different things like that to hold accountable for. But I think at the end of the day, we have to remember we're there to really take care of our patients and give them the best quality care and make them as healthy as we can be. And we can't get too wrapped up and too focused in clicking the right boxes and get disengaged from that.

Dr. Lisa Belisle:

Something keeps coming up for me that I think comes up in many of the shows that we do. And that in the end, it really is all about relationships. And when I'm sitting with a patient, I want to be able to work with that person and really in a team, as you've suggested, not just me, but the other people who work in my office and this patient and this patient's family. And I want to have a positive relationship. I don't want a patient to find, come in and feel like they have to be defensive because that seems really. That seems like a harsh term. But sometimes I know that when I'm sitting with people, I am getting the entire medical. I am representative of all of the doctors that have ever done poorly for the patients who come through the door. And that's a heavy burden for me to lift. I would prefer to have somebody come through the door and sit with them and say, I'm on your side. Let's see if we can build this relationship together. I completely understand that you've had difficulties in the past with the medical system at large, or maybe your particular doctor. But let's see where we can start as human beings and start with the human level and really understand it that way. It sounds like this is something that you encourage as well.

Dr. Lisa Ryan:

Definitely, I get to do that. It's the nice thing about being a pediatrician, because I just oftentimes, especially with newborn babies, I'm starting that relationship for the first time with families and with children. And I've been there long enough now that I'm starting to see the children of the children. And it's just. It's great to be in a community. It's great to have that relationship. I don't always make people happy. I understand that, and that's part of human nature. But I think really having that conversation and not feeling like you as a healthcare provider, have to justify the system or justify what's happened to somebody in the past, but to acknowledge that there were issues and there were problems and things that you weren't happy with, and how can we move forward and make this a better relationship than what you've had in the past, I think that's crucial.

Dr. Lisa Belisle:

Lisa, how can people find out about the Maine Medical Association?

Dr. Lisa Ryan:

We have a wonderful website, mainmedical.com you can Google it. And there's lots of information about the medical association, about all the different committees and all the activities and all the things that are going on within the medical association. They are located the office is located in Manchester. And, you know, I certainly, as president this year, encourage anyone to really reach out to me. I want to hear from the members. I want to hear from healthcare providers.

Dr. Lisa Belisle:

I do encourage people to find out what the medical association is doing. If you are a healthcare provider or a patient, it's still it's a very worthwhile organization. And also reach out to Dr. Lisa Ryan, who is a pediatrician at Bridgeton Hospital and the president of the Maine Medical Association. Thanks so much for coming in and talking to us about what's going on in healthcare and for being part of Love Maine Radio.

Dr. Lisa Ryan:

Well, thank you so much. It's been a pleasure and it's always a pleasure to meet with you and talk to you about things again. So I'm thrilled to be here and thank you so much.

Dr. Lisa Belisle:

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Dr. Lisa Belisle:

Love Maine Radio is all about loving Maine. But we can't really think about loving Maine if we don't think about loving ourselves and really our hearts. So today we have with us Dr. Craig Brett, who is the head of cardiology at Mercy Hospital And. And he's also the subject of an article that I wrote for the wellness issue of Maine magazine in January. Thanks so much for coming in and talking to us today.

Dr. Craig Brett:

Thank you. Lisa.

Dr. Lisa Belisle:

Craig, you and I have some similar backgrounds. We both went to the University of Vermont. We both have children who are roughly the same age. I think you have four.

Dr. Craig Brett:

That's correct.

Dr. Lisa Belisle:

And I have only three. Okay, so you beat me on that one.

Dr. Craig Brett:

That's many still.

Dr. Lisa Belisle:

Yeah, it's still more than. So you're busy, and you've been living this busy life for quite a while. The thing that strikes me most about you, though, is that even as a busy doctor, it's been important for you to maintain balance. So let's talk about that. Let's talk about how it is that moving to Maine has enabled you to create a life that is one of balance between your personal life, your professional life, your family.

Dr. Craig Brett:

Well, it sounds like you and I both know where to be in the Northeast, both in Burlington at the University of Vermont, and now in Portland, Maine. I think we've been to the nicest places in the Northeast, and I think we're very fortunate that here in Maine we have the ability to have balance in our lives with the recreational opportunities that are so nearby. We're in a fantastic medical community, which was a major draw for me, and to have those two things together and be able to access those with fairly low hassle. What more could you ask for?

Dr. Lisa Belisle:

You're originally from New York.

Dr. Craig Brett:

That's correct.

Dr. Lisa Belisle:

So when you decided that you were going to raise your children, what was it specifically about Maine and Cape Elizabeth, where you live, that caused you to understand that this would be a good place for children to grow up?

Dr. Craig Brett:

Well, my children are having a very different upbringing than what I had in much. I was in much more of an urban environment in New York. And although it was a great childhood, I think what my kids have here is just wonderful. They get to see their parents enjoy recreational opportunities and stay healthy as a result. I think they've benefited from that. I think the ability to have good schools nearby and to be around people that are motivated and want to do things with their lives has just been fantastic for them.

Dr. Lisa Belisle:

Why did you choose to be a cardiologist?

Dr. Craig Brett:

I knew early on I wanted to go into medicine, and the cardiology interest came later. And I think it was looking around and realizing that the pace of change and the pace of scientific information and kind of knowing the best way to treat patients was just moving really quickly in cardiology compared to some Other fields.

Dr. Lisa Belisle:

So unlike some people perhaps, who are concerned about the pace of change, you were excited by it.

Dr. Craig Brett:

Yeah. And not to pick on some of my other colleagues, but I just. When I look back over my. It's now almost 20 years of practice. The advances in cardiology are just incredible. And I'm not sure, I'm not sure all of our other specialties have seen those kind of advances. And, you know, they're not all technological advances, although many of them are, but just basic understanding of disease processes. I think we've done pretty well in cardiology.

Dr. Lisa Belisle:

It's also fortunate or unfortunate, I guess, that heart disease is the leading killer of Americans, American adults. So I think that more research has gone into it. We know that this is a huge problem. It's not only killing people, but it's also causing morbidity and, you know, long term problems after having heart attacks and strokes and other things related to the heart. So this has been a benefit to your field.

Dr. Craig Brett:

Well, you're right, Lisa, absolutely. I mean, heart disease and stroke are the number one killer of men and women and lead the next three causes combined. And every day nine Mainers die of heart disease. So it's clearly a major health problem, incredibly expensive health problem, and one that we've made some strides on. The mortality rates for heart disease is declining, but it's still a major problem.

Dr. Lisa Belisle:

So there are various risk factors for heart disease. One of them is smoking. I assume that that has the fact that our smoking rates have declined to a certain place and now they've kind of leveled off. But I assume that that's had a positive impact on heart disease.

Dr. Craig Brett:

No question. I think, you know, the understanding of, of the dangers of smoking and the impact that smoking has on the health of blood vessels that's been appreciated now for several decades, has led to some decline in the incidence of heart disease. Maine is still a pretty high smoking incidence state though, so there's still work to be done, but it is better than it was in years past.

Dr. Lisa Belisle:

And is it true that with smoking, once you stop, you actually can reverse some of the damage that the tobacco and the products that are in cigarettes and tobacco products that they. Yeah. So you can reverse that damage?

Dr. Craig Brett:

No question. You know, we have patients all the time who come in who have had a cardiac event, a heart attack, say, and maybe they were smokers, maybe they had other risk factors that they had some control over, like they were overweight or very sedentary. And when people can change those, and not everybody does, but when they can, you can really See that the course of this disease change.

Dr. Lisa Belisle:

So you just mentioned another couple of risk factors for heart disease, and those would be weight and sedentary lifestyle. So what do we know about those? This seems to be something we have. We're struggling actually more with. Whereas smoking rates have declined, the obesity rates have risen.

Dr. Craig Brett:

You're absolutely right. And for a time, there was some controversy about whether obesity was actually a cardiac risk factor. That seems to be pretty much put to bed. It is. And the reason it is is not just the weight that someone is carrying around, the excess weight that somebody who is obese may be carrying around, but the way that that extra weight changes their metabolism. So people that are obese tend to have a very characteristic profile of elevation of a certain type of lipid or fat that's measured in the bloodstream called triglycerides. That elevation also causes risk of plaque buildup in arteries, that obesity. The presence of obesity also results in a body's resistance to the effect of insulin, which we know can create problems in blood vessels. So there's something about the obese state that causes these other metabolic changes that. That we know are directly harmful to the blood vessels.

Dr. Lisa Belisle:

So you're talking about insulin resistance, and that's really related to diabetes. So there's a lot of crossover between the people who have diabetes, the people who are obese, people who have heart disease. Must be an interesting thing for you to try to tease out how to manage all of these problems that are coexisting.

Dr. Craig Brett:

Well, you know, there are several problems that coexist, as, you know, as you mentioned, being obese, having high blood cholesterol, particularly these triglycerides, the insulin resistance, which is the precursor of diabetes. Often their blood pressure is elevated, so it's multiple things, but it really all comes back to that profile. And you can correct all of those things in many cases, just with getting someone's metabolic state back to normal by significant weight loss and exercise. It still remains the best medication we have, so to speak.

Dr. Lisa Belisle:

You're a big fan of exercise. You yourself are a cyclist, and you enjoy skate, skiing on the river in Maine in the winters. So what do you talk to your patients about? Because not everybody is going to be a cyclist. Not everybody is going to enjoy going out in the snow. What do you suggest?

Dr. Craig Brett:

You know, it's so much easier when. When you just love exercise and you miss it when you don't get it. So I think, you know, for those of us that have that temperament, it's easy. Unfortunately, not everybody has that temperament, and for so many of my patients, exercise is just. It's work, it's a chore. You know, they have to drag themselves to wherever they're going to do their exercise activity. For those people, it's a real challenge. And I think these are people that maybe exercise and fitness and doing these types of things has never been a big part of their life, or maybe it was at one point and they just lost track of it and got to a physical state that didn't allow it anymore. So for those people, it is a real challenge, and I don't think there's an easy answer. I think people need to find something that they like to do that burns calories, hopefully in an aerobic fashion. And there's some programs locally that try to promote that, that we direct our patients to. But it is a key thing to find an activity, something that will allow some fitness and hopefully weight loss for these patients.

Dr. Lisa Belisle:

So it really is about enjoyment. You have to find something that you like to do.

Dr. Craig Brett:

I think the people that are successful at it enjoy the activity. I think people where it's always a chore, always a drag, you know, they may do it for a while. It doesn't necessarily become part of their life forever. And so it's an ongoing struggle. But if they can find something they like to do and do it and they get better at it and their body feels better at a certain level of that activity, then it's easy.

Dr. Lisa Belisle:

So we've been talking about things that we enjoy when it comes to physical activity. What about when it comes to eating? That's something. You're a lipidologist. So a lipidologist is somebody who specializes in the fats that are problematic for our arteries. Food is an interesting question these days, isn't it?

Dr. Craig Brett:

There is, and I think everybody out there, so many of my patients out there are confused because there's so many conflicting recommendations that come out seemingly on a weekly basis about what's good, what's not good. Can you eat eggs? Can you eat a margarine? Is butter actually better for you? It just goes on and on and on and can be. Can drive people nuts. And I think a lot of it comes back to just common sense and some basic. Eat certain food groups in moderation. We know for certain that saturated fats and trans fats are bad. These are fats that you see in animal meats predominantly. So you keep that moderate. We know that. That whole grains, we know vegetables, we know most fruits, on the other hand, are good and will lower the bad levels of the Cholesterol and in some cases raise the so called good levels of the cholesterol. So, you know, these are not groundbreaking kind of recommendations. These really get back to a lot of common sense. And I think nitpicking about certain elements is can we use, should we always use olive oil or can we sometimes use safflower oil? I think that's missing the big picture. I think a diet moderate in saturated fats and animal fats, predominantly consuming whole grains, fruits, vegetables, keeping animal protein, you don't have to exclude it completely, but keep it moderate and try to get fish once or twice a week. These are basic recommendations that are still the cornerstone of what we tell people.

Dr. Lisa Belisle:

I have in my family, people who are involved in the paleo diet, which I think doesn't have to be meat, it's definitely low carb. But I know that some people interpret the paleo diet as needing to be more meat because you're cutting out carbs and you need the calories and they want the protein load. So how does that impact one's heart? Do we know?

Dr. Craig Brett:

I think the low carbohydrate diets definitely have their place for the right people. So people that need to lose weight, that have pre diabetes, that have triglycerides elevations, they do need to be on a low carbohydrate diet. And you do replace those calories, typically with protein and often with animal protein. And it's interesting, most people, when they do that diet, if you look at their lipid profiles, they improve, their triglycerides come down, the bad cholesterol levels don't change too much. They might change a little bit, but not too much. There are some people though that have certain genetic predisposition relating to how their liver metabolizes cholesterol, that when they go on one of these low carbohydrate, high protein diets, their bad cholesterol goes crazy and it goes real high. So I think you can do these, these low carbohydrate diets I think can be useful, but they probably should be done under some supervision and making sure at some point a lipid profile, a cholesterol profile is checked if you're going to do that.

Dr. Lisa Belisle:

there are people in Maine, and this is something that you and I talk about in the article for Maine Magazine that are genetically predisposed to having high cholesterol levels. And in fact we had Dr. Derville McCann who's doing a study out of Lewiston and in a small sort of enclave of people who have particularly high cholesterol levels. So genetics are something that we can't really avoid if we're going to metabolize things differently, probably more poorly. That is the way that it is.

Dr. Craig Brett:

It's true, Lisa. You know, we live in a corner of the United States that has a real spike in the instance of this genetic abnormality that goes by the abbreviation FHE for familial hypercholesterolemia. And it's often seen in a French Canadian population. And it's a genetic abnormality where the liver doesn't properly clear the bad cholesterol levels. And this is an incredibly frustrating condition for people because I see people that look like you, they're fit, they're, you know, they're proper weight, they eat right and yet their bad cholesterol level is 350. And they are so frustrated that they can't change that with diet and exercise because they're already eating a prudent diet and exercising and it's terrible for them. These are people that there's just no other option besides medication, unfortunately. But it is treatable and we see a fair number of these people up here. As a lipidologist practicing in northern New England is especially interesting When I go to my meetings, I think my colleagues are a little jealous that I see all these FH patients that they don't have to the same incidence.

Dr. Lisa Belisle:

So we've talked about weight and we've talked about not smoking. We've talked about diet, sedentary lifestyle. One thing we haven't talked about is blood pressure and pulse, which isn't as much of A risk factor. And I want to talk about stress and the relationship between stress and blood pressure, impulse, and just overall cardiac health and what we know about it now, because I think that this is shifting and it's a special interest of yours.

Dr. Craig Brett:

I have been fascinated with the association between stress and heart disease for some time, and there's so many anecdotes. But the clinical evidence is indisputable that people that are chronically stressed have a higher instance of cardiac events than people who don't record chronic stressors. When you evaluate them, it's not entirely clear if chronic stress actually causes atherosclerosis, which is the name of the plaque buildup in the arteries that leads to heart attack, or whether chronic stress just serves as a trigger in people who already have that problem. So, you know, just to kind of review briefly the stress response. You know, humans benefit greatly from the ability to generate a stress response. So when you're faced with a stressor, you have a very immediate activation of your autonomic nervous system. Your heart rate goes up, your blood pressure goes up, your blood sugar goes up, ready for fast energy. Your ability to clot increases so that if you get injured in this fight or flight type of state, you can heal quicker. Your body shunts blood away from kind of more elective functions like digestion and shunts blood over to the muscles, really activates the body for action. And as humans have evolved, this has clearly been a beneficial response. And even in today's society, having that ability is helpful for certain situations. The problem is when those systems are activated chronically, like people who are just stressed out of their mind, and those systems are just constantly activated. Then we see people with problems of hypertension or high blood pressure, diabetes from the high blood sugar, the propensity to clot makes one more susceptible to having a heart attack or stroke. I think we're all familiar with the symptoms people can have when they're chronically stressed. Jittery, they might have some stomach upset, poor digestion, they're a little forgetful, they may be depressed. They're just not. They're not functioning like they should. When these systems are chronically activated. And we see the end result of this as an increased incidence of cardiovascular events like heart attack and stroke. We kind of joke at Mercy Cardiology, where I am, that we know which employers, which places of employment are suffering the most stress, because we'll see clusters of employees come in from certain places during certain times and say, oh, things must be really bad over there. But the association is really it's very clear between these chronic stressors and events, there does seem to be certain stressors that may be particularly bad. Marital discord is a terrible stressor. Chronic marital discord, it's one that's actually been studied. Where this activated system really can be, can be shown and event rates are higher. Caretaker stress, where you're caring for somebody who may be ill or disabled, you know, typically a loved one at home, that generates a tremendous chronic stress response that's quite harmful or can be quite harmful. Workplace stress has been studied, as I mentioned, and particularly, you know, folks who are in a high demand, low control type situation at work, you can measure real profound activation of their chronic stress systems.

Dr. Lisa Belisle:

In our conversation, you mentioned how important you thought it was for us to work with our children in helping them to understand what stress was, what it did to them physically, and how they could mitigate the impact of stress. Because some of the things that we're asking them to do are probably more stressful than we realize. And use the example of kids sports, you said this is something that we're supposed to have as a stress reliever. And if you're an adult, maybe running is a stress reliever. But there's so much pressure on kids in addition to doing their schoolwork and their school play and playing the piano, and then you add kids sports on top of it. So we're actually layering stress onto this generation that's coming up behind us.

Dr. Craig Brett:

I totally agree. I mean, their world, I have teenagers, you have teenagers, Their world can be so stressful. And I'm always amazed at how my kids have to face that and have done okay doing that so far. But I do worry about that. And it is very ironic, as you point out, that sometimes these youth sports, which, you know, if done right, are an incredibly healthy experience for kids, but unfortunately are not done right in many occasions and can be a tremendous stressor. And, you know, the kids oftentimes will need to do something, you know, completely not sport related to find their relaxation, which is, which is a little ironic, kind of opposite from what their parents, you know, find they have to do. But I think that's, you know, it gets back to them finding where they can center themselves, where they can get to a place that, you know, that, where they're not surrounded by that stress. And I think for every kid, that's different. But there's no question the world that they are in right now is not what we had. And I worry about how those stressors starting at this age, you know, may accumulate into adulthood, when they start becoming more at risk for. For the vascular problems that we see later in life.

Dr. Lisa Belisle:

And knowing that we as parents need to find our own way of dealing with stress. Maybe if we're doing yoga or meditation or tai chi or qigong or something, that kind of slows everything down for us. Maybe our children coming up behind us can see how that would be important to integrate into their own lives.

Dr. Craig Brett:

I think that kind of modeling is really important, and I'm not so good at advising people what they should do to find that type of state of relaxation, because it's so different for different people. I know some of my friends like to get on a motorcycle and go for a ride, and other people would find that enormously stressful. And some people find yoga or other activities to be helpful. So I think you just have to find it yourself. You have to find what centers you and what distracts you from all those external stressors that are. That we know can be so detrimental when they're chronic.

Dr. Lisa Belisle:

Any final thoughts as we head into 2015 about staying healthy? I mean, I love the fact that you're a preventive cardiologist rather than an interventional cardiologist. So you're trying to keep people in a good place before anything bad happens to their hearts. What are some suggestions that you have for people?

Dr. Craig Brett:

I think, you know, it's amazing. I see people every day over at Mercy who are otherwise, like, totally in control of their professional life, and they feel like they're all together, and yet they don't know some of the basic numbers in terms of what their own risks may be for developing heart disease. So I think if I could get one word of advice out there is know your numbers. You know, everybody as an adult should know what their lipid profile looks like, whether they have this genetic abnormality that puts them at risk for vascular disease. You should know what your blood pressure is, know what your family history is. Know if you have a profile that, you know, could really benefit from very aggressive preventive measures so that my interventional colleagues don't need to ever see them. I think that, you know, that continually surprises me. And then I think the other thing is, as we've been talking about, I think people need to really understand what the effect of chronic stress is on their body, because I think that's a little underappreciated. Everybody knows stress is bad, but I think the actual effects of that chronic activation and how that promotes clotting and how that may promote atherosclerosis. I think if people know what that's doing to their body, then they may be a little bit more proactive in trying to manage that as best they can.

Dr. Lisa Belisle:

Well, Dr. Brett, I really appreciate your coming in and talking to me today. Obviously, as someone who cares for Maine Hearts, it's important that you're out there doing the work that you do and keeping Maine's hearts healthy. Because we all love Maine Radio, so we need to have healthy hearts so that we can keep on loving our state. We've been speaking with Dr. Craig Brett, who is a cardiologist, the head cardiologist at Mercy Hospital. Thanks so much for coming in and being a part of our show.

Dr. Craig Brett:

Thank you Lisa. Anytime.

Dr. Lisa Belisle:

You have been listening to Love Maine radio show number one 73 Maine Wellness 2015. Our guests have included Dr. Lisa Ryan and Dr. Craig Brett. Love Maine Radio is downloadable for free on itunes. We love to hear from you, so please let us know what you think of Love Maine Radio. 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 Love Maine Radio to you each week. This is Dr. Lisa Belisle. I hope that you have enjoyed our Maine Wellness 2015 show. Thank you for allowing me to be

Dr. Lisa Belisle:

a part of your day.

Dr. Lisa Belisle:

May you have a bountiful life.

Dr. Lisa Belisle:

Sam.