Letter From the Lipid Spin Editors: Tele-Lipidology?

“I sometimes joke that if you come to our hospital missing a finger, no one will believe you until we get a CAT scan, an MRI and an orthopedic consult. We just don’t trust our senses.” ~ Dr. Abraham Verghese

Recently, I had the opportunity to reread an old article on the importance of recognizing that achilles tendinitis in a child might be an early physical finding in familial hypercholesterolemia (FH).¹ Just after this, I happened to read an article in The New York Times by a colleague of mine, Dr. Danielle Ofri,² which discusses the concerns, issues, and perhaps diminishing role of the physical exam in the provider/patient relationship. The article, which is thoughtful and reasonable in it’s assessment and conclusions, got me thinking about how this impacts the specialty of clinical lipidology.

No one practicing clinical lipidology would underestimate the importance of the physical exam. I have written about this before; we have dedicated and entire issue of the LipidSpin to this topic.³ In the diagnosis of inherited lipid disorders, physical diagnosis skills are crucial. The presence of peripheral stigmata of cholesterol deposition such as: xanthoma, xanthelasma, corneal arcus, palmar xanthoma, planar xanthoma, lipemia retinalis, and eruptive xanthoma are all well recognized as part of the physical diagnosis leading to detecting and treating lipid disorders. Diagnostic criteria for many lipid disorders such as familial hypercholesterolemia include the physical exam findings.

In her article, Dr. Ofri points out that the insertion of electronic medical records into the office visit creates a barrier between the patient and the practitioner — often removed when both enter the exam room. While the discovery of physical findings can take place here, often this is when the best “eye-to-eye” contact takes place. Personally, I find this is the time that subtle and seemingly less important aspects of the patients’ medical history come to light. This may also be the time that an accompanying partner, spouse or parent is absent, perhaps an opportunity for patients to answer questions more honestly.

Although the EMR is one barrier to this process, it can also be of help. A welldesigned EMR will ask for presence or absence of physical findings to assist in the diagnosis. It may also act as a prompt for additional studies or lab testing. On the other hand, this proliferation of additional available testing might also serve to disconnect the clinical lipidologist from the physical exam. While imaging studies, biomarkers, sterol absorption markers, genetic testing, and lipoprotein analysis can be useful in the diagnosis and treatment of patients with lipid disorders, their proliferation can sometimes cloud issues in diagnosis and management. Recent data published in Europe and from clinical trials here in the U.S. has changed the way we think of patients with FH. Overlap between phenotype and genotype is not uncommon, and variations in clinical presentation seem to be the norm rather than the exception.⁴

This leads me to a final proliferative development that I find both exciting and potentially concerning — the slow but steady development of telemedicine and its role in our field of clinical lipidology.^5,6 One might think that the online intake of a history and lab data, along with a phone interview or video-chat might be sufficient for evaluation of a patient with a lipid disorder. For many without access to a specialist this might be true.7 I do not, however, believe that this process is better than or should replace face-to-face interaction. If these live visits continue to diminish and marginalize the physical exam, we might as well all put on our bedroom slippers, pull up a monitor, and go to work!

“Declare the past, diagnose the present, fore-tell the future.” ~ Hippocrates  

References are listed on page 35 of the PDF.