Transcription of Dr. Lowell Gerber for the show Heartfelt, #74
Dr. Lisa When you think of Valentine’s Day, obviously we think of hearts and we’re thinking more about hearts as they relate to love but we also think about hearts as they relate to blood and physiology and of course I think about it this way because I’m a doctor so I’ve invited one of my fellow doctors, Dr. Lowell Gerber, a cardiologist who practices in Freeport to come in and talk to us about this wonderful organ that helps us pump blood throughout our body and really keeps us alive. Thanks for coming in.
Dr. Gerber: Well thank you for such a nice introduction because I too feel that the heart is the source of love and relationships in life. However what you described earlier, in medical school, the medical profession, I sometimes have arguments with my colleagues who say that the heart only exists to hold the two lungs together or the heart only exists to provide a source of blood supply to the brain or the heart only exists to circulate blood to the gastrointestinal tract, to the ovaries, or uterus or whatever their organ of interest is and I’m very pleased to be part of a discussion where we can talk more about the holistic effects of the heart and what it represents.
Lisa: You and I spoke on the phone yesterday and it was interesting to me because you were an interventional cardiologist for …
Dr. Gerber: 30 years.
Lisa: 30 years and I think you described an early sense that really the body was just a box around the heart. When you were … this is the heart, this is your focus, you got to go in there, you’re going to do what you need to, to the heart and the body just becomes a box.
Dr. Gerber: Well and actually it’s … when I step back and have this out of body experience and look back and what I was doing so after the body was lying medicated and I had my means and mechanisms for getting into the body but the heart actually was located in a box suspended over the body when you catheterize it. For many of the newer physicians I think it’s unfortunate that they take this as a video game. Truly for 30 years I was focused on a very small portion in fact when I was putting in a stent in a coronary artery. I was interested in a segment of the artery that was may be 1 to 2 cm long and may be 3 mm in diameter and beyond that it was somebody else’s territory.
I had an interest in cardiac rehabilitation and got my masters degree in exercise physiology and I never gave that up but as I went into medical school I became like all the other doctors and basically put aside everything that I had learnt in the science of anatomy, physiology, pathology, biochemistry and began to follow the guideline-based medicine that we’re all now accustomed to.
Lisa: I want to step back and explain to people who have never been in a cardiac cath lab and may be people who have been but don’t really realize what you’re saying that … and I was part of this when I was a medical resident, a medical student. You go in there, the person is on the table. Stuff is happening to the person. What you’re looking up at is basically a screen, a television screen. So it really does feel like you’re kind of monkeying your fingers around in a very highly skilled way to get the achieved result up on a screen. That must have been a very kind of … let’s just say, disembodied experience.
Dr. Gerber: That’s why I can’t … reflecting back, I’m like 30 years in the cath lab as an out of body experience because we got very accustomed to knowing a patient by the disease that they had and our exposure to the patient very often, mainly physicians I know really didn’t examine the patient very much, interventionalists when they met the patient, there was a small opening over the groin area, now over the wrist and for me that was really the introduction. We try to avoid that now and get to know our patient’s better but still it is a very impersonal way of taking care of patients. This is the surgical approach. There are many people who have bonded with their surgeons or with their obstetricians.
I don’t know as many that bonded with their interventional cardiologist because typically the relationship is quite short what used to be an experience where somebody would have a heart attack. They come in. They’ll be in the hospital for two weeks. Now they come into the emergency room. They’re met with a very skilled team who makes their assessments very quickly. There’s a stopwatch that starts ticking. There’s a time frame to get them into the cardiac catheterization laboratory to get the procedure completed, and it used to be called the door-to-balloon time and now it’s the call-to-balloon time. From the time the patient calls for help, the stopwatch starts.
Lisa: And the balloon is …
Dr. Gerber: The balloon is the device that’s put into the artery to deploy, use it to deploy a little piece of metal that’s called a stent. When the artery is blocked, we open it with a balloon and then put a stent in there to keep it open. It’s all on the clock right now. Now there are case managers who are meeting with the family when the patients come into the emergency room with a heart attack to begin the discharge planning. A patient may come in with a heart attack and be out of the hospital within 24 hours. The whole time that we had to bond with the patient, develop a physician-patient relationship, to take advantage of that teachable moment when the patient and the family are suffering a medical crisis and they’re more open to listen to things, that’s really been diminished.
For many patients, they’re in and out so quickly, for many of them, quite literally it’s difficult for them to believe that anything bad really happened because it goes so quick, they’re sedated, they’re treated very humanely but the teachable moment is gone and so one of my interests is to make lifestyle changes for people. Usually that teachable moment is when the patient and the family are very much open to a lifestyle change but that’s gone for many.
Lisa: Well after 30 years being an interventional cardiologist, for people who are listening in an interventional cardiologist, just to find out a little bit.
Dr. Gerber: There are different types of cardiologists. Back when I started training, there was no such thing as an interventional cardiologist. There were clinical cardiologists who were physicians that often worked in their office and there were invasive cardiologists who often did most of their work or some of their work in the hospital doing these procedures where you actually do something to the patient to make a diagnosis. That something was usually putting a small tube into an artery or peripheral artery usually in the groin and then advancing the tube up into the arteries of the heart and taking a picture of the heart, and often putting a tube into the chambers of the heart to measure the pressures and that was called catheterization.
The invasive cardiologist did cardiac catheterization measuring the pressures of the structure and function of the heart in coronary angiography. It was cardiac catheterization and coronary angiography. Then in the late 70s and early 80s for the first time, we were able to actually do something to the artery besides take a picture of it or measure its function. The first things that were done were using a balloon to stretch the artery open and at the same time we learnt how to stretch the arteries in the legs open, the arteries in the kidneys. The arteries actually into the brain were done very early but the problem was they kept coming back.
Then in the mid 80s and early 90s, we introduced putting little pieces of metal around that balloon called the stent, and that’s probably one of the most frequent procedures done in the United States today is opening an artery through the cardiac catheterization, measuring the pressures and function and the coronary angiography taking the pictures are a preliminary step. Then the next step is actually to do something to the patient to change them. That’s putting the balloon and the stent in.
That has gone well beyond that now because now we put artificial valves in without surgery. We put stents in the carotid arteries to hopefully prevent stroke, into the renal arteries to prevent kidney failure, and the arteries of the legs to relieve symptoms. It has really expanded and now we do this in not only in neonates to avoid recurrent congenital heart surgeries, but there are procedures in utero when the fetus takes …
Lisa: You’re talking about neonates …
Dr. Gerber: We’re talking about babies before they’re born.
Lisa: Babies before they’re born.
Dr. Gerber: This whole idea of interventions in cardiology and radiology, I’ve got to give a lot of recognition and respect to the interventional radiologist who helped this field develop. It’s not just cardiology, it’s not just radiology, it’s been neurologists, it’s been nephrologists. It’s really been blossoming physicians who want to do something for their patients, more proactive than surgery.
Lisa: Well this is a good place from me to jump in because what you just said this time describing, I think it’s really helpful because we hear these terms and people who’re listening, they hear these terms but we don’t always get them defined as clearly as that. The term’s very technical. I mean, you, you, it sounds like a very technical field where you have to be very skilled with your, like you’ve to be intelligent, you’ve to be able to use your fingers in a way to manipulate the things that need to go into very small spaces and it’s … what we’ve been able to offer patients is truly amazing and you’ve been able to prolong lives, you’ve been able to do really wonderful things with the technology. After 30 years of doing this technical stuff, you’ve really shifted the way that you now practice not as, and you’re in the process of shifting … so …
Dr: Gerber: Well, one of my interests became what’s called now multivascular disease and that’s why I try to bring in all those other disciplines because this thing, disease process not only affects the coronary arteries but it affects arteries throughout the body. You reach a point as people age and develop other medical problems that promote this atherosclerosis, do we get to a point where we’re going to put stents in two carotid arteries, two renal arteries, three coronary arteries, and arteries in legs. Where does it end? Maybe we’re approaching this a little too late.
Now my father was a dentist and he got interested in dental prevention very early and was at odds with the Chicago Dental Society because prevention really wasn’t something people were really interested in then. Maybe some of that rubbed off on me as I’ve maintained my interests in interventions but also in cardiac rehab and prevention. A lot of what we’ve heard about prevention has been pretty much held as blasphemy that it doesn’t work, it can’t work, and that anybody who tries to reverse these things is a quack. I believe that.
I had a fair number of patients who were getting chelation therapy in Florida where I practiced for a long time that have failed chelation therapy. The disease progressed despite it and through a course we just had this as this more proved that you can’t change it and what we do as interventional cardiologists putting in a balloon and stent is the answer. Then as we got better at putting balloons and stents, the technology got better, the devices got safer.
We, I’m speaking generically amongst interventional cardiologists and radiologists, started to feel well if most heart attacks occur with a plaque that’s less than 50% blockage, I don’t think most people know that. Most people think that if you’ve severe blockage that’s when you have a heart attack. Well if it happens acutely or if a plaque ruptures and it blocks an artery then people have a heart attack but most of those heart attacks occur from plaques that are less than 50% obstruction of the lumen. In fact, most of them are 30% and we call this now a vulnerable plaque because we know more about the pathophysiology.
Still many of my colleagues felt that well if stenting a 70% to 90% stenosis is a good thing then maybe we should be stenting the 30% to 50% stenoses to prevent them from ever having a heart attack and that was called plaque sealing, s-e-a-l-i-n-g. We hear a lot now about ceilings, fiscal capital debt ceilings but we’re talking about a different type of sealing. Physicians thinking that they were doing a good thing for their patients by sealing these vulnerable plaques in vulnerable patients, we began to create a new disease category of stent thrombosis and stent dissections. We always have to keep in mind that we want to do something for a patient and that to our patients. There is a lot of drive to do things to people for lot of different reasons.
Lisa: You’re right that again, it’s very important. If you’ve a patient who comes in with a lesion you certainly don’t want him to have a heart attack or a stroke so it’s not that this doesn’t have its place but you’ve been working more upstream than that literally and figuratively, I think. You’ve been working more with metabolic disease, with obesity, with dietary changes, and you’ve been trying to get people to a place where you’re trying to impact things before they get to the place where they need to have a stent. Talk to me about that.
Dr. Gerber: This is where I start the conversation with my patients, and I started out my life doing exercise physiology with a master’s degree, was working at a Ph.D. in that. In medical school, I was doing research in endothelium, injecting very minute amounts of what’s called endotoxin and it’s an inflammatory component of bacterial cell walls and studying the interaction between the blood and the vessel wall. I had been looking at that for 30 years.
As I got into interventional cardiology, my life was taken care of the other end of that experimental model that is the effects with chronic disease on the endothelium of plaque buildup. I’ve been trying to put that together, but it’s always been at a distance. It’s been a research interest. It’s been a clinical interest. Then what happens that at age 50, I think I mentioned this at age 50, I realized that I had been doing triathlons, I had been in cross-country team, then an athlete all my life, I was doing triathlons and then at age 50, I started to slow down. I started to gain weight.
I had done nothing different about my exercise regimen or my diet but I was slowing down and gaining weight and my running partner who was 73 years old was starting to pull ahead of me. We would run one day, swim one day, cycle one day, do resistance training one day. Then often we would go and look at the course and do the course because to be competitive, you really had to know the course. You had to know where to leave your bike, where to leave your shoes, where to leave or pickup your goggles. We would do that one day and just do a light workout and then we’ll compete and take a day off. We did that almost every employee could do the triathlon more than once a week if he really wanted to.
My own doctor told me that I should give up the Mediterranean diet that I was on because there was too much fat in it and I should go on a very low-fat diet, get the fat out of my diet, and I should start doing what I told my patients. They should workout 3 to 5 days a week at 30 to 45 minutes of moderate intensity because I was eating too much fat and I was overtraining. I did that and I gained more weight. My cholesterol wasn’t bad, but it never got where we wanted and he wanted to start me on statins. My blood pressure was never really high at rest, but on the treadmill test, it went up a little bit too much and so he wanted me to take an ACE inhibitor. Both my mom and dad had coronary artery disease but both at very late age, but he wanted to be preventive and started me on aspirin.
Now I am on aspirin, beta-blocker, statin, and ACE inhibitor and I’m following the advice I give my patients and I’m gaining weight, my cholesterol is not getting to target, my blood sugar, my fasting blood sugar, it was normal but it was in the upper range, the 90s, and he is telling me that I realize, Dr. Gerber, that you’re very, very busy. You make round to do all these procedures but you need to start taking care of yourself. You need to follow this diet and do this exercise. Then I just kind of got very flushed and had this I call it the aha moment, where I said to myself, oh my God! He is accusing me of not … I’m doing exactly what I should be doing, in fact I’m doing less than what I used to be doing and I’m gaining weight, my blood pressure is going up, my blood sugar and my cholesterol is not at target.
I said, oh my God, my patients weren’t lying to me. I was so arrogant that I would get up 3 o’clock in the morning with a patient having a heart attack, put a balloon in a stent, in the Widowmaker, it’s the proximal part of the artery. If that closes off completely they die. We get them into lab, open a valve by patting on the back, saved your life, pat myself on the back, I saved his life and I’d give him this regimen to follow and ask him to see me back in six weeks to three months and if they weren’t at target that they hadn’t made the goals I set for them, I would have them see my dietitian about a very low-fat diet. I’d have them go to the gym that I selected because they were very medically oriented type of gym and have them follow American College Sports Nursing Guidelines that were recommended, and I’d have them come back and they still hadn’t made their progress.
Again I was so arrogant, I would see you better really get with the guidelines here because you’re going to have another heart attack and nobody maybe able to get to you quick enough to save your life, and they’d say doc, look at me. Here’s my journal. I go to your dietitian, here’s my exercise log, I go to your gym, I breathe air, I drink water, I eat quinoa and look at me. Then when I did it to myself, when I gained 50 pounds, had metabolic syndrome with pre-diabetes, pre-hypertension. My cholesterol was a little bit too high, and then found I had a plaque in my carotid. I said, “Oh my God, I am doing it to myself following the guidelines.” That’s where my life shifted 180 degrees. I said, “You know what? Something’s wrong here.” I had to find out what was wrong.
Lisa: What are you doing differently now? What do you now offer your patients and now practice yourself?
Dr. Gerber: What I had to do for myself was find out why wasn’t I following those guidelines that are supposed to work for everybody? What I did is just had to go back in my memory to where was I when I was working on my Ph.D. in exercise physiology when I was studying body composition and nutrition. I went back and looked at what we knew 40 to 50 years ago and looked at where we are now, and then looked for a type of physician that had a more of a holistic approach to treating the human body than the guidelines. In other ways, what it is about Lowell Gerber that his diet isn’t the same for him as other people that exercise or what are the metabolic hormonal factors are there?
I found a physician that would do that that would have a very personalized approach to find out from detailed history, physical, family history, biochemistry, hormonal patterns where am I today and as most of us in medicine have had to learn, some of us the hard way is that patients have wants and needs and I knew where I wanted to go, but he knew where I needed to go and they weren’t the same because he was thinking about individualized personalized care and I want to follow the guidelines because that’s what I had been taught. It took me a little bit while to wipe my slate clean and follow what they had told me to do that as a former researcher, physician, Ph.D. candidate to go back and look at it for myself and make up my own mind.
Lisa: I could spend hours and hours on so many different aspects of this because I know this is something you’ve dedicated your entire life so it’s too hard to encapsulate this down into an hour long show. How can people find out more about the work that you’re doing in the community and where can they hear you speak and connect with you personally? What’s the best way to reach you?
Dr. Gerber: Well at this moment, I’m actually in a metamorphosis professionally. I’ve done cardiology now for 30 years. Finished my cardiology training, I hate to say this in 1980, and transitioning work to the fulltime practice of a combination of preventive aging, preventive cardiology, and weight management. I’ve been actually questioned by some of my patients about why would a physician who’s interested in preventive aging include children and families by developing a medical retreat for my fantasy would be to have baby boomers with their parents and their kids because when I see a middle-aged woman who comes in who wants to lose weight and she’s got kids at home and her own parents to care for, and she is working because of the economy, she didn’t have time to fix different meals. So part of the challenge is to figure out the dynamics of the family as well as the dynamics. It has to be a lifestyle to stick with. It may not be perfect but it’s better than what they’re doing.
I see children who are and you probably see them as well, there are infants. Most recent I took care of a 9-year-old who had obesity, hypertension, pre‑diabetes, and hyperlipidemia and the answer by his pediatrician was to make him work out more and put him on antihypertensives, glucose lowering, and statin drugs.
Lisa: When people come to see you, you don’t do that for them, and I know your practice is in transition but how do people contact you?
Dr. Gerber: I have a webpage and you can go to www.leanerme.com or the new complete packs of Leaner Me as the weight management aspect. I have an age management practice which was live younger, love longer, and be strong and those two are being combined into a single program called Younger Leaner Me. All those will lead to me. I didn’t bring a business card today because those are being, I’ve got consultants, my goodness, telling me how to design the card, how many letters to have in it, and that’s the part of this I don’t like, but in order to get the word out as we’re doing for me now, people need to know how to get a hold of me so www.leanerme.com is probably the easiest. I hope to have the new practice up and running full probably by Valentine’s Day. That’s kind of my target right now.
Lisa: Perfect. As I said you just are a wealth of information and I know that there are many, many more shows that we could do on various aspects of what you’re doing, and I congratulate you for spending all of this time and really trying to understand things that you’ve gotten great personalized plans for people, preventive cardiology plans, and other weight loss plans. I appreciate your coming in and speaking with us today. We’ve been talking with, Dr. Lowell Gerber, whose cardiology practice is in Freeport.
Dr. Gerber: Thank you so much for helping me get the message out for particularly putting it on Valentine’s Day, and I will be giving this talk on Preventive Cardiology in Freeport in Portland, and it will be in the newspaper and on my website.