Going to new primary care doc: is it reasonable to ask for advanced lipids?

[Ruth]

Apologies if this is the wrong section for this question or if it's been covered before.

Later this week I have an appointment for a physical with a new primary care doctor assigned to me through my Obamacare (Kaiser) insurance. (I'm between jobs now so no longer have my previous insurance.) Besides getting my HRT Rx renewed, I plan to ask her for basic labs (which I assume she would want to do anyway, especially since I haven't had any done since 2014) and also ask that my HbA1c and fasting insulin be tested.

I'm wondering if I should ask her for advanced lipids or whether perhaps that would be unreasonable given that I am a 47 year-old female in good health, with no history of having anything amiss on the traditional cholesterol tests or bad family history, etc. Perhaps the advanced lipid tests that members discuss here frequently are something regular primary care physicians don't really deal in? If all goes well I am planning to mention my 4/4 status "off the record" and I see from the doctor's info page on the Kaiser website that one of her professional interests is hypercholesterolemia, so maybe she might be hip to apoe4 and thus wouldn't just automatically consider me "low risk". I'd just love to make sure something isn't brewing that I'm unaware of, and at the very least get a good baseline for the future....

I don't want to be too pushy with a new doctor who's never met me before, but also don't want to fall into my usual medical trap of being overly deferential/people-pleasing. Any thoughts appreciated!

[Julie G]

Good question, Ruth. Many of us struggle with this all of the time. If you have a good rapport with your new physician, why NOT ask if you could reveal some off-the-record genetic information? If she's agreeable, you could point out that your 4/4 status puts you at a high risk of CAD. As such, you'd like to check your advanced lipids. Another one time test that all E4 carriers should request is your Lp(a) level. This is a genetically driven independent CAD risk factor. Current thinking is that moderating LDL-P or ApoB is more important for folks with high levels. Good luck! Let us know how it goes.

[apod]

I think it's fairly reasonable to ask. If you're going to test lipids with routine labwork, you might as well actually test them well -- a job worth doing is worth doing right.

On the other hand, my primary care doctor (an excellent cardiologist / surgeon) feels that advanced lipids are basically useless -- as in "You're not going to actually... change what you're eating based on these results... are you?" and feels like it's better to not look for trouble unless you're prepared to handle potentially negative results with follow-up surgeries or pharmaceutical drugs... I ended up doing my advanced labs off the record.

You'll have to feel it out with your doctor. I'm on the lookout for a good Functional Medicine practitioner, so I have a few different guys to bounce things off.

[ru442]

Mine actually was very open given my cardio risk, and turns out her mom is 3/4. My mantra is it does not hurt to ask, especially if insurance will cover, in which case it really is not up to your gp imho.

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[Tiramisu1984]

What's the harm in asking? I brought bredesen's study to an appointment with my primary, and she ordered every lab she thought insurance would pay for.

[Nancy]

Yes, I would ask. Doctors are so busy these days, it's ok to be proactive. Your health is important.

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[KatieS]

Ruth, with my insurance-covered doctor, I ask for certain labs (i.e. HCY. VitD, A1c, insulin, B12) with a list of my changes I will make should the result confirm the need for these changes. I asked for a "one-time" advanced lipid panel which discovered a discordance, basically my normal LDL but high LDL particle count and an unbelievably high lp(a). My best friend (3/3, but +CA score) was unable to have an advanced lipid panel with Kaiser. Many intuitions are under protocols that prohibit primary care doctors from being able to order this test, so she used Walk-In lab. Since her labs were consistent with the basic lipid panel, this will be a one-time lab for her.

[ABrain4Me]

I tried to have my PCP order cholesterol sub-particle testing, and she refused, stating they weren't necessary. She used to routinely measure Vitamin D levels, and has stopped that testing as well. I believe she's now having to follow protocols of her medical group. She also had told me that the above tests would be denied as experimental by my insurance coverage.

Sure enough, when I went to Dr Gundry and had his testing, my insurance denied all of it as experimental and investigational. The mainstream has not bought into these tests as medically necessary unfortunately.

[Ruth]

Thanks to everyone for their input! So helpful and I really appreciate it. Well, I saw the new doctor today and while she didn't seem super-informed about apoE4, she was very kind and seemed genuinely concerned when I got a little teary-eyed talking about my cognitive/cardio concerns. She had heard of 23andMe but didn't seem to really know much about it (she is from another country but with excellent English; also new to this particular area I think as well, which is 23andMe's backyard) so we went online and I showed her the site, how it works, the fun ancestry info, how from it I got the expanded info from Promothease, etc. I got the feeling she had never had a "healthy" patient bounce into her office with my situation before, so at the very least I felt like I was possibly helping pave the way for future apoE4 folks she might encounter.

She has ordered basic labs and HbA1c, and as we talked about it seemed to be looking in the database she was working in in Kaiser for a way to order a fasting insulin test outside of T1D and T2D. But we're going to video chat on Friday about my lab results, and I will see if she's agreeable to ordering more tests at that point; probably it depends if something questionable comes up. If not, I will just do the other tests myself, no big deal.

So all in all, it was fine. This morning I also decided to just have it all in my chart and be out there about it (with the medical profession, at least) and be done with it. I can't afford to purchase long term care insurance so I just won't worry about that angle anymore, or any other similar hypotheticals. Rejecting that feeling of having to be secret felt good, one less thing to stress about.

[Nancy]

So glad it went well. Now she'll know more about it to help others, as well. Good job!

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