Dr. Josh Wageman brings a rare blend of expertise to cardiovascular prevention. With credentials spanning physical therapy, biochemistry, and Yale PA training, he's transformed how we understand lipid science through brilliant, accessible metaphors that make complex medical concepts understandable to everyone.
At the heart of our conversation is Josh's innovative framework that reimagines cardiovascular health as a "home security system" and cholesterol management as living in a "safe lipid neighborhood." Rather than overwhelming listeners with biochemical pathways, he translates these concepts into vivid metaphors - LDL particles become mailmen delivering packages, HDL serves as the police force, and lipoprotein(a) represents potential felons threatening arterial walls. This approach fulfills what Josh describes as the true test of understanding: "If you can explain it to somebody who may not be familiar with the topic."
Josh challenges several persistent misconceptions about cholesterol. He explains why LDL isn't inherently "bad" (it's only problematic when depositing cholesterol in arterial walls) and why high HDL doesn't necessarily mean protection. "Just relying on your HDL cholesterol to tell you anything about its functionality is irresponsible," he notes, sharing examples where patients with impressive HDL numbers had extensive coronary disease.
Most powerfully, Josh advocates for shifting cardiovascular care from reactive to preventive approaches. He explains why standard risk calculators miss significant disease and why additional tools like coronary artery calcium scoring can be life-saving. Through a striking example of a physically fit friend whose 10-year risk was calculated at just 2.3%, yet required five-vessel bypass surgery, Josh demonstrates why we need to look beyond traditional metrics.
Beyond technical expertise, Josh emphasizes the human element in medicine: "No one cares how much you know until they know how much you care." His approach reminds us that effective healthcare requires not just knowledge, but the ability to communicate in ways patients understand and trust.
Want to prevent heart attacks, strokes and dementia? Find "The Home Security System in the Lipid Neighborhood" on Amazon and follow Josh on LinkedIn and Twitter for more insights that could save your life.
Amazon: https://www.amazon.com/Security-System-Lipid-Neighborhood-Complicating/dp/B0DTJ1HJ4Y
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Ashley (00:00):
Hello and welcome to Shadow Me Next, a podcast where
I take you into and behind thescenes of the medical world to
provide you with a deeperunderstanding of the human side
of medicine.
I'm Ashley, a physicianassistant, medical editor,
clinical preceptor and thecreator of Shadow Me Next.
It is my pleasure to introduceyou to incredible members of the
(00:22):
healthcare field and uncovertheir unique stories, the joys
and challenges they face andwhat drives them in their
careers.
It's access you want andstories you need, whether you're
a pre-health student or simplycurious about the healthcare
field.
I invite you to join me as wetake a conversational and
personal look into the lives andminds of leaders in medicine.
(00:44):
I don't want you to miss asingle one of these
conversations, so make sure thatyou subscribe to this podcast,
which will automatically notifyyou when new episodes are
dropped, and follow us onInstagram and Facebook at shadow
me next, where we will reviewhighlights from this
conversation and where I'll giveyou sneak previews of our
upcoming guests.
Today's guest has one of themost unique backgrounds we've
(01:07):
ever featured on the show andsomehow he makes it all feel
effortless.
Dr Josh Wagman holds a doctoratein physical therapy, a PhD in
biochemistry and is aYale-trained physician assistant
.
He's also a nationallyrecognized lipid specialist,
teaching clinicians across thecountry how to approach
cardiovascular prevention withclarity, evidence and a little
(01:31):
creativity.
What makes Josh stand out isn'tjust the alphabet soup behind
his name.
It's the way he connects withpeople, whether he's mentoring
students, caring for patients orspeaking at medical programs.
He uses analogies, humor andillustrative storytelling to
make even the most complextopics like lipoproteins and
(01:53):
atherosclerosis easy tounderstand and even enjoyable.
In this conversation we talkabout his book the Home Security
System and the LipidNeighborhood, which reframes
cholesterol and cardiovascularrisk into a language we can all
understand.
We dive into how he teachesboth patients and clinicians to
(02:14):
embrace prevention, what'smissing from traditional medical
education, and how meaningfulcare often starts with time,
attention and compassion.
Meaningful care often startswith time, attention and
compassion.
Please keep in mind that thecontent of this podcast is
intended for informational andentertainment purposes only and
should not be considered asprofessional medical advice.
(02:34):
The views and opinionsexpressed in this podcast are
those of the host and guests anddo not necessarily reflect the
official policy or position ofany other agency, organization,
employer or company.
This is Shadow Me Next with DrJosh Wagman.
Hey, josh, thank you so muchfor joining us today on Shadow
(02:58):
Me.
Next, I cannot wait to talk toyou about number one your road
in your career to where you'reat right now, but also this
incredible resource in this bookthat you have authored.
Thank you for joining us.
Thanks for jumping in.
Josh (03:06):
Hey, thank you so much for having me.
I love doing this and it'salways a pleasure.
Ashley (03:12):
Thanks, josh.
So you have your PhD inbiochemistry, you're a doctor of
physical therapy and you're aPA.
You graduated from Yale.
Oh my gosh, can you take us onthis educational journey?
Tell us a little bit about howyou ended up?
Yeah, yeah.
Josh (03:29):
It's.
If anybody has even a remotelysimilar background, I'd like to
meet that person.
But basically all that, thatcomically viscous alphabet soup
of letters behind my name, itreally just means that I'm very
limited on useful life skills,except going to school and
taking tests, and but you know,so I have all these these
(03:49):
letters like, oh, what does thatmean?
But really it's been aprivilege just to have all these
opportunities.
But what I always say is, themagic is in the person, not the
credential, and so but I'llexplain a little bit of how this
happens.
So my first doctorate wasactually in physical therapy,
and so I'm a physical therapistand, uh, you know I keep a
treatment table at church sothat somebody walks in with a
(04:12):
Trendelenburg gate.
You know I can help them withtheir trochanteric bursitis or
whatever, so so I do, uh, youknow, pro bono stuff there.
But, um, so you know that wasmy first doctorate.
It was actually I got really,really sick when I was in PT
school and that catalyzed mylove for endocrinology and
biochemistry.
And so, even though I graduatedPT school and worked as a
(04:33):
physical therapist, there wasnever a sense of finality that I
was done there just because Igot really really really super
sick and nobody could reallyfigure it out.
And so I was like, well, I'mgoing to try and figure this
stuff out.
And I was like, man, this stuffis really really cool.
So anyway, so that helpedfoster the person I became along
the way.
And so I was like, well, I'mkind of old so I don't want to
(04:55):
go all the way back to medschool.
So I figured I'd go to PAschool and that was a super fun
time and went through the YaleSchool of Medicine for PA school
enjoyed PA school a ton.
That was a super fun time.
And went to through the YaleSchool of Medicine for PA school
enjoyed PA school a ton.
That was, that was a blast.
And then couldn't help myselfand ended up getting my working
on my PhD along the way as faras cholesterol disturbances and
(05:16):
Alzheimer's disease.
But really a lot of thishappened too because I'm a lipid
specialist.
So I'm best known as a lipidspecialist.
I teach lipid physiology andcholesterol.
I'm best known as a lipidspecialist.
I teach lipid physiology andcholesterol homeostasis across
the country.
I'm adjunct faculty at variousmedical programs.
I'm also a medical scienceliaison and I have to remember
to say that nothing I'm sayinghere today reflects the opinions
(05:37):
or medical strategies of Amgen,just so that we can have our
unadulterated fun.
But anyway, I'm best knownnowadays as teaching lipids and,
for you know, writing booksabout lipids and so.
But really, the way that Ibecame a lipid specialist, I
wish it was some really great,you know, humanitarian reason
where I had some uncle Steve orsomething and he had premature
(05:59):
cardiovascular disease and Iwanted to devote my life's work
to helping people avoid the samefate.
But actually it was because Ihad a patient cancel one day and
I was sitting there and I wasreading some stuff.
I read voraciously everythingyou know, from Brave New World
to the Journal of ClinicalLipidology, and so I was like,
(06:20):
okay, well, basics oflipoproteins, which is kind of
what the article title wassomething obnoxiously
condescending like that, and Iwas like, how hard can this be?
You know, I mean I can justthrow down a pentose phosphate
pathway.
If you're lucky, I might throwin a Cahill cycle, you know.
I thought, okay, I'm good atthis stuff.
And so I read this article thatwas supposed to be a rudimentary
review of this topic and Ibarely understood any of it and
(06:40):
it made me mad.
So, anyway.
So I devoted myself to learningall this stuff and, you know,
took the lipid boards and things, and so anyway.
So that's how that happened.
But along the way I'vehopefully gleaned some things
that can help people not haveheart attack, strokes and
dementia, which is my whole goalfor what I do on a day to day
basis and my whole goal inwriting this book that I'm sure
(07:03):
we're going to talk about thehome security system in the
Olympic neighborhood.
Ashley (07:07):
That's incredible.
I think it is so funny that itwas a challenge to you.
Hey, I want to understand thisbetter.
Why am I not understanding this?
I think I get it.
And for you to feel that waywith all of your education and
all of your background knowledge, then to take a step back and
realize the people that this isactually affecting how little
(07:27):
they probably understand andrealize and know about lipids,
how they affect you, what organsthey affect, the things that
they do on those organs, thingslike that.
Josh (07:37):
Yeah.
Ashley (07:38):
That's probably where you got the idea for the book.
Josh (07:40):
Yeah, yeah, and you know, whenever you tackle any sort of
subject, you want to make surethat you understand it, and I
think one of the ways that youshow that you can understand
something is if you can explainit to somebody who may not be as
familiar with the topic.
And I read lots of things andwe some of our favorite teachers
(08:02):
, I think, along the wayprobably painted things, using
metaphors and using wordpictures, rather than just
dealing with esotericbiochemical pathways and hey, I
love me some esotericbiochemical pathways, right, but
most people are normal and theydon't prefer those things.
They like to deal in thingsthat are more relatable to them.
And so that's where I was likehuh, I want to come up with a
(08:24):
relatable framework for nothaving heart attacks, strokes
and dementia.
And so, basically, what I cameup with is I was and I would
start saying this to my patientstoo I said, hey, you and I have
the common goal of you nothaving heart attacks and strokes
and then, down the line,dementia.
Yes, that is, that is true.
So for you, I want you to havea great home security system and
(08:46):
I want you to live in a safelipid neighborhood.
So your home security systemhas four basic pillars normal
blood sugars, normal bloodpressures, keep inflammation low
and don't smoke or do drugs.
Those are bad.
Every ApoB containinglipoprotein, the vast majority
(09:06):
of those being LDL particles,are potential criminals that can
infiltrate your arterial abode.
And the Lp little a particles.
If you pick the wrong parentswith that genetic risk factor,
those are the felons, becauseper particle, they're about six
and a half times as likely tocause mischief in your arterial
wall than your run-of-the-millLDL particle.
Okay, so let's look at thesethings.
We have many ways of measuringyour parameters of blood glucose
(09:26):
metabolism, and I would saythat that extends beyond just
blood sugar to insulin control.
Your insulin control, your lifeis one of my mantras.
Okay, so nobody ever said boy,new year's resolution 2025, I'm
going to be more insulinresistant.
No, you know.
And nobody ever said you knowwhat?
Today's the day I start smoking.
This is a good health choice.
No, so there's the axiomsnormal blood sugar, normal blood
pressure, keep inflammation lowand don't smoke or do drugs.
(09:53):
But then our lipid panelrequires some context and that
requires a little moreunderstanding, because it can
kind of look like you're livingin a rough lipid neighborhood on
paper, but people don't live onpaper.
So one of my catchphrases isgot plaque, get a CAC.
What's a CAC?
Coronary artery calcium score?
It's the colonoscopy of theheart, without the nasty pregame
show, because anybody who'sever done a bowel prep knows
that that, will you know,temporarily ruin your social
life and probably destroy yourbathroom also and so.
(10:15):
But with the CAC you lay down,it's a low dose CT scan about
the same amount of radiation asa mammogram, virtually nothing.
And it shows you if you havecalcified plaque in your
coronaries or if you don't.
And that's actually a latefinding in the atherosclerotic
disease process.
It shows you have you beenbroken into?
And if you have been brokeninto, do you want to keep living
(10:36):
in the same rough lipidneighborhood that got you broken
into or do you want to considermoving to a safe, gated
community with fewer lipidcriminals?
Seems reasonable.
Put another way, if you have anyplaque in your coronaries, do
you want that plaque stable orunstable?
And we know from variousstudies like ICONIC that most
myocardial infarctions don'toccur in a vessel with
significant stenosis.
(10:56):
You're fine until you're not.
It's a vulnerable plaque.
It ruptures and then you're100% included.
No good and so.
But are there ways to conferplaque stability.
Are there ways to even furtherregress that plaque and further
stabilize it?
Yes, and so we should probablywant to do those and get ahead
of the game, and one of my goalsis to shift the paradigm for
cardiovascular disease fromreactionary to preventive, and I
(11:18):
think we can do that with justa little bit more understanding
of the various tools in ourtoolbox and the various
diagnostic, both biomarkers froma blood based standpoint and
imaging, to help inform ourdecision making process.
Ashley (11:32):
There's two, there's two directions that I want to take
from this, and both of them bothof them kind of, I would love
to hear your experience and justspeaking with patients about
these sorts of things, because Ithink with both and tell me if
I'm wrong we really are going tohave to partner with our
patients when it comes to makingchanges in this.
So the first well, I'll tellyou what the two are.
The first one is illustrativepatient education, and the
(11:55):
person that I spoke with rightbefore you, dr Zareik, he brings
a he's an internal medicineattending.
He brings a whiteboard into theroom with his, with his
residents, with the patients,with everybody, and he literally
does many.
Ted talks on the whiteboardwith a marker.
You are illustrative in thesense that you use your words to
(12:17):
tell these stories to patients.
That better illustrates, andclinicians at this point,
because you're teachingclinicians how to process this
too, to better illustrate thiswhole process that you just
described.
So, number one, illustrativepatient education.
We'll get to that.
Number two is preventivemedicine, and this is obviously
something you feel verypassionate about, first being
the illustrative patienteducation.
(12:39):
Tell me about this.
Does this work?
Josh (12:43):
Oh yeah, it takes time, though.
Right, and that's one of themany flaws of our medical system
is people are wheeled in andout in five to 10 minute visits.
How are you supposed toaccomplish anything in that
amount of time, and especiallywhen people have questions and
they want to talk about otherstuff, and I mean you want to
talk about your lives, you wantto talk about other stuff, and I
mean I, I mean you want to talkabout your lives, you know you
want to talk about.
Ashley (13:02):
Hey, how's your kids doing?
You know, oh.
Josh (13:04):
Oh yeah, no, no, my kid did a grand slam last night and
having that human element ishuge.
So you have to have some timeand you also have to meet people
where they're at, because, eventhough you know you and I might
understand, you know PI3,kinase, akt signaling, when it
comes to you know the insulinpathway, these people are just
like I, those you're sayingwords, but I don't understand
(13:26):
them and I hate you and I'mgoing to walk out, you know.
So you don't want that, and soyou meet people where they're at
and that's why I was like Ineed to come up with a way that
people can actually understandwhat we're doing here, because a
good reason for a patient isnot I'm a doctor or I'm a PA or
whatever your title is.
You know, and you're justbludgeoning them over the head
with your rationales and theydon't understand them because
(13:49):
it's their life.
You know, you want to help themwith their life, but together
you are leading them kind of tothat conclusion that you know
because you have, you know, someexperience and some clinical
acumen, hopefully.
Conclusion that you knowbecause you have you know, some
experience and some clinicalacumen, hopefully.
But together, you know, it's alot better when you get there
together, rather than, you know,you're just forcing them and
they feel forced, rather than,hey, let's, let's take this
(14:12):
journey together.
And so that's why I think it'sreally important to tell stories
and to make it in a way thatpeople understand.
And I have a lot of, you know,metaphors in my back pocket, and
sometimes the first one doesn'twork, so it's like, all right,
let's try number two, you know.
And so to find a way that canreally resonate with them.
And so, and that's why there'slots of metaphors and there's
(14:33):
pictures in my book, you know,and my daughter, who turns eight
tomorrow happy birthday to Mia.
She can explain to you, youknow, how potentially
atherogenic particles arecleared via the LDL receptor,
and she can tell you what PCSK9does.
And she can tell you about theApoB, the ApoBear, you know, and
that's her favorite part of thebook, you know, because there's
pictures there.
So, anyway, so if you can comeup with a way that people from
(14:55):
various walks of life, withvarious backgrounds, with
varying degrees of expertise,can really vibe with you, that
that means a lot, and thenpeople are going to buy in to
what you think is going to bebest for the trajectory of their
life when it comes tocardiovascular health as well,
and so cause a lot of clinicians.
You know they complain oh,people don't do this, people are
(15:15):
noncompliant.
I mean I had like a couple um,but really, if you explain it in
a way that makes sense, youknow, I think it's logical and
they realize that you care aboutthem.
No one cares how much you knowuntil they know how much you
care.
Ashley (15:30):
I love that.
I really, really like that.
No one cares how much you knowuntil they know how much you
care.
And it does take time.
That does take time.
I mean you can't just walk inwith a sign I wish you could
assign, you hold it up and yousay I really care about you
Trust me, trust me.
No, and I think I think the sameholds true both for that
(15:51):
illustrative patient education,but also for preventive medicine
too.
Okay, tell me about this whenyou're talking with a patient
about this sort of thing, assomebody who really gets it
right, Somebody who understandswhat you're saying and is on
board, what is something thatyou explain to them that
surprises them?
What's the biggest surprisethat patients go?
What?
Josh (16:12):
Yeah.
So I think I mean there's a lotof misconceptions and that's
why I had to write a book, youknow.
But really I think thathistorically, in our didactic
programs, even two people gettaught LDL bad, hdl good,
everybody.
Take a statin, you know, putthem in the drinking water, you
(16:32):
know.
And so.
So I like to address thosemisconceptions most of the time.
And so the first one LDL bad.
Well, ldl particles are notinherently bad, they're mailmen.
Right, most mailmen are not baddudes.
Their job is to deliver themail.
What's the mail?
Triglyceride packages.
And then they go home todeliver.
At the end of the day, that'sgreat.
(16:52):
But if one of these mailmen,instead of delivering
triglyceride packages to themuscle cell or fat cell,
delivers packages to yourarterial wall and runs a stretch
in your arterial wall, wellthat's a bad mailman.
And we need to discuss how toaddress the corrupt workforce,
because you cannot haveatherosclerosis without one of
(17:13):
these mailmen going rogue andrunning a stretch in your
arterial wall.
And then it's the maladaptiveimmune response that results in
foam cells, fatty streaks,plaque formation, which can
subsequently lead to clinicalevents.
And so we have to establishthose things, because people you
know they don't, it's hard toknow what to believe as a
consumer, even a clinician,because you know some people
will be like oh no, cholesterolis is amazing.
(17:35):
Well, a lack of cholesterolisn't compatible with life, you
know, it's an important part ofour cell membranes.
We need them for bile acids.
We need them for steroidhormones.
20 to 25% of our total bodycholesterol is in the brain.
Ashley (17:45):
Pretty important up there, so you know so all these
things you have to.
Josh (17:48):
It requires some context and so, but just to say that
this is bad or this is good, no,no, no, no, no.
And so we have to.
It's a little more complicatedthan that.
It's not binary.
Additionally, something thatpatients I think this is very
common for patients is theythink that HDL is good.
They call it the goodcholesterol.
They come in and they're likewell, my ratio is good, like
(18:10):
their triglyceride to HDL ratio.
Okay.
So what I'll say is HDLcholesterol, hdl particles they
can do a lot of good things.
Okay.
So HDL particles are kind oflike the police force.
They can actually arrive at thescene of a crime in the
arterial wall and if there's acholesterol laden perpetrator,
they can actually efflux thatout of the arterial wall, take
(18:31):
it back to the liver and we canbe okay.
So that's cool.
Hdl particles can actuallyincrease glucose uptake into
skeletal muscle.
Well, that's a reallycharitable community activity.
So they can do all these thingsand there's a bunch of other
things they can do as well.
But just a static measure ofHDL cholesterol on your blood
panel gives you no idea of itsfunctionality.
(18:53):
You don't know if this is agood cop or maybe not so good.
A lot of times, people withreally high HDL cholesterol,
they will have dysfunctional HDLparticles and they will have
advanced cardiovascular disease.
So I had a patient who she cameinto me and she was like, oh
yeah, you know, I'm fine, don'tworry about my cholesterol.
I mean, my, my good cholesterolis so high, you know.
(19:13):
And she wasn't, you know,insulin resistant.
So triglycerides were, wereokay, and her HDL cholesterol
was like 108 or something.
And she was telling me about herfamily history.
Though, and her family historyis telling me a far different
story, you know, and her, youknow, brothers are all having
MIs and pretty early age andpeople are having strokes.
And I'm like, yeah, let's get,let's get that CAC.
You know that coronary arterycalcium score, and and her 10
(19:36):
year risk calculator was quitelow too, which you know, I'll
tell you how I feel about thoseand she had a coronary artery
calcium score of over a thousand.
Ok, so she had advanced diseaseand we had to intervene
appropriately there.
So, anyway, so, basically, justrelying on your HDL cholesterol
, you know, to tell you anythingabout its functionality is
irresponsible now and so, anyway, so that's, that's the HDL
(19:56):
story and that was a long windedanswer to that because I think
it's interesting.
That's the HDL story, and thatwas a long-winded answer to that
because I think it'sinteresting.
But really just relying on thatto tell you what to do or not do
, or if you're invincible or not, no, and then obviously statins
do some good things but they'renot a panacea.
So, being aware of our othertools in the toolbox when it
comes to lipid-lowering therapy,when you've identified
(20:21):
atherosclerosis and you wouldprefer that to never result in a
clinical event, you know andyou're wanting to stabilize that
plaque, potentially regressthat plaque, get people living
in a safer lipid neighborhood.
There are ways to do thatbeyond just worshiping at the
altar of high intensity statins.
You know I'm a big combophilicfan.
You know, if we can understandthe combination of therapies
(20:42):
that we can use if we need to inorder to get somebody living in
a safer, lippid neighborhood,it makes sense from not only a
biochemical standpoint but in away that cannot jeopardize their
home security system and theirquality of life in the process.
Trying to simplify some ofthese really, really complicated
topics is great, so that peoplecan actually take ownership of
their own health and also helpclinicians help their people do
(21:05):
that as well.
Ashley (21:07):
It's great though, because you're right.
If, if largely if, somebodydoes not understand why you're
asking them to do something andmake a huge life change, the
likelihood of them actuallydoing it is probably pretty low.
You know, I mean it's like whywould they want to partner with
you?
It's like what did you sayearlier?
I'm a doctor, I'm a PA Likethat's not a good reason for a
(21:27):
patient just to believe whatyou're saying.
You know so.
No, I think that's so good.
Not a good reason for a patientjust to believe what you're
saying.
You know so.
No, I think that's so good.
Josh, I am so interested tohear what you're going to say to
this because you went to YalePA school.
I went to the university ofFlorida PA school.
I think we both had a stellareducation when it came to our
medical education, our PA schooleducation, and you lecture to a
bunch of medical schools aswell, and in these schools and
things like that.
Tell me, in your opinion, whatis missing right now from the
(21:52):
way that things are taught inthese clinical programs, whether
it's MD, DO, PA, NP, maybe PT,things like that.
Are we missing something in oureducation right now Because you
have such a?
I should have prefaced it bysaying you have such a great
grasp on this very complicatedconcept.
You have such a great grasp onthis very complicated concept.
(22:13):
What are we missing here, whenwe educate our soon-to-be
clinicians?
Josh (22:17):
Yeah, yeah.
So there's so much to know andI agree, I mean my program was
fantastic at Yale, I loved it.
But there's just too much toknow because the way board exams
are wired, you know it's like,oh, I have to remember what you
know von Gierke disease is, andso there's all these things that
you just have to memorize foryour board exams.
(22:39):
And board exams are just awhole bunch of information and
they're not really gearedtowards being preventive.
So if we just incorporated morepreventive medicine into our
didactic programs.
Yeah, there are times when youhave to say, okay, this is your
answer for the board exam.
High intensity statin is alwaysthe answer for the board exam.
(23:02):
But from a practical standpoint, let's talk about how to
actually do this.
You know a little bit moreintelligently and using things
like the coronary artery calciumscore, and that has gained a
little more prominence and it ispart of our guidelines.
But my issue with guidelines isguidelines are not the be all
end all either.
The 10-year risk calculatorsthey miss a lot of people, they
underestimate some, theyoverestimate others, and so, for
(23:24):
instance, my buddy he, you know, had lipoprotein little a, the
felon of the lipid neighborhood,as his one risk factor One,
risk of protein little a, thefelon of the lipid neighborhood,
um as his one risk factor.
One risk factor he, his 10-yearrisk calculator was 2.3 percent
.
And you know he told me abouthis family history.
I'm like, yeah, I don't likethat.
And uh, get your lpla, get yourcac tested.
His lpla was 128 milligrams perdeciliter, which is quite high.
(23:44):
And then his cac was 2814 um.
So any score above zero meansyou have been broken into um.
Any score 300 and above youhave equivalent risk of having a
heart attack, as people whohave had prior events.
2814 is absolutelystratospheric.
He had so much disease that hehad to have a five vessel
cabbage and he had that one yearago.
(24:05):
And uh, yeah, 2.3%.
He was given the attaboy,you're fine, keep doing what
you're doing.
And he was not insulin resistantat all.
No blood pressure elevations.
His HSCRP you know not specificmeasure of systemic
inflammation was 0.4.
So not elevated.
And he had decided to not dodrugs or smoke.
And so this was a guy, superfit guy.
I run with him, I left with him.
He's actually going to be doinga half Ironman here in a couple
(24:27):
months.
He's stronger than he was evenbefore the surgery.
Already half Ironman here in acouple months.
He's stronger than he was evenbefore the surgery already.
But this is a guy who, I mean,he might not even be here if we
hadn't just gotten twoadditional tests rather than
just relying on 10-year riskcalculators and our basic
cholesterol metrics.
So I think that we can do a lotbetter job across the board,
and it starts with not just ourdidactic programs but just
(24:50):
education across the board, andI want to equip both patients
and clinicians with thisinformation in a way that they
can understand, so that we canget ahead of the game when it
comes to cardiovascular diseaseand atherosclerosis.
Ashley (25:04):
So this book, josh, your book that you've written the
Home Security System in theLipid Neighborhood
Uncomplicating Cholesterol,cholesterol and cardiovascular
disease and you have just givenus fantastic examples of the
goodness that is in this book,and you mentioned it's for
patients and clinicians alike.
Is that true?
Could just about anybody hop onAmazon right now and grab your
book, open it up and say youknow what?
(25:25):
I want to learn more about thisfor X reason?
Josh (25:30):
Yeah, yeah, and I've gotten good feedback from both
clinicians and patients alike asfar as it being helpful in that
regard, and there are certainsections that are more for
clinicians.
But I tell you, it's like youremember those choose your own
adventure books where it's like,okay, I have the option of, you
know, taking this route, or Ihave this option of going down
(25:50):
here and it's like, oh, thatwasn't the right one.
I got dismembered by a hippo.
You know, I'm like, hey, thisis like a choose your own
adventure book.
You can just go on to the nextpart.
But really, even if you justread the first few pages of it,
you get these core concepts ofthe home security system, lipid
neighborhood and got plaque, geta CAC.
Oh, what's LPLA, the, the felonof the lipid neighborhood, you
know so.
So I, even if you, you know,just had a, you know, cursory
(26:13):
glance or two, then I think youwould be able to benefit from it
.
And you know, my goal is forpeople to laugh a little, learn
a little and then come away witha relatable framework for not
having heart attack, strokes anddementia at the end of the day.
Ashley (26:26):
Which is which is just such a amazing goal.
Thank you so much for writingthis book and for making it
available to everybody, which isreally, really neat.
A medical text that we can allread and all benefit from is
huge.
Josh, before I ask you our lastquestion, I do want to talk
about a segment on the showcalled Quality Questions.
This is where we discussinterview questions that you
(26:48):
have either asked or that you'vebeen asked that have been
really meaningful or memorablein one way or the other.
Do you have one of thesequality questions?
Before we hear what Josh'squality question is, keep in
mind that there's more interviewprep, such as mock interviews
and personal statement reviewover on shadowmenextcom.
There, you'll find amazingresources to help you as you
(27:10):
prepare to answer your ownquality questions.
Josh (27:13):
Yeah, what I like to ask people is for them to tell me
about a time where they enteredinto a situation and they had a
certain expectation of what wasgoing to occur and the reality
ended up being far differentthan their expectation and how
they navigated that situation.
Being far different than theirexpectation.
(27:34):
And how they navigated thatsituation, because life is full
of curveballs and it's howyou're able to adapt to those
unforeseen circumstances thatoften catalyzes what you're
really supposed to do when yougrow up and it kind of helps you
forge your identity too in whatyou're becoming.
Ashley (27:48):
That's a really, really great one, because I think it
gives a lot of students orclinicians the opportunity to
talk about sometimes some reallytough things.
I think we all have thoseexperiences that we would like
to bring into a conversationduring an interview, but we
don't want to sound like anegative Nancy or just like a
Debbie Downer, I don't know whatthe male?
Josh (28:07):
versions of negative Nancy's and Debbie Downerers are
yeah, I'll have to come up withsomething clever.
Ashley (28:12):
Yeah, Negative, Nathan's , I guess, but but you know, I
think it's a great opportunityfor a student or clinician to
you know, address this andshowcase how, how resilient they
were.
Really, I think it's a greatquestion.
Josh, I have spent so much funchatting with you.
I already feel like I have abetter understanding, so many
(28:32):
concepts that I, you know.
Hdl is good.
Let's talk about this a littlebit more.
So thank you so much forbreaking that down for us.
Tell me about for our finalquestion, tell me about a moment
at any point in your incrediblecareer that you are just proud
of.
Josh (28:45):
You know, life is a series of little moments and if
you wait around for the bigthings like, oh, I got this
degree or I graduated here, tookmy board exam, if you're just
waiting around for the bigmoments, you're going to be
perpetually disappointed.
And so it isn't just one momentthat means so much to me.
(29:07):
It's, it's just the individualtimes when somebody truly told
you that what you did for themmade an impact on their life.
And a lot of it is the, thepictures people give me, the
cards that my patients will giveme through the years, um, those
, those mean a lot to me.
And, and the one that Ispecifically remember, and all
(29:28):
of them kind of blend togetherin my mind.
But there was a gal who hadbeen blown off for so many years
, um, as, and and she actuallyhad pituitary Cushing's and she
had been dismissed by a bunch ofproviders and, um, you know,
cushing's can be a little trickysometimes as far as that workup
and so I and, and then therewere still people that were
(29:49):
dismissive, and I ended upfinding the right guy to do the
you know, transphenoidalhypophysectomy for, and you know
it changed her life and she'sdoing amazing and really got her
life back, and so that's reallyreally special when you're able
to invest in somebody.
One of my favorite quotes iswhen God gives a gift, you wraps
(30:09):
it in a person, and if you areable to have that role and just
be somebody who cared, that'ssuch a privilege and a blessing
to have those opportunities.
A lot of times it's.
You know just that you took thetime with them to explain some
things and just to show that youknow that person isn't just a
(30:30):
lab number or some sort ofdiagnostic imaging test.
That's a, that's a real personand, uh, you really care about
them as an individual.
Ashley (30:39):
That's so true.
I love the fact that youmentioned that it's not just
about the big moments.
It really isn't.
It's a it's culmination of thelittle moments, which I think is
so perfect.
Josh, thanks so much for takingthe time to spend with us on
shadow me next.
This has been a fantasticconversation.
Where can we find you?
Where can we find your book ifwe have more questions?
Josh (30:58):
Yeah, yeah, you can generally find me wherever there
are lipid discussions going on,but you can find me on LinkedIn
.
And you can find me on x,formerly known as Twitter, and
it's just.
You know my name, josh Wegman.
It looks like Wageman, but it'sWegman.
And then for my book, if youjust go to Amazon and you type
(31:20):
in the home security system inthe Lipid neighborhood, it'll
pop up there, and one of mygoals, too, is to have it very
affordable.
I just want it to be a resourcefor people.
Ashley (31:29):
Josh, thank you.
Thank you for everything you'vedone, thank you for what you
will continue to do and thanksfor joining us here on shadow me
next.
I appreciate it.
Thank you so much.
Thank you so very much forlistening to this episode of
shadow me next.
If you liked this episode or ifyou think it could be useful
for a friend, please subscribeand invite them to join us next
Monday, as always.
(31:50):
If you have any questions, letme know on Facebook or Instagram
Access.
You want stories you need.
You're always invited to shadowme next.
Hello and welcome to Shadow Me Next, a podcast where
I take you into and behind thescenes of the medical world to
provide you with a deeperunderstanding of the human side
of medicine.
I'm Ashley, a physicianassistant, medical editor,
clinical preceptor and thecreator of Shadow Me Next.
It is my pleasure to introduceyou to incredible members of the
(00:22):
healthcare field and uncovertheir unique stories, the joys
and challenges they face andwhat drives them in their
careers.
It's access you want andstories you need, whether you're
a pre-health student or simplycurious about the healthcare
field.
I invite you to join me as wetake a conversational and
personal look into the lives andminds of leaders in medicine.
(00:44):
I don't want you to miss asingle one of these
conversations, so make sure thatyou subscribe to this podcast,
which will automatically notifyyou when new episodes are
dropped, and follow us onInstagram and Facebook at shadow
me next, where we will reviewhighlights from this
conversation and where I'll giveyou sneak previews of our
upcoming guests.
Today's guest has one of themost unique backgrounds we've
(01:07):
ever featured on the show andsomehow he makes it all feel
effortless.
Dr Josh Wagman holds a doctoratein physical therapy, a PhD in
biochemistry and is aYale-trained physician assistant
.
He's also a nationallyrecognized lipid specialist,
teaching clinicians across thecountry how to approach
cardiovascular prevention withclarity, evidence and a little
(01:31):
creativity.
What makes Josh stand out isn'tjust the alphabet soup behind
his name.
It's the way he connects withpeople, whether he's mentoring
students, caring for patients orspeaking at medical programs.
He uses analogies, humor andillustrative storytelling to
make even the most complextopics like lipoproteins and
(01:53):
atherosclerosis easy tounderstand and even enjoyable.
In this conversation we talkabout his book the Home Security
System and the LipidNeighborhood, which reframes
cholesterol and cardiovascularrisk into a language we can all
understand.
We dive into how he teachesboth patients and clinicians to
(02:14):
embrace prevention, what'smissing from traditional medical
education, and how meaningfulcare often starts with time,
attention and compassion.
Meaningful care often startswith time, attention and
compassion.
Please keep in mind that thecontent of this podcast is
intended for informational andentertainment purposes only and
should not be considered asprofessional medical advice.
(02:34):
The views and opinionsexpressed in this podcast are
those of the host and guests anddo not necessarily reflect the
official policy or position ofany other agency, organization,
employer or company.
This is Shadow Me Next with DrJosh Wagman.
Hey, josh, thank you so muchfor joining us today on Shadow
(02:58):
Me.
Next, I cannot wait to talk toyou about number one your road
in your career to where you'reat right now, but also this
incredible resource in this bookthat you have authored.
Thank you for joining us.
Thanks for jumping in.
Josh (03:06):
Hey, thank you so much for having me.
I love doing this and it'salways a pleasure.
Ashley (03:12):
Thanks, josh.
So you have your PhD inbiochemistry, you're a doctor of
physical therapy and you're aPA.
You graduated from Yale.
Oh my gosh, can you take us onthis educational journey?
Tell us a little bit about howyou ended up?
Yeah, yeah.
Josh (03:29):
It's.
If anybody has even a remotelysimilar background, I'd like to
meet that person.
But basically all that, thatcomically viscous alphabet soup
of letters behind my name, itreally just means that I'm very
limited on useful life skills,except going to school and
taking tests, and but you know,so I have all these these
(03:49):
letters like, oh, what does thatmean?
But really it's been aprivilege just to have all these
opportunities.
But what I always say is, themagic is in the person, not the
credential, and so but I'llexplain a little bit of how this
happens.
So my first doctorate wasactually in physical therapy,
and so I'm a physical therapistand, uh, you know I keep a
treatment table at church sothat somebody walks in with a
(04:12):
Trendelenburg gate.
You know I can help them withtheir trochanteric bursitis or
whatever, so so I do, uh, youknow, pro bono stuff there.
But, um, so you know that wasmy first doctorate.
It was actually I got really,really sick when I was in PT
school and that catalyzed mylove for endocrinology and
biochemistry.
And so, even though I graduatedPT school and worked as a
(04:33):
physical therapist, there wasnever a sense of finality that I
was done there just because Igot really really really super
sick and nobody could reallyfigure it out.
And so I was like, well, I'mgoing to try and figure this
stuff out.
And I was like, man, this stuffis really really cool.
So anyway, so that helpedfoster the person I became along
the way.
And so I was like, well, I'mkind of old so I don't want to
(04:55):
go all the way back to medschool.
So I figured I'd go to PAschool and that was a super fun
time and went through the YaleSchool of Medicine for PA school
enjoyed PA school a ton.
That was a super fun time.
And went to through the YaleSchool of Medicine for PA school
enjoyed PA school a ton.
That was, that was a blast.
And then couldn't help myselfand ended up getting my working
on my PhD along the way as faras cholesterol disturbances and
(05:16):
Alzheimer's disease.
But really a lot of thishappened too because I'm a lipid
specialist.
So I'm best known as a lipidspecialist.
I teach lipid physiology andcholesterol.
I'm best known as a lipidspecialist.
I teach lipid physiology andcholesterol homeostasis across
the country.
I'm adjunct faculty at variousmedical programs.
I'm also a medical scienceliaison and I have to remember
to say that nothing I'm sayinghere today reflects the opinions
(05:37):
or medical strategies of Amgen,just so that we can have our
unadulterated fun.
But anyway, I'm best knownnowadays as teaching lipids and,
for you know, writing booksabout lipids and so.
But really, the way that Ibecame a lipid specialist, I
wish it was some really great,you know, humanitarian reason
where I had some uncle Steve orsomething and he had premature
(05:59):
cardiovascular disease and Iwanted to devote my life's work
to helping people avoid the samefate.
But actually it was because Ihad a patient cancel one day and
I was sitting there and I wasreading some stuff.
I read voraciously everythingyou know, from Brave New World
to the Journal of ClinicalLipidology, and so I was like,
(06:20):
okay, well, basics oflipoproteins, which is kind of
what the article title wassomething obnoxiously
condescending like that, and Iwas like, how hard can this be?
You know, I mean I can justthrow down a pentose phosphate
pathway.
If you're lucky, I might throwin a Cahill cycle, you know.
I thought, okay, I'm good atthis stuff.
And so I read this article thatwas supposed to be a rudimentary
review of this topic and Ibarely understood any of it and
(06:40):
it made me mad.
So, anyway.
So I devoted myself to learningall this stuff and, you know,
took the lipid boards and things, and so anyway.
So that's how that happened.
But along the way I'vehopefully gleaned some things
that can help people not haveheart attack, strokes and
dementia, which is my whole goalfor what I do on a day to day
basis and my whole goal inwriting this book that I'm sure
(07:03):
we're going to talk about thehome security system in the
Olympic neighborhood.
Ashley (07:07):
That's incredible.
I think it is so funny that itwas a challenge to you.
Hey, I want to understand thisbetter.
Why am I not understanding this?
I think I get it.
And for you to feel that waywith all of your education and
all of your background knowledge, then to take a step back and
realize the people that this isactually affecting how little
(07:27):
they probably understand andrealize and know about lipids,
how they affect you, what organsthey affect, the things that
they do on those organs, thingslike that.
Josh (07:37):
Yeah.
Ashley (07:38):
That's probably where you got the idea for the book.
Josh (07:40):
Yeah, yeah, and you know, whenever you tackle any sort of
subject, you want to make surethat you understand it, and I
think one of the ways that youshow that you can understand
something is if you can explainit to somebody who may not be as
familiar with the topic.
And I read lots of things andwe some of our favorite teachers
(08:02):
, I think, along the wayprobably painted things, using
metaphors and using wordpictures, rather than just
dealing with esotericbiochemical pathways and hey, I
love me some esotericbiochemical pathways, right, but
most people are normal and theydon't prefer those things.
They like to deal in thingsthat are more relatable to them.
And so that's where I was likehuh, I want to come up with a
(08:24):
relatable framework for nothaving heart attacks, strokes
and dementia.
And so, basically, what I cameup with is I was and I would
start saying this to my patientstoo I said, hey, you and I have
the common goal of you nothaving heart attacks and strokes
and then, down the line,dementia.
Yes, that is, that is true.
So for you, I want you to havea great home security system and
(08:46):
I want you to live in a safelipid neighborhood.
So your home security systemhas four basic pillars normal
blood sugars, normal bloodpressures, keep inflammation low
and don't smoke or do drugs.
Those are bad.
Every ApoB containinglipoprotein, the vast majority
(09:06):
of those being LDL particles,are potential criminals that can
infiltrate your arterial abode.
And the Lp little a particles.
If you pick the wrong parentswith that genetic risk factor,
those are the felons, becauseper particle, they're about six
and a half times as likely tocause mischief in your arterial
wall than your run-of-the-millLDL particle.
Okay, so let's look at thesethings.
We have many ways of measuringyour parameters of blood glucose
(09:26):
metabolism, and I would saythat that extends beyond just
blood sugar to insulin control.
Your insulin control, your lifeis one of my mantras.
Okay, so nobody ever said boy,new year's resolution 2025, I'm
going to be more insulinresistant.
No, you know.
And nobody ever said you knowwhat?
Today's the day I start smoking.
This is a good health choice.
No, so there's the axiomsnormal blood sugar, normal blood
pressure, keep inflammation lowand don't smoke or do drugs.
(09:53):
But then our lipid panelrequires some context and that
requires a little moreunderstanding, because it can
kind of look like you're livingin a rough lipid neighborhood on
paper, but people don't live onpaper.
So one of my catchphrases isgot plaque, get a CAC.
What's a CAC?
Coronary artery calcium score?
It's the colonoscopy of theheart, without the nasty pregame
show, because anybody who'sever done a bowel prep knows
that that, will you know,temporarily ruin your social
life and probably destroy yourbathroom also and so.
(10:15):
But with the CAC you lay down,it's a low dose CT scan about
the same amount of radiation asa mammogram, virtually nothing.
And it shows you if you havecalcified plaque in your
coronaries or if you don't.
And that's actually a latefinding in the atherosclerotic
disease process.
It shows you have you beenbroken into?
And if you have been brokeninto, do you want to keep living
(10:36):
in the same rough lipidneighborhood that got you broken
into or do you want to considermoving to a safe, gated
community with fewer lipidcriminals?
Seems reasonable.
Put another way, if you have anyplaque in your coronaries, do
you want that plaque stable orunstable?
And we know from variousstudies like ICONIC that most
myocardial infarctions don'toccur in a vessel with
significant stenosis.
(10:56):
You're fine until you're not.
It's a vulnerable plaque.
It ruptures and then you're100% included.
No good and so.
But are there ways to conferplaque stability.
Are there ways to even furtherregress that plaque and further
stabilize it?
Yes, and so we should probablywant to do those and get ahead
of the game, and one of my goalsis to shift the paradigm for
cardiovascular disease fromreactionary to preventive, and I
(11:18):
think we can do that with justa little bit more understanding
of the various tools in ourtoolbox and the various
diagnostic, both biomarkers froma blood based standpoint and
imaging, to help inform ourdecision making process.
Ashley (11:32):
There's two, there's two directions that I want to take
from this, and both of them bothof them kind of, I would love
to hear your experience and justspeaking with patients about
these sorts of things, because Ithink with both and tell me if
I'm wrong we really are going tohave to partner with our
patients when it comes to makingchanges in this.
So the first well, I'll tellyou what the two are.
The first one is illustrativepatient education, and the
(11:55):
person that I spoke with rightbefore you, dr Zareik, he brings
a he's an internal medicineattending.
He brings a whiteboard into theroom with his, with his
residents, with the patients,with everybody, and he literally
does many.
Ted talks on the whiteboardwith a marker.
You are illustrative in thesense that you use your words to
(12:17):
tell these stories to patients.
That better illustrates, andclinicians at this point,
because you're teachingclinicians how to process this
too, to better illustrate thiswhole process that you just
described.
So, number one, illustrativepatient education.
We'll get to that.
Number two is preventivemedicine, and this is obviously
something you feel verypassionate about, first being
the illustrative patienteducation.
(12:39):
Tell me about this.
Does this work?
Josh (12:43):
Oh yeah, it takes time, though.
Right, and that's one of themany flaws of our medical system
is people are wheeled in andout in five to 10 minute visits.
How are you supposed toaccomplish anything in that
amount of time, and especiallywhen people have questions and
they want to talk about otherstuff, and I mean you want to
talk about your lives, you wantto talk about other stuff, and I
mean I, I mean you want to talkabout your lives, you know you
want to talk about.
Ashley (13:02):
Hey, how's your kids doing?
You know, oh.
Josh (13:04):
Oh yeah, no, no, my kid did a grand slam last night and
having that human element ishuge.
So you have to have some timeand you also have to meet people
where they're at, because, eventhough you know you and I might
understand, you know PI3,kinase, akt signaling, when it
comes to you know the insulinpathway, these people are just
like I, those you're sayingwords, but I don't understand
(13:26):
them and I hate you and I'mgoing to walk out, you know.
So you don't want that, and soyou meet people where they're at
and that's why I was like Ineed to come up with a way that
people can actually understandwhat we're doing here, because a
good reason for a patient isnot I'm a doctor or I'm a PA or
whatever your title is.
You know, and you're justbludgeoning them over the head
with your rationales and theydon't understand them because
(13:49):
it's their life.
You know, you want to help themwith their life, but together
you are leading them kind of tothat conclusion that you know
because you have, you know, someexperience and some clinical
acumen, hopefully.
Conclusion that you knowbecause you have you know, some
experience and some clinicalacumen, hopefully.
But together, you know, it's alot better when you get there
together, rather than, you know,you're just forcing them and
they feel forced, rather than,hey, let's, let's take this
(14:12):
journey together.
And so that's why I think it'sreally important to tell stories
and to make it in a way thatpeople understand.
And I have a lot of, you know,metaphors in my back pocket, and
sometimes the first one doesn'twork, so it's like, all right,
let's try number two, you know.
And so to find a way that canreally resonate with them.
And so, and that's why there'slots of metaphors and there's
(14:33):
pictures in my book, you know,and my daughter, who turns eight
tomorrow happy birthday to Mia.
She can explain to you, youknow, how potentially
atherogenic particles arecleared via the LDL receptor,
and she can tell you what PCSK9does.
And she can tell you about theApoB, the ApoBear, you know, and
that's her favorite part of thebook, you know, because there's
pictures there.
So, anyway, so if you can comeup with a way that people from
(14:55):
various walks of life, withvarious backgrounds, with
varying degrees of expertise,can really vibe with you, that
that means a lot, and thenpeople are going to buy in to
what you think is going to bebest for the trajectory of their
life when it comes tocardiovascular health as well,
and so cause a lot of clinicians.
You know they complain oh,people don't do this, people are
(15:15):
noncompliant.
I mean I had like a couple um,but really, if you explain it in
a way that makes sense, youknow, I think it's logical and
they realize that you care aboutthem.
No one cares how much you knowuntil they know how much you
care.
Ashley (15:30):
I love that.
I really, really like that.
No one cares how much you knowuntil they know how much you
care.
And it does take time.
That does take time.
I mean you can't just walk inwith a sign I wish you could
assign, you hold it up and yousay I really care about you
Trust me, trust me.
No, and I think I think the sameholds true both for that
(15:51):
illustrative patient education,but also for preventive medicine
too.
Okay, tell me about this whenyou're talking with a patient
about this sort of thing, assomebody who really gets it
right, Somebody who understandswhat you're saying and is on
board, what is something thatyou explain to them that
surprises them?
What's the biggest surprisethat patients go?
What?
Josh (16:12):
Yeah.
So I think I mean there's a lotof misconceptions and that's
why I had to write a book, youknow.
But really I think thathistorically, in our didactic
programs, even two people gettaught LDL bad, hdl good,
everybody.
Take a statin, you know, putthem in the drinking water, you
(16:32):
know.
And so.
So I like to address thosemisconceptions most of the time.
And so the first one LDL bad.
Well, ldl particles are notinherently bad, they're mailmen.
Right, most mailmen are not baddudes.
Their job is to deliver themail.
What's the mail?
Triglyceride packages.
And then they go home todeliver.
At the end of the day, that'sgreat.
(16:52):
But if one of these mailmen,instead of delivering
triglyceride packages to themuscle cell or fat cell,
delivers packages to yourarterial wall and runs a stretch
in your arterial wall, wellthat's a bad mailman.
And we need to discuss how toaddress the corrupt workforce,
because you cannot haveatherosclerosis without one of
(17:13):
these mailmen going rogue andrunning a stretch in your
arterial wall.
And then it's the maladaptiveimmune response that results in
foam cells, fatty streaks,plaque formation, which can
subsequently lead to clinicalevents.
And so we have to establishthose things, because people you
know they don't, it's hard toknow what to believe as a
consumer, even a clinician,because you know some people
will be like oh no, cholesterolis is amazing.
(17:35):
Well, a lack of cholesterolisn't compatible with life, you
know, it's an important part ofour cell membranes.
We need them for bile acids.
We need them for steroidhormones.
20 to 25% of our total bodycholesterol is in the brain.
Ashley (17:45):
Pretty important up there, so you know so all these
things you have to.
Josh (17:48):
It requires some context and so, but just to say that
this is bad or this is good, no,no, no, no, no.
And so we have to.
It's a little more complicatedthan that.
It's not binary.
Additionally, something thatpatients I think this is very
common for patients is theythink that HDL is good.
They call it the goodcholesterol.
They come in and they're likewell, my ratio is good, like
(18:10):
their triglyceride to HDL ratio.
Okay.
So what I'll say is HDLcholesterol, hdl particles they
can do a lot of good things.
Okay.
So HDL particles are kind oflike the police force.
They can actually arrive at thescene of a crime in the
arterial wall and if there's acholesterol laden perpetrator,
they can actually efflux thatout of the arterial wall, take
(18:31):
it back to the liver and we canbe okay.
So that's cool.
Hdl particles can actuallyincrease glucose uptake into
skeletal muscle.
Well, that's a reallycharitable community activity.
So they can do all these thingsand there's a bunch of other
things they can do as well.
But just a static measure ofHDL cholesterol on your blood
panel gives you no idea of itsfunctionality.
(18:53):
You don't know if this is agood cop or maybe not so good.
A lot of times, people withreally high HDL cholesterol,
they will have dysfunctional HDLparticles and they will have
advanced cardiovascular disease.
So I had a patient who she cameinto me and she was like, oh
yeah, you know, I'm fine, don'tworry about my cholesterol.
I mean, my, my good cholesterolis so high, you know.
(19:13):
And she wasn't, you know,insulin resistant.
So triglycerides were, wereokay, and her HDL cholesterol
was like 108 or something.
And she was telling me about herfamily history.
Though, and her family historyis telling me a far different
story, you know, and her, youknow, brothers are all having
MIs and pretty early age andpeople are having strokes.
And I'm like, yeah, let's get,let's get that CAC.
You know that coronary arterycalcium score, and and her 10
(19:36):
year risk calculator was quitelow too, which you know, I'll
tell you how I feel about thoseand she had a coronary artery
calcium score of over a thousand.
Ok, so she had advanced diseaseand we had to intervene
appropriately there.
So, anyway, so, basically, justrelying on your HDL cholesterol
, you know, to tell you anythingabout its functionality is
irresponsible now and so, anyway, so that's, that's the HDL
(19:56):
story and that was a long windedanswer to that because I think
it's interesting.
That's the HDL story, and thatwas a long-winded answer to that
because I think it'sinteresting.
But really just relying on thatto tell you what to do or not do
, or if you're invincible or not, no, and then obviously statins
do some good things but they'renot a panacea.
So, being aware of our othertools in the toolbox when it
comes to lipid-lowering therapy,when you've identified
(20:21):
atherosclerosis and you wouldprefer that to never result in a
clinical event, you know andyou're wanting to stabilize that
plaque, potentially regressthat plaque, get people living
in a safer lipid neighborhood.
There are ways to do thatbeyond just worshiping at the
altar of high intensity statins.
You know I'm a big combophilicfan.
You know, if we can understandthe combination of therapies
(20:42):
that we can use if we need to inorder to get somebody living in
a safer, lippid neighborhood,it makes sense from not only a
biochemical standpoint but in away that cannot jeopardize their
home security system and theirquality of life in the process.
Trying to simplify some ofthese really, really complicated
topics is great, so that peoplecan actually take ownership of
their own health and also helpclinicians help their people do
(21:05):
that as well.
Ashley (21:07):
It's great though, because you're right.
If, if largely if, somebodydoes not understand why you're
asking them to do something andmake a huge life change, the
likelihood of them actuallydoing it is probably pretty low.
You know, I mean it's like whywould they want to partner with
you?
It's like what did you sayearlier?
I'm a doctor, I'm a PA Likethat's not a good reason for a
(21:27):
patient just to believe whatyou're saying.
You know so.
No, I think that's so good.
Not a good reason for a patientjust to believe what you're
saying.
You know so.
No, I think that's so good.
Josh, I am so interested tohear what you're going to say to
this because you went to YalePA school.
I went to the university ofFlorida PA school.
I think we both had a stellareducation when it came to our
medical education, our PA schooleducation, and you lecture to a
bunch of medical schools aswell, and in these schools and
things like that.
Tell me, in your opinion, whatis missing right now from the
(21:52):
way that things are taught inthese clinical programs, whether
it's MD, DO, PA, NP, maybe PT,things like that.
Are we missing something in oureducation right now Because you
have such a?
I should have prefaced it bysaying you have such a great
grasp on this very complicatedconcept.
You have such a great grasp onthis very complicated concept.
(22:13):
What are we missing here, whenwe educate our soon-to-be
clinicians?
Josh (22:17):
Yeah, yeah.
So there's so much to know andI agree, I mean my program was
fantastic at Yale, I loved it.
But there's just too much toknow because the way board exams
are wired, you know it's like,oh, I have to remember what you
know von Gierke disease is, andso there's all these things that
you just have to memorize foryour board exams.
(22:39):
And board exams are just awhole bunch of information and
they're not really gearedtowards being preventive.
So if we just incorporated morepreventive medicine into our
didactic programs.
Yeah, there are times when youhave to say, okay, this is your
answer for the board exam.
High intensity statin is alwaysthe answer for the board exam.
(23:02):
But from a practical standpoint, let's talk about how to
actually do this.
You know a little bit moreintelligently and using things
like the coronary artery calciumscore, and that has gained a
little more prominence and it ispart of our guidelines.
But my issue with guidelines isguidelines are not the be all
end all either.
The 10-year risk calculatorsthey miss a lot of people, they
underestimate some, theyoverestimate others, and so, for
(23:24):
instance, my buddy he, you know, had lipoprotein little a, the
felon of the lipid neighborhood,as his one risk factor One,
risk of protein little a, thefelon of the lipid neighborhood,
um as his one risk factor.
One risk factor he, his 10-yearrisk calculator was 2.3 percent
.
And you know he told me abouthis family history.
I'm like, yeah, I don't likethat.
And uh, get your lpla, get yourcac tested.
His lpla was 128 milligrams perdeciliter, which is quite high.
(23:44):
And then his cac was 2814 um.
So any score above zero meansyou have been broken into um.
Any score 300 and above youhave equivalent risk of having a
heart attack, as people whohave had prior events.
2814 is absolutelystratospheric.
He had so much disease that hehad to have a five vessel
cabbage and he had that one yearago.
(24:05):
And uh, yeah, 2.3%.
He was given the attaboy,you're fine, keep doing what
you're doing.
And he was not insulin resistantat all.
No blood pressure elevations.
His HSCRP you know not specificmeasure of systemic
inflammation was 0.4.
So not elevated.
And he had decided to not dodrugs or smoke.
And so this was a guy, superfit guy.
I run with him, I left with him.
He's actually going to be doinga half Ironman here in a couple
(24:27):
months.
He's stronger than he was evenbefore the surgery.
Already half Ironman here in acouple months.
He's stronger than he was evenbefore the surgery already.
But this is a guy who, I mean,he might not even be here if we
hadn't just gotten twoadditional tests rather than
just relying on 10-year riskcalculators and our basic
cholesterol metrics.
So I think that we can do a lotbetter job across the board,
and it starts with not just ourdidactic programs but just
(24:50):
education across the board, andI want to equip both patients
and clinicians with thisinformation in a way that they
can understand, so that we canget ahead of the game when it
comes to cardiovascular diseaseand atherosclerosis.
Ashley (25:04):
So this book, josh, your book that you've written the
Home Security System in theLipid Neighborhood
Uncomplicating Cholesterol,cholesterol and cardiovascular
disease and you have just givenus fantastic examples of the
goodness that is in this book,and you mentioned it's for
patients and clinicians alike.
Is that true?
Could just about anybody hop onAmazon right now and grab your
book, open it up and say youknow what?
(25:25):
I want to learn more about thisfor X reason?
Josh (25:30):
Yeah, yeah, and I've gotten good feedback from both
clinicians and patients alike asfar as it being helpful in that
regard, and there are certainsections that are more for
clinicians.
But I tell you, it's like youremember those choose your own
adventure books where it's like,okay, I have the option of, you
know, taking this route, or Ihave this option of going down
(25:50):
here and it's like, oh, thatwasn't the right one.
I got dismembered by a hippo.
You know, I'm like, hey, thisis like a choose your own
adventure book.
You can just go on to the nextpart.
But really, even if you justread the first few pages of it,
you get these core concepts ofthe home security system, lipid
neighborhood and got plaque, geta CAC.
Oh, what's LPLA, the, the felonof the lipid neighborhood, you
know so.
So I, even if you, you know,just had a, you know, cursory
(26:13):
glance or two, then I think youwould be able to benefit from it
.
And you know, my goal is forpeople to laugh a little, learn
a little and then come away witha relatable framework for not
having heart attack, strokes anddementia at the end of the day.
Ashley (26:26):
Which is which is just such a amazing goal.
Thank you so much for writingthis book and for making it
available to everybody, which isreally, really neat.
A medical text that we can allread and all benefit from is
huge.
Josh, before I ask you our lastquestion, I do want to talk
about a segment on the showcalled Quality Questions.
This is where we discussinterview questions that you
(26:48):
have either asked or that you'vebeen asked that have been
really meaningful or memorablein one way or the other.
Do you have one of thesequality questions?
Before we hear what Josh'squality question is, keep in
mind that there's more interviewprep, such as mock interviews
and personal statement reviewover on shadowmenextcom.
There, you'll find amazingresources to help you as you
(27:10):
prepare to answer your ownquality questions.
Josh (27:13):
Yeah, what I like to ask people is for them to tell me
about a time where they enteredinto a situation and they had a
certain expectation of what wasgoing to occur and the reality
ended up being far differentthan their expectation and how
they navigated that situation.
Being far different than theirexpectation.
(27:34):
And how they navigated thatsituation, because life is full
of curveballs and it's howyou're able to adapt to those
unforeseen circumstances thatoften catalyzes what you're
really supposed to do when yougrow up and it kind of helps you
forge your identity too in whatyou're becoming.
Ashley (27:48):
That's a really, really great one, because I think it
gives a lot of students orclinicians the opportunity to
talk about sometimes some reallytough things.
I think we all have thoseexperiences that we would like
to bring into a conversationduring an interview, but we
don't want to sound like anegative Nancy or just like a
Debbie Downer, I don't know whatthe male?
Josh (28:07):
versions of negative Nancy's and Debbie Downerers are
yeah, I'll have to come up withsomething clever.
Ashley (28:12):
Yeah, Negative, Nathan's , I guess, but but you know, I
think it's a great opportunityfor a student or clinician to
you know, address this andshowcase how, how resilient they
were.
Really, I think it's a greatquestion.
Josh, I have spent so much funchatting with you.
I already feel like I have abetter understanding, so many
(28:32):
concepts that I, you know.
Hdl is good.
Let's talk about this a littlebit more.
So thank you so much forbreaking that down for us.
Tell me about for our finalquestion, tell me about a moment
at any point in your incrediblecareer that you are just proud
of.
Josh (28:45):
You know, life is a series of little moments and if
you wait around for the bigthings like, oh, I got this
degree or I graduated here, tookmy board exam, if you're just
waiting around for the bigmoments, you're going to be
perpetually disappointed.
And so it isn't just one momentthat means so much to me.
(29:07):
It's, it's just the individualtimes when somebody truly told
you that what you did for themmade an impact on their life.
And a lot of it is the, thepictures people give me, the
cards that my patients will giveme through the years, um, those
, those mean a lot to me.
And, and the one that Ispecifically remember, and all
(29:28):
of them kind of blend togetherin my mind.
But there was a gal who hadbeen blown off for so many years
, um, as, and and she actuallyhad pituitary Cushing's and she
had been dismissed by a bunch ofproviders and, um, you know,
cushing's can be a little trickysometimes as far as that workup
and so I and, and then therewere still people that were
(29:49):
dismissive, and I ended upfinding the right guy to do the
you know, transphenoidalhypophysectomy for, and you know
it changed her life and she'sdoing amazing and really got her
life back, and so that's reallyreally special when you're able
to invest in somebody.
One of my favorite quotes iswhen God gives a gift, you wraps
(30:09):
it in a person, and if you areable to have that role and just
be somebody who cared, that'ssuch a privilege and a blessing
to have those opportunities.
A lot of times it's.
You know just that you took thetime with them to explain some
things and just to show that youknow that person isn't just a
(30:30):
lab number or some sort ofdiagnostic imaging test.
That's a, that's a real personand, uh, you really care about
them as an individual.
Ashley (30:39):
That's so true.
I love the fact that youmentioned that it's not just
about the big moments.
It really isn't.
It's a it's culmination of thelittle moments, which I think is
so perfect.
Josh, thanks so much for takingthe time to spend with us on
shadow me next.
This has been a fantasticconversation.
Where can we find you?
Where can we find your book ifwe have more questions?
Josh (30:58):
Yeah, yeah, you can generally find me wherever there
are lipid discussions going on,but you can find me on LinkedIn
.
And you can find me on x,formerly known as Twitter, and
it's just.
You know my name, josh Wegman.
It looks like Wageman, but it'sWegman.
And then for my book, if youjust go to Amazon and you type
(31:20):
in the home security system inthe Lipid neighborhood, it'll
pop up there, and one of mygoals, too, is to have it very
affordable.
I just want it to be a resourcefor people.
Ashley (31:29):
Josh, thank you.
Thank you for everything you'vedone, thank you for what you
will continue to do and thanksfor joining us here on shadow me
next.
I appreciate it.
Thank you so much.
Thank you so very much forlistening to this episode of
shadow me next.
If you liked this episode or ifyou think it could be useful
for a friend, please subscribeand invite them to join us next
Monday, as always.
(31:50):
If you have any questions, letme know on Facebook or Instagram
Access.
You want stories you need.
You're always invited to shadowme next.
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