18 August 2011

Hypertension, and my first patients

Though med school has barely begun, I've had the opportunity to don my white coat, stethoscope, and reflex hammer and examine a total of five patients in an outpatient setting. All five presented with high blood pressure, all five had previously been diagnosed with hypertension, and all five had stopped taking their hypertensive medications simply because they didn't feel like taking them anymore. It's a fitting condition for my first patients to have, in that hypertension exemplifies both the spirit and the limitations of medical practice.

My first patient was a friendly man with an all-too-common story--he was overweight, lacked health insurance, and had severe hypertension. Although he had been on drugs for hypertension in the distant past, he stopped taking his meds years ago because he felt better. He came to clinic because when he recently had his blood pressure checked, it was extremely high (the reading I obtained was a good 40 ticks higher than I had ever seen before). I sought out the supervising physician, who examined him, wrote some prescriptions, ordered some labs to see if his kidneys were damaged, and instructed him to return in a few weeks. I played pharmacist and gave him several weeks' supply of hypertensive drugs to get started.

Another patient had hypertension despite maintaining a good diet and healthy weight, as well as hypokalemia (too little potassium in the blood). The doctor suspected hyperaldosteronism (often, a tumor of the adrenal glands that overexpresses aldosterone, a hormone affecting blood pressure). Another was a fit teenage athlete with a clean bill of health, except for a menacingly high blood pressure of unknown etiology (unclear cause).

Technology gives us remarkable tools to combat hypertension. An easy-to-use, inexpensive, and reusable device (the sphygmomanometer, or blood pressure cuff) reliably diagnoses hypertension. You need not travel further than your local supermarket to check (within seconds! free!) whether the "silent killer" lurks in your arteries. But the most effective interventions are beyond medicine's grasp. Sure, we can prescribe diuretics and ACE inhibitors, but public health is best equipped to tackle the problems that usually cause or exacerbate hypertension--the shocking and indefensible amount of sodium in processed foods; and people eating poor diets, exercising too little, and weighing too much. Funding PE in schools or having the FDA follow through on its proposal to regulate salt in processed foods would far outstrip the concerted efforts of thousands of well-meaning doctors and medical students.

Telling the patient, "improve your diet" and "exercise more" doesn't help either. Two of my patients don't speak English--how are they going to figure out what foods have lower sodium when they go shopping? Another has no job--how will they pay for more expensive, but healthier foods? Another has a bad knee--how are they going to exercise?

So we prescribe them meds, and many patients take them for a few months and then stop. It's hard to blame them--while the drugs have side effects, hypertension feels fine. Like bad sunburns, the punishment for having high blood pressure is years or decades off. If a patient isn't motivated to make lifestyle changes to combat hypertension, how motivated will they be to stick with their meds?

The point is, science only gets the doctor so far. We understand the biochemical mechanism of hypertension, we understand how deadly it is, we can easily diagnose it, and we know how to cheaply and effectively treat and even prevent it. Yet hypertension still afflicts a third of adults in the U.S. and kills a substantial fraction of them. We can't escape the fact that patients are people, with people's foibles, strengths, and shortcomings. This makes treating chronic illness frustrating and sometimes ineffectual. But that I am dealing not just with kidneys and arteries and hearts, but with people, is what also makes clinical medicine intensely rewarding.