Every patient is an experiment

Aug 24 2010 Published by under Medicine, [Medicine&Pharma]

Mrs. Charbin's blood pressure just kept going up.  She felt fine---no chest pain, no shortness of breath, no headaches---but the numbers put her at risk.  At 55, her risk of developing heart disease at some point in her life is high, and is made even higher by her hypertension.  For each 20 mm Hg rise in systolic blood pressure (the "top" number), the risk of heart disease doubles.  Her systolic blood pressure has consistently been in the 160's.  She did a great job cutting down on salt, and she was already exercising as much as her arthritis would allow. It was time to try medication.

The data on the treatment of hypertension is extensive.  We not only have a wide range of medication options, but we know the risks and benefits of treatment. We also know that most people with high blood pressure will need at least two medications to bring their blood pressure to goal, a goal based on decreasing the risk of complications such as heart attack and stroke.

Based on this data, I started Mrs. Charbin on a thiazide-type diuretic.  These are inexpensive, effective, and well-tolerated.  Except in her.  When she came to see me two weeks later, her blood pressure was much better, but she was feeling a bit weak, and a little dizzy.   I drew some blood and found that her sodium level was pretty low.  This is a known complication of thiazide diuretic therapy, so I changed her to a dihydropyridine calcium channel blocker.  Two weeks later her blood pressure was fine, but her legs were uncomfortably swollen---once again, a known complication of the medication.  So I again changed her therapy, this time to an ACE inhibitor.  Any physicians reading will know what happened next---she developed a dry, nagging cough, a side effect requiring cessation of therapy.

Finally, I changed her to an ARB.  This class of drugs is related to ACE-I's.  I had to call her insurance company and explain why a more expensive drug was required (including the fact that I did not try beta blockers because of a resting low heart rate).  Once it was approved, she did great.  About two months after deciding to start drug therapy for her blood pressure, we'd found a regimen that worked.

Science-based medicine relies on data from large studies, but these data do not create a cookie-cutter approach to medicine.  The data tell me what is likely to happen when I fail to control blood pressure, and guide me toward success at reducing the risks of hypertension.  What the data don't tell me is how much my patient can afford to spend on medicine, how well they're able to remember their medicine, whether they will tolerate a particular medicine or not.  Each patient is an experiment, but one based on an extensive and living repository of data.

One of the lessons we've learned from science is that it works.  A failure of one particular science-based intervention does not invalidate all of science.  Science embraces failure, explains it in a way that makes sense and helps one improve.  I'm always fascinated by the argument that goes, roughly, "my medicine is different, and not susceptible to your science."  The argument often goes with a pitch for some alternative medicine technique that hasn't managed to get itself validated by scientific investigation.

One of these techniques is acupuncture, a technique that in aggregate has not been found to work better than placebo.  But true believers will not be deterred by the absence of supportive data (there are lots of good data, just not supportive data).  At the New York Times Well Blog, Tara Parker-Pope had a piece yesterday that repeats some of the misunderstandings of these true believers.

The most telling quote is the one from Dr. Alex Moroz, a trained acupuncturist:

There is a body of literature that argues that the whole approach to studying acupuncture doesn’t lend itself to the Western reductionist scientific method.

This is a common refuge for those who hold to practices that cannot be scientifically validated.  Rather than admit that acupuncture is no more effective than randomly poking someone with toothpicks, they argue that we Westerners and our fancy science are the real failure.  And it is fundamentally bad thinking.  Science is a technique for investigating and understanding the world, one that works.  One of the basic tenets of the scientific method is that we do not get to change the rules to suit our beliefs.  If engineers design a bridge and testing shows that it will collapse under real-life conditions, they don't just change the calculations, because physics doesn't change.

Biology doesn't either.  There are no "meridians of energy" in the human body.  They don't exist, and therefore, they cannot be manipulated.  Ignoring this fact does not change it.

Every patient is an experiment, but one that obeys certain basic physical laws, and is informed by data.  But as Parker-Pope reports:

[a]cupuncture believers say it doesn’t really matter whether Western scientific studies find that the treatment has a strong placebo effect. After all, the goal of what they call integrative medicine, which combines conventional and alternative treatments like acupuncture, is to harness the body’s power to heal itself. It doesn’t matter whether that power is stimulated by a placebo effect or by skillful placement of needles.

It actually matters quite a bit.  Knowingly prescribing a treatment that is no better than placebo is not harmless.  Worse, this mindset that allows one to ignore science when it is inconvenient is dangerous.  Mrs. Charbin's blood pressure didn't get better through judicious application of placebo.  It got better through an understanding of the pathophysiology and pharmacology of the treatment of high blood pressure.   If I found these facts to be inconvenient, my patient would be the one to suffer for my arrogance.

References

Aram V. Chobanian, MD; George L. Bakris, MD; Henry R. Black, MD; William C. Cushman, MD; Lee A. Green, MD, MPH; Joseph L. Izzo, Jr, MD; Daniel W. Jones, MD; Barry J. Materson, MD, MBA; Suzanne Oparil, MD; Jackson T. Wright, Jr, MD, PhD; Edward J. Roccella (2003). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report--Correction JAMA: The Journal of the American Medical Association, 290 (2), 197-197 DOI: 10.1001/jama.290.2.197

The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group, . (2002). Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) JAMA: The Journal of the American Medical Association, 288 (23), 2981-2997 DOI: 10.1001/jama.288.23.2981

41 responses so far

  • Pascale says:

    You didn't try thr Arizona red lizard jasper?

  • palmd says:

    Yeah. Tasted like chicken.

  • Calcagus says:

    In America,are you still allowed to use betablockers with thiazides in non diabetics? They're about 5th line in the UK.

  • palmd says:

    ALLHAT would argue that thiazides should be first line in everyone.

  • lrlee says:

    Is there a study proving the Placebo Effect exists?

  • Dianne says:

    I assume the patient is a composite?

  • palmd says:

    Most certainly. You know that by now. Remember when you got me to pull down a case that didn't seem anonymized enough?

  • makarios says:

    Great post and a pleasure to read.
    However, if you had listened to Diane Rehm today you would have learned that you could have solved the whole problem with Relaxation techniques. They also work for early Parkinsons by increasing the brain's production of L-dopa.
    My toungue just got stuck to my cheek

    Makarios

    • JJM says:

      Over ten years ago, Diane Rehm was off the air for several months. She was having trouble speaking, it was eventually diagnosed as spasmodic dysphonia (which is treatable). I have wondered whether she would have been diagnosed faster if she were not so trusting of quacks.

      • palmd says:

        Rehm's struggle with dysphonia has been fascinating, and she has done some work to publicize voice disorders, but I still think they are little known and little understood by the public and by many medical professionals.

  • Nathan Myers says:

    That placebo effect just keeps getting better and better.

  • James Pannozzi says:

    Every patient an experiment??

    Thanks for being honest. So much for "science" backed medicine based on "evidence". The facts, and you've been openly honest about them, speak volumes.

    The fundamental epistemological error that you are making is what Homeopath-Chemist Lionel Milgrom calls "scientism" and people espousing this theory, for which you've fallen hook, line and stethoscope, he characterizes as the "new fundamentalists".

    Before reading on, I urge you, and the readers to have a look, see link below, at what he is saying. (Side note: Milgrom is an accomplished chemist before becoming a Homeopath; I do not agree with his rather curious quantum interpretations of Homeopathy but that aside, his deeply perceptive depiction of underlying motivations and fallacies in the attacks on so called alternative medicine are very illuminating)

    Link to Milgrom on "Scientism" and the New "Fundamentalists".
    http://www.anh-europe.org/news/anh-feature-beware-scientism’s-onward-march

    This point of view, if you care to delve more deeply into its philosophical implications, and despite your obvious dedication, represents a dehumanization of the patient and their reduction to the status of an object - a broken machine or organism for which the appropriate "fix" in the form of the pharmaceutical
    drugs with, "side" effects. The even casual observer will note the completely nonchalant manner in which you accept the necessity of these "side" effects and work around them, both perverting your therapeutic intent and sabotaging it by introducing new complications into an already sick patient. Oh! oops, patient's legs are swollen, gotta change to some other type of drug. Ho Hum, let's see, what shall we try next.

    If you read what Milgrom is saying, and it is pretty shocking, medicine, that is the conventional medicine that you practice, the medicine that we all, including myself, rely on, is falling under the spell of idealogues who are carefully narrowing the focus of science and "evidence" in order to create a veneer of mathematical certainty and proof in a field in which the tens of thousands of variables render such an attempt absurd.

    So, agree with it or not, I would take another look at the Homeopaths, and other systems of medicine, before launching again into your weekly tirades about "science" and "evidence" with such narrowly defined focus as to exclude ALL evidence, even of doctors and patients themselves, which does not fit into predetermined and carefully proscribed moulds - one size does NOT fit all.

    Try to see if Milgrom is right, that the philosophical implications and reasonings behind the anti-alternative medicine cult under whose spell you have so easily fallen, in fact rest more on logical positivism than on the rational empiricism that we might have expected, before allowing your opinions to be shaped and stamped with a seal of approval by idealogues whose goals you appear to know nothing about. [HINT: Their attempt to block funding for Homeopathy via the NHS in Britain backfired in their faces after a long media campaign of innuendo, misrepresentation and appeals to "science". The British government, wisely, would have NONE of it.]

    Oh, and be careful on those case descriptions, I've heard that a big Hippa on the loose can be dangerous!

    • James Sweet says:

      Wow, James Panozzi, that's a really stupid response.

      CAM practitioners accused SBM of using a one-size-fits-all approach which dehumanizes their patients. When PalMD argues against a one-size-fits-all approach, you say he is dehumanizing his patients.

      At the risk of being a dick, I would like to suggest that you are "an idiot, brain-damaged, and a retard."

    • CivilUnrest says:

      Wow.

      I can't even imagine how you think a patient with high blood pressure should be treated. Would you simply avoid any treatment for fear of a side effect? How is that OK?

  • palmd says:

    My initial response to this lengthy response is that you either were not capable of understanding what I wrote, or you simply chose not to.

  • Dianne says:

    So, agree with it or not, I would take another look at the Homeopaths, and other systems of medicine, before launching again into your weekly tirades about “science” and “evidence” with such narrowly defined focus as to exclude ALL evidence, even of doctors and patients themselves, which does not fit into predetermined and carefully proscribed moulds – one size does NOT fit all.

    I never have understood how homeopaths and other quacks get away with their claim that they are "individualizing" their treatments when they also make claims that their particular snake oil (whatever it happens to be) is good for everything from fibromyalgia to heart disease to cancer.

    In contrast, a good internist does do a lot of individual tailoring and consideration of a number of details. Consider someone with cancer. If that person went to Hulda Clarke (before she died of myeloma), he might be told to take her "cure for all cancers" without further consideration. If the same person went to an allopathic doctor, a lot more details would be considered: What type of cancer is it? Is it limited to the organ or origin? How healthy is the patient otherwise? What is his lifestyle like currently (ie is he still working, up most of the day, in bed due to illness)? Does he smoke? Did he ever? What are his goals in therapy? What does he specifically NOT want? Then there are a number of disease specific details to be consdiered. Suppose it's lung cancer. What type? Small cell or non-small cell? If non-small cell, adeno or other? Does it have an EGFR activating mutation? Only after this information is obtained can one make a plan-and a backup plan. Suppose the tumor is an EGFR positive adenocarcinoma with multiple metastases. That will generally respond to tarceva. Great, start there...but what if it doesn't? What if it responds but the patient has an unacceptable side effect? What are we going to do when the tumor stops responding?

    So, on the one hand, "western" medicine which tailors treatment to the individual and, as PalMD indicates, considers alternatives knowing that, as we don't know everything about biology sometimes our best guesses will be wrong and we'll have to go to the next option. On the other, we have "alternative" medicine in which the practioner throws a one size fits all treatment at the patient and blames him when it fails-claiming it failed because the patient was too pesimistic or ate the wrong foods, or some other nonsense. So where does this idea that naturopathy is more individualized come from?

  • Dianne says:

    Off topic, what's your opinion of stents vs CABG?

  • palmd says:

    Great, ask hard questions. That's a post I've started and stopped a half a dozen times.

  • OleanderTea says:

    James Pannozzi used the word "quantum" (..."I do not agree with his rather curious quantum interpretations of Homeopathy" ...)

    Can we come up with a Godwin-like law to invoke whenever "quantum" comes up in the conversation?

  • Greg says:

    Thank you for a great post.

    Please continue "launching...into your weekly tirades about “science” and “evidence”".

    Greg.

  • James Sweet says:

    Every time acupuncture comes up on medical skeptic blogs, I have resolved to pitch the following crazy idea, on the hopes that perhaps somebody in a position to do research into these sorts of things will be inspired:

    Therapeutic spa.

    There seems to be a trend in studies comparing acupuncture, sham acupuncture, and unrelated placebo, that while the acupuncture fails to outperform the sham acupuncture, the sham acupuncture often does better than non-acupuncture-based placebos. It's not always statistically significant, so it could just be a fluke, but it does give one pause. Moreover, we know that, at least when it comes to subjective patient outcomes, a placebo intervention seems to consistently outperform no intervention.

    So how can we capture this benefit without the ethical disaster of lying to/deceiving patients?

    When my wife briefly dabbled with getting acupuncture treatments, I came along for one of them. They put her in a dimly lit room with relaxing music and incense, gave her personal attention for several minutes, then let her relax for several more. It looked... really kinda nice. No surprise this makes people feel good, right?! My wife subjectively found that acupuncture "worked for her", but being pretty skeptical herself, she also came to the conclusion that it was most likely because she basically got a spa visit that was mostly paid for by my insurance.

    And there ya go: Therapeutic spa. If a patient has subjective complaints such as generalized pain which a doctor feels would benefit from a placebo, the doctor can write him a prescription for the spa. The doctor can be completely honest -- "This has been shown to improve subjective outcomes in many patients" (assuming this is backed up by research, of course). There is no pretense of medical intervention, or at least no pretense of some mechanism at work that is not actually at work. In addition, by using the label "therapeutic", you avoid implications that it is "all in the patient's head". You acknowledge the patient has a legitimate problem, one that will benefit from increased relaxation.

    The prescription also means insurance can pay for it, assuming insurance companies can be made to go along with it. But why wouldn't they? My insurance will pay for acupuncture with a co-pay. Why wouldn't they pay for the same thing, sans the lies?

    Therapeutic spa. I'm tellin' ya man, it could really work. All it needs is some research and (assuming that bears it out as an effective way of delivering an ethical placebo) some advocates.

    • Kevin says:

      I recently wrote about a friend of mine (only 25 years old) that's in the end stages of cancer. She's gone through all the chemo and surgeries she could, and now she's shelling out tons of money for what appears to me to be essentially a spa treatment.

      Of course, the peddlers of the place say that all of their "alternative therapies" actually treat the cancer, and the positive attitude may actually help in some way, but for her, even if it's all in her head, it might still be worth it.

      http://bit.ly/a2Fto3

  • Composer99 says:

    Pannozi: holy strawman, Batman!

  • Dr Anold L. Goldman says:

    But Hahneman showed that the diluent, water, is altered and retains a therepeutic property once sufficient dilution is achieved. Then like-affects-like comes into play.
    Why don't you ignorant philo-scientists just understand this? It's so obvious!
    You just have to believe, like Dorothy! ther's no place like home...There's no place like home...etc

  • Nathan Myers says:

    The patient isn't any sort of experiment, if the physician is any sort of competent. Each attempted treatment is a sort of experiment.

    When the physician fails to offer a satisfactory treatment (as any honest physician will admit happens with distressing frequency) the patient is obliged to run experiments using alternatives the physician feels unable to offer. Often those work, often for reasons poorly or not understood. Usually they don't, although that's not predictable. You have to do the experiment to know.

    When a treatment fails, that provides the control to measure the effects of other treatments against. It's not a double-blind control, but for an individual patient it's the best you can do, and much better than nothing. That's the same whatever sort of intervention you are trying. A coherent theory is nice, and statistical data from other patients helps guide choices, but ultimately what works for the patient is the best treatment. Any misgivings at that point are just ideology, worse than useless.

  • palmd says:

    ...words, words, words...

  • rob says:

    why i myself have developed a new homeopathic treatment. it involves injecting the remedy rather than imbibing it. this lets the treatment get absorbed by the body more quickly and does not allow stomach acid to reduce the potency of the remedy.

    i call it:

    Subcutaneous Homeopathic Injection Treatment

  • rob says:

    @OleanderTea:

    the new law would also have to cover the terms "energy" and "eastern" as well as "quantum"

    we should call it Pal's law or Orac's law.

    we can let the two of them decide it in a cage match.

    (i suspect PalMD would have the advantage over a blinky box though...)

    • OleanderTea says:

      I suggest combine both into PalOrac, and just stick that in a thread whenever someone argues from "quantum", 'eastern', and/or 'energy'. As in:

      "Blahblahblah QuantumEasternEnergyHolistic blablahblah meanies!"

      "I call PalOrac!"

      *thread ends*

  • Nathan Myers says:

    Pal: I wonder who you think you're fooling.

  • palmd says:

    That implies some sort of plan and sinister intent. Interesting.

    • Nathan Myers says:

      I see, just cheap abuse. If that's what you want your blog to be about, that's up to you.

      But what would be so bad about scruples? Try them, you might like them.

  • makarios says:

    James Sweet
    There is no pretense of medical intervention, or at least no pretense of some mechanism at work that is not actually at work. In addition, by using the label “therapeutic”, you avoid implications that it is “all in the patient’s head”. You acknowledge the patient has a legitimate problem, one that will benefit from increased relaxation.

    Are you saying that if " it's in the patient's head" it is not a legitimate problem?

    Makarios

    • James Sweet says:

      Oh no, heavens no, absolutely not! Unfortunately, however, many people tend to perceive it that way. They are wrong, of course, but that perception is not going away, and so we need to take that into account.

      If you'll indulge me in waxing a bit philosophical for a moment... We are all naturally Cartesian dualists. We think of the mind as being not just independent from the body, but independent from physical constraints entirely. "Free will" and all that. We naturally tend to assume that anything that is "in the mind" can be changed by a mere act of will.

      Everything in the previous paragraph is of course complete hogwash. The mind is just another part of the body, subject to physical constraints of all sorts. I'll dodge the "free will" discussion for the moment, but certainly a mental disorder can be just as concrete and inexorable as a broken arm or an infected wound. You can't just think it away.

      And yet still, because we are naturally dualists, we tend to think that way anyway. So when somebody is experiencing a symptom, and you say that the symptom is psychogenic, there is a tendency for people to parse that as "not real" -- which can be very insulting to someone experiencing a very real symptom!

      The fact that the insult is in their dualistic interpretation rather than in the intention is not always relevant. How many patients have rejected a psychogenic diagnosis, seeking instead to find a doctor who will tell them that their illness is indeed a "physical" problem (even though a proper rejection of dualism ought to make it obvious that a psychogenic problem is a physical problem) and give them some questionable treatment, rather than attacking the illness directly?

      Re-reading my comment, I see why you thought I was saying that. That was not at all my intention -- rather, my point was that the label "therapeutic" can potentially help avoid the perception that treating a symptom as if it were psychogenic somehow invalidates the experience of that symptom. A psychogenic symptom is just as real as any other, of course.

    • James Sweet says:

      Or, in brief: What Vicki said :)

  • Vicki says:

    I'm not James, but I can think of two reasons to avoid the implication that the problem is psychological. One is that if you say something is psychological, the tendency is to either refer to a psychiatrist or psychologist, or just write a prescription for an anti-depressant. The other is that there is still a stigma around mental illness, and "are you saying I'm crazy?" is likely to increase stress and reduce the chances of actually helping the patient.

    "You're under a lot of stress, you need to relax" can be okay, but labeling something as an anxiety disorder is still problematic.

  • Joel Spinhirne says:

    If you have a patient that has recurring body-wide pain and extreme fatigue that has lasted more than a year and you want to use science to test whether X treatment works, what measurement(s) do you make pre- and post-treatment to produce a clinical study that supports the underlying reality?

    In this hypothetical, let's say the reality is that the treatment produces significant reductions in the body-wide pain and fatigue in 98% the afflicted. How do you produce a legitimate, science-based study that supports this? Again, specifically, what measure or tests do you use?

  • Joel Spinhirne says:

    This is a restatement of an earlier reply:

    If you are a clinical researcher, how do you test a treatment for recurring body-wide pain and extreme fatigue that has lasted more than a year? How do you use science to test whether X treatment works? What measurement(s) do you make pre- and post-treatment to produce a clinical study that supports or indicates the underlying reality?

    In this hypothetical, let’s say the reality is that the treatment produces significant reductions in the body-wide pain and fatigue in 98% the afflicted. How do you produce a legitimate, science-based study that supports this?

  • Joel Spinhirne says:

    The silence is expected.