How to stem the incipient epidemic of hypertension

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On November 13, 2017, an epidemic of hypertension broke out and could rapidly affect tens of millions of Americans.  The epicenter of the outbreak was traced back to the halls of the Anaheim, CA, convention center where the annual meeting of the American Heart Association was taking place.

The pathogen was released in a special 488-page document labeled “Hypertension Guidelines.”  The document’s suspicious content was apparently noted by meeting personnel, but initial attempts to contain it with an embargo failed and the virus was leaked to the press.  Within minutes, the entire healthcare ecosystem was contaminated.

At this point, strong measures are necessary to stem the epidemic.  Everyone is advised not to click on any document or any link connected to this virus.  Instead, we are offering the following code that will serve both as a decoy and as an antidote for the virulent trojan horse.

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Does Bergen, Norway, hold the key to the mystery of hypertension?

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At the beginning of my new book, Socrates engages Geoffrey Rose to discuss one of the most fascinating conceptual questions regarding hypertension.

The question is the following:  Compared to normal subjects, do hypertensive patients constitute a distinct population of patients?  In other words, if we go out and measure the resting blood pressure of a large swath of the population and plot the numbers as a distribution curve, do we get two separate bell-shaped curves or just one?

 

A “2-peak” distribution of systolic BP

The answer to that question was the subject of an intense debate that began in the mid 1950s and lasted a couple of decades until it died down in the 1970s without any settled conclusion.  Yet, an answer to that question is of critical importance not just for our understanding of hypertension, but for medical science in general and, by implication, for the direction of our healthcare system.

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Evidence that women are better cooks than men

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I must admit that my initial reaction to the now famous study by Ashish Jha and colleagues—showing that female internists achieve slightly better 30-day inpatient mortality rates than male internists—was one of annoyance.  “Here we go again,” I thought.  “Data mining at the service of political correctness.”  And I was pleased to read David Shaywitz reply to the study with a piece in Forbes aptly titled “When Science Confirms Your Cherished Beliefs—Worry.”

That said, I must give credit to the study authors for generating a lot of interesting discussion and for stimulating Saurabh Jha to write his magnificent commentary “Homme Fatale.”

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How I learned to stop worrying and love practicing without EBM

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If you’ve enjoyed my previous take-downs of evidence-based medicine but can’t let go of your attachment to the randomized controlled trial, this post is for you.

My aim is to show you practical ways you can safely and effectively exercise clinical judgment without recourse to “evidence-based” knowledge, provided you follow simple but fundamental principles of clinical care: circumspection, parsimony, and due respect to patient autonomy.

What’s more, I will make my case against RCTs using examples that EBM apologists have precisely identified as paradigmatic of this “single greatest medical advance.”

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Three cheers for the statin war

The days of healthcare utilitarianism are numbered!

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If anyone has any lingering doubts that the promises of evidence-based medicine are quickly evaporating, the recent blog post by Larry Husten on the statin war should quickly dispel them.  Husten gives an excellent account of the latest battle opposing the pro- and the anti- camps.

What happened?

The pro-statinists published a 30-page diatribe in The Lancet.  Statins save lives, they assert.  The evidence is incontrovertible.  Yes, they can have side effects such as muscle pain, no one disputes that.  But drawing attention to those side-effects—as the anti-statinists do—endangers patients who now find a reason to refuse to take the life-saving drugs.  There’s evidence of that happening.

The anti-statinists voiced their position in the BMJ.  Statins cause muscle pain and fatigue, they assert.  The evidence is incontrovertible.  Yes, they can save lives, no one disputes that.  But trumpeting the benefits or down-playing the harm—as the statinists do—prevents patients from partaking in the glorious activity of “shared-decision making.”  There’s evidence of that happening.

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Beauty, chemistry, and natural philosophy

Summer reflections

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About a year ago, Theral Timpson interviewed Stanford chemist Carolyn Bertozzi on his Mendelspod podcast.  I only heard the show recently and enjoyed it.  The title caught my attention: “Is the future of biology a return to chemistry?”

Bertozzi made some interesting comments about her field, which she regards as “the central science,” and Timpson probed her about her expectations for the place of chemistry in what is otherwise expected to be “the century of biology.”

The discussion was of interest to me for two reasons.

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The mother of all medical errors

Iatrogenesis in perspective

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A study published a couple of months ago in the BMJ  made headlines for claiming that medical errors are the third leading cause of death.  As expected, the reactions were swift and polarized.

For some, the study confirmed that the self-serving healthcare system is utterly careless about the welfare of patients.  For others, the claim was complete hogwash, based on faulty methodology designed to justify further regulatory oversight.

The two positions are not necessarily mutually exclusive.

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Risk-factor medicine

An industry out of control

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If concepts could get awards, then “risk factor” would surely be a Nobel prize winner.  Barely over 50 years of age, it enjoys such an important place in medicine that I suspect most of us doctors could hardly imagine practicing without it.  Yet, clearly, the concept is not native to our profession nor is its success entirely justified.

A few years ago, on the occasion of the risk factor’s fiftieth anniversary, my colleague Herb Fred and I published an editorial highlighting some of the problem with the use of this concept.  I will summarize here some of those points.

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Risk factors, causes, and the diet-lipid hypothesis

A conversation with a reader about medicine's Ptolemaic epicycles

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I shared with a reader an editorial I co-wrote in 2010 entitled “Risk-Factor Medicine: An Industry Out of Control?” Subsequently we had the following e-mail exchange, which I thought might be of interest to other readers of Alert and Oriented.  I was impressed by Robert’s comments and learned a few things from him and from the links he provided.

On April 29, 2016, Robert wrote:

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Against surgical excellence

How inept decision models are targeting surgical practice

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A Vox.com piece about decision-making caught my attention this morning.

The story was compelling.  A 12-year-old boy had intractable seizures from a leaking vascular malformation in the brain.  A first neurosurgeon would not operate and recommended radiation therapy instead.  The patient’s mother sought another opinion from a Mayo Clinic neurosurgeon who was adamant that an operation should be undertaken.  The second surgeon surgeon was undeniably right.  The patient is now a bright, fully-functional researcher at the University of California San Francisco.

So far, so good?  Not so, according to Vox.  That there should be a smart mom making a smart decision, and a smart doctor carrying out a successful surgery is apparently a problem.

Why?  Because the more cautious surgeon had a different opinion and, had the mom compliantly accepted his recommendation, the child could have been worse off.  Variability in judgment, as always, is the enemy.

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