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.
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