A pound of prevention: Overtreatment

President Franklin D. Roosevelt died at age 63 from uncontrolled high blood pressure. In those days it was not recognized as a medical problem. If he had lived today, he would have almost certainly been treated with drugs that would control his blood pressure, giving him extra years of life. High blood pressure is called "the silent killer" because it causes no apparent symptoms or discomfort. Clearly, the drugs are useful to people with high blood pressure.

But for people with only mildly elevated blood pressure, or readings at the upper limit of normal, now called "prehypertension," the risks of harm from the disease are very low. The risk of harmful side effects from the drugs may outweigh the risk of the disease, especially for the elderly.

Once experts have drawn a line in the sand that separates "health" from "disease," we forget that there are shades of gray, and often no real sharp dividing line exists.

Advice for those receiving drug prescriptions for conditions with no apparent symptoms: Do your homework about the tradeoffs of the drugs, and discuss them with your doctor. As Dr. Abigail Zuger says, "a pound of prevention is worth a closer look."

Read another story on drug side-effects in the elderly.

Thanks to Dr. Abigail Zuger for her source article in the New York Times of Jan. 25 about the book Making People Sick in the Pursuit of Health, by H. Gilbert Welch, Lisa Schwartz, and Steven Woloshin.

I can’t hear you while I’m listening: Communicating with your doctor

A stethoscope amplifies inaudible heart and lung sounds in a very satisfying way. If, however, the owner of the organs under evaluation decides to make a comment during the exam, what results is a painfully loud, unintelligible blast of noise directly into the doctor's head.

It was during such an interruption almost 30 years ago that Dr. Richard Baron, a Phiadelphia internist, grumbled at his patient: "Shhh. I can't hear you while I'm listening." The phrase has undoubtedly been said by many, but Dr. Baron was the one with the wit to stop and laugh (and reflect at length in a classic medical article), realizing that he had enunciated in pure koan form probably the single greatest tension in modern medical practice.

Against the siren song of all those beautiful instruments and machines, whatever the patient has to say is sometimes just an annoying interruption.

This is a caution about the use of technology. It's also a caution to patient advocates, to ensure we don't get in the way of the doctor's listening to the patient.

Advice: Find a doctor who listens to you – and do your part by enabling him or her to listen fully, in every sense of the word.

Read another physician listening story. Thanks to Dr. Abigail Zuger for the source story in the New York Times on Oct. 27.

Ten years ago, she had one year to live: Mistrust of doctors’ opinions

Dr. Abigail Zuger's story:
A patient and I have been conducting an increasingly existential dialogue on these subjects for years now – not easy to sustain in 15-minute segments, even less as we both realize we are getting exactly nowhere.

She has untreated HIV infection with an immune system now so dysfunctional that it is quite extraordinary for her to be still in the pink of health.

Which she is, no doubt about it. She feels fine. At some point in the past a health care professional hazarded that she had a year to live, and after 10 years she lost all faith in expert predictions.

From my own long experience with patients just like her, I know the very unpleasant future that surely awaits her. She has no interest in letting my memories drag her across the river. She only knows she feels fine. Furthermore, she has tried all the drugs that will change her risk, and every one of them makes her feel sick.

We have tossed this all around many times, and each time she enumerates the same paradox: I, with my gloomy warnings and my new ideas for medication, am trying to make her sick. She is determined to stay healthy.

Healthy to infect others, I point out. Healthy to leave her son an orphan. Healthy until she gets sicker than anyone needs to be.

Healthy in the here and now, she insists. Healthy not to throw up every morning, healthy enough to go to work, pay the bills and buy the kid a set of drums. Healthy to feel like herself.

Clearly, there is health, and there is health, and sometimes the twain just will not meet. Meanwhile, every time I look at her lab reports I feel a little sick.

When epidemic infection came to town in the old days, it was usually clear who was sick and who was well. Yet in the midst of New York's typhoid outbreaks of the early 20th century, one of the healthy was Mary Mallon, "Typhoid Mary," the cook who carried the germ, infected dozens of others, yet never got sick.

Health is as hard to define as love or happiness, and even harder to trap and keep.

Advice to victims of medical errors: Remember that even after you've had a doctor make a mistake, doctors are still right much more often than they're wrong.

Thanks to Dr. Abigail Zuger for the source article in the Sept. 30 issue of the New York Times.

With great enthusiasm and conviction: The placebo effect

His late mother-in-law, Sarah, had been a concert pianist who developed painful arthritis in her old age and found her doctors to be generally useless when it came to satisfactory pain control. "So, being an independent, take-charge individual, she subscribed to Prevention magazine, in order to learn more about the multiple remedies suggested in each month's issue" for symptoms like hers.

Predictably, every couple of months Sarah would make a triumphant phone call and announce with "great enthusiasm and conviction" that a new food or supplement or capsule had practically cured her arthritis. Unfortunately, each miracle cure was regularly replaced by a different one, in a cycle her son-in-law ruefully breaks down for detailed analysis in his book, Snake Oil Science.

He makes it clear exactly how the natural history of most painful conditions conspires with the placebo effect to make almost any treatment appear to work, so long as the recipient hopes and believes it will.

Placebos sometimes work. Their effects are characteristically mild and temporary. They are more or less indistinguishable from the effects of most alternative treatments, as Dr. Bausell describes.

R. Barker Bausell's advice: If you're bent on trying alternative medicine, find an appealing therapy and an enthusiastic practitioner, then plunge in wholeheartedly to maximize the placebo effect and prolong its duration.

Browse for related stories in the index at the very bottom of this page, or read a contrary story about the value of traditional non-scientific methods.

Thanks to Dr. Abigail Zuger for the source story in the Dec. 25 issue of the New York Times.