Dr. Sam Online

So, as I’m surfing the web earlier today, I happened upon the “Health & Healing” discussion forum at www.craigslist.com, which is basically a typical fun Internet free for all.

Lots of folks with lots of opinions on there.

Anyway, I came across one post from a user going by the name of “dlwhiz” that expressed the following.

“I need to find natural cures for high blood pressure. Anyone have a cure, pills are not working, they make me sick.”

There was of course a plethora of answers from all sorts of folks. These anonymous Internet posters offered all sorts of advice basically ranging from “Quit being so lazy, get some exercise!” to “Use some different medicines” to “Try these great herbal remedies!” (I’m paraphrasing here to capture the general tone of most of the posts…these aren’t actual verbatim quotes)

Some of the answers I read were better than others, but most of them had one glaringly huge flaw, one which as a physician I saw immediately and which I think most physicians would similarly pick up on immediately.

What was this horrible flaw?

As far as I could see, none of these responders had hardly any clue whatsoever regarding anything pertinent about this patient, other than he or she is at least somewhat Internet competent, is able to communicate in English, and claims to have high blood pressure.

Armed with this little tidbit of knowledge, many of these posters felt completely qualified to embark upon the practice of telemedicine! (Before I get angry replies, please note that I did say many of these posters, not all of these posters.)

Amazing!

Folks, you can’t properly diagnose and treat any medical condition without a proper history and physical exam. I’m sorry, but that’s just the way it is.

It may not be fun to read this, but the fact of the matter is that when you offer specific advice to a specific patient with a specific stated medical complaint, even behind the thin veil of anonymity offered by the Internet, you are in fact attempting to practice medicine.

Not only is this against the law without a medical license (in every jurisdiction I’m aware of), it’s potentially downright dangerous, not only to any potential patient who might actually take your advice, but also to your own personal fortune as once you engage in this practice of medicine, you are in fact making yourself a legitimate target for a potential medical malpractice lawsuit.

How can you possibly offer this patient advice for “curing” his or her high blood pressure without first knowing such fundamentals as the persons age, gender, previous medical and surgical history, family medical history, social history including (smoking history, alcohol use, illicit drug use), current medications, allergies, etc? How can you make a diagnosis on this person without even knowing so much as just what their actual blood pressure is?

Running a medical practice is damn expensive. There is a tremendous amount of overhead and headaches involved. Most doctors are at least somewhat intelligent. Trust me, if it were possible to practice safe and effective medicine via craigslist, we would! We can’t however, so we don’t even try. You shouldn’t either.

So, what’s this patient to do about his or her high blood pressure?

I’m assuming (and this is a big assumption) that the patient has been to some sort of health-care practitioner since there is the claim that “…pills are not working, they make me sick.” Why do I say this is a huge assumption? Well, I don’t know what these “pills” are. For all I know, they are some sort of over the counter or herbal product, or they could be medications that were prescribed to some other person. Not saying any of this is the case, just that it could be as far as I know.

Assuming that this initial assumption is correct, and that “dlwhiz” has in fact seen a health-care practitioner, my strongest recommendation would be to GO BACK to that person and discuss this issue further. There may be further tests that need to be done to look for underlying causes of high blood pressure. There may be some other medication or medications or some other lifestyle modification(s) that need to be pursued. There may be some reason the pills aren’t working. There may be some reason they are making you sick. There are just so many potential variables here that there needs to be a competent health-care practitioner (preferably a physician, in my opinion) coordinating all of this.

Okay, I’ll get off my soapbox now and offer some general advice.

Some of the advice that was offered on that craigslist thread was in fact pretty decent advice, when taken in the broad general sense, rather than directed at an particular individual person, such as “dlwhiz.” Certainly folks should get proper exercise, eat right, maintain a healthy weight, abstain from tobacco use, etc.

High blood pressure, otherwise known as hypertension is serious business. If it is out of control, it needs to be brought under control. This post is not meant to be an exhaustive treatise on the topic of hypertension, so I’ll merely mention that elevated blood pressure greatly increases your chances of developing a multitude of serious and potentially fatal medical problems. Folks, have your blood pressure regularly checked, as part of your total preventative health-care program, and keep it under proper control.

In one of my earlier posts I compared health to playing a hand of “no-draw” or “hold-em” poker. There are some factors that are simply out of our control to do anything about. These are primarily genetics, or in other words factors that we have inherited. Think of these as being the cards you are dealt.

There are other factors however that can be thought of as “How we play the hand we are dealt.” These are the factors that we do in fact have some degree of control over. These factors include things like our food and water intake, sleep habits, exercise habits, sexual habits, use of substances like alcohol, tobacco, and drugs, medications, etc.

Some folks are really lucky and get dealt a great hand. These are like the poker players who get dealt a Royal Flush. It seems like no matter what they do, they just can’t lose. We’ve all seen or heard about the rare old geezer who lives a long life and never seems to get sick, all the while eating terrible foods, smoking, drinking and generally not taking care of themselves. Well God has certainly smiled upon them, so I reckon I will too. I won’t however recommend that the rest of us follow their lifestyle habits.

Some other folks fall at the other end of the spectrum. They just get dealt a lousy hand. They can do everything right and still end up with terrible health. For them, I can only say, “I’m sorry for you,” and be thankful that we have some true miracles of modern medicine that can help some of these folks, with more being discovered and developed all the time.

The vast majority of us however are dealt neither a “Royal Flush” nor are we dealt an absolutely hopeless hand in this hereditary genetics poker game called life. Fortunately, most of us are dealt are fairly decent hand, and with a little bit of luck, if we play our cards right, we can count on a reasonable chance of leading a long healthy happy life.

As I mentioned, I don’t intend this to be a long diatribe on hypertension, but I will offer these little tidbits.

1. Absolutely, optimizing one’s lifestyle should be the number one item on the list when dealing with hypertension. There are multiple things that we have control over that can and frequently do have an effect on our blood pressure. Things already mentioned such as exercise, obesity, dietary salt intake, over the counter medications, tobacco alcohol and illicit drug use, water intake, sleep, etc. (as well as others that I’m sure I’m not thinking of as I am just spouting this list off the top of my head) all need to be addressed and potentially modified.

2. Every person is an individual, so what has a big or small effect in one person may not have that same effect in another person. That said, if you look at the population as a whole, the one lifestyle factor that has the most effect on blood pressure in the most people is weight. If you have an above normal weight, losing weight will have the biggest “bang-for-the-buck” so to speak, in the most people. Why is this? Well, in my opinion, while it appears that excess body fat in and of itself can have a direct effect on our blood pressure, the very lifestyle habits that tend to promote weight loss (i.e. healthy diet, healthy salt intake, adequate exercise and sleep, etc) also each have their own individual direct effects on blood pressure. Even if you don’t attain a normal health weight, and remain overweight or obese, losing some weight has the potential to have a beneficial effect on your blood pressure. That said, shoot for a normal healthy weight! For some ideas on weight loss, there are several previous posts in this blog which address that issue.

3. While there is some evidence for benefit from some non-pharmaceutical products in the treatment of high blood pressure (with some products having stronger evidence than others), I am not aware of any such products that will “cure” hypertension. I am also not aware of any such products that will typically do as good a job or better job in the treatment of hypertension as what we see with conventional pharmaceutical medications. The best I am aware of any product being able to achieve is to potentially help one control their blood pressure. I am not aware of any product that will “cure” it. I am also not aware of any such products that can be said to be completely without risk of detrimental side effects (including potentially death).

Please note, that I am no shill for the pharmaceutical industry however. I am equally unaware of any prescription medication that will “cure” hypertension, and am equally unaware of any prescription medication that is without similar risk.

I guess the big difference here is that prescription medications are typically presented with acknowledgment of that risk right up front. I don’t know how many times I’ve heard some patient tell me that the herbal product they are taking is completely safe because it is “all natural.” I typically remind them of the fact that rattlesnake venom is also “all natural” and ask them if they would like an injection of some. Further, although we all see the dramatic news stories when some prescription medication becomes the next big target for the trial lawyers, the prescription medications in this country (I will apologize to my international readers here, but I’m primarily addressing a U.S. audience) have by and large been rigorously tested for both safety and efficacy using proven standard double blind placebo controlled clinical studies. In this country at least, such standards typically do not apply to non-prescription herbal or “all natural” medications.

Now then, after having said all that, I will throw this additional caveat out there. Dr. Sam is by no means all-knowing. Just because I am not personally aware of something, doesn’t mean it isn’t true. I am massively in favor of learning new things. So, if any of my readers have interesting information about good rigorously tested evidence of beneficial effects and safety profiles of particular herbal products, etc., I am completely open to hearing about this and would love to have such information forwarded to me for my own review and edification. In advance, I’ll say “Thanks” here for any such info I receive!

4. If unable to control one’s blood pressure through lifestyle alone, or until one is able to get it under control through lifestyle modification (keep in mind that such modifications may take considerable time to have a beneficial effect), you might need prescription medications to get the job done. Some people will be able to get their pressure to a desired level with just a low dose of a single medication. Others will require high doses of multiple medications. Most folks will fall somewhere in between. The average adult with hypertension will typically require 2-3 concurrent medications to get their blood pressure under good control. Again, however, let me emphasize that medications should not be looked upon as a substitute for healthy habits. Rather, they should be looked upon as a supplement to such healthy lifestyle habits. It’s really not okay to just say, “Oh, I can’t lose any weight, so I’ll just take pills rather than address my diet and activity level,” for instance.

As mentioned, any of these medications have potential for side effects. Sometimes these may be temporary, or may be able to controlled via modifying the dose or method of delivery (topical vs oral, with food or without, morning vs evening dose, etc.). Any undesirable effects should be discussed with the prescriber and/or the pharmacist filling the prescription.

5. I think I touched upon this above, but it bears repeating here, that oftentimes there are other underlying undiagnosed medical conditions that may be affecting one’s blood pressure. If a person is engaging in proper lifestyle habits and the blood pressure can still not be brought under good control, even with multiple medications in multiple anti-hypertensive classes, there should be a redoubling of efforts to look for such potential underlying causes. Things like renal artery stenosis (disease causing blockage of the artery to a kidney), pheochromocytoma (a type of adrenal gland tumor), and thyroid disease, for instance, as well as many other potential causes should all be investigated.

So, I realize this has been a rather long-winded post (as most of mine unfortunately tend to be) and I apologize for that. In a nutshell, my message to “dlwhiz” and others is that yes absolutely, the Internet can and should be used for the valuable educational resource that it is. Use it to educate yourself about all sorts of subjects, including health-care topics relevant to your personal situation. Do not however look upon it as ever being any sort of replacement for developing and maintaining a good working relationship with a qualified, caring, and competent physician. It is a supplement to such a relationship at best.

My other message here is “Don’t try to practice medicine if you aren’t qualified to do so and/or don’t try to practice it in an inappropriate manner (such as via anonymous web forums).”

I hope this info might prove somewhat helpful and beneficial and hope it is received in the spirit in which it is intended.

Cheers, and Good Health To You and Yours!

….Sam