FEATURE

Patient not doing well; certainly intervene.

Prof. B. M. Hegde,
hegdebm@gmail.com

William Osler, one of the great thinkers in modern medicine, had said way back in 1905 that: “when the patient is doing well DO NOT interfere.” This statement of his reverberates in my ears each time I see apparently healthy people being labelled with all kinds of new “doctor-thinks-you-have-a-disease” syndromes only to suffer in the long range of multiple ADRs (Adverse Drug Reactions). The latter, in turn, are then treated with some more drugs! Thus starts the never ending cycle of human misery. I am now observing a new syndrome of people suffering and doctors not doing anything about their suffering as long as the laboratory reports are within the doctors’ accepted norms!
I had the misfortune of seeing a good friend of mine who wanted to see me for some time now but could not. My mistake! Let us call him Mr Singh, which is not his real name, anyway. Mr Singh is an important VVIP of this state. He is a fit seventy seven full of enthusiasm to work but, has no energy at all. In fact, he saw me when he was in Mangalore for a lecture. This gentleman, while travelling in an A/C first class compartment all by himself en route to Bangalore, woke up at 2AM feeling dizzy and vomited repeatedly. He had to wait till day break when the train reached Bangalore where he was too weak even to get out of the train. To cut the long story short, he found himself in a Corporate Hospital in Bangalore. He has lot of praise for that hospital and its staff, both medical and nursing. That was six months ago.
They kept him in the ICU for four days and then sent him home after exhausting all their gadgets on him with a long list of medicines with the probable diagnosis of a cerebellar infarct, damage to a small area of the hind brain which looks after our balance in addition to many other functions. They had told Mr Singh to keep seeing his personal physician on follow up. His personal physician added a couple of more tablets to the list. He was going for a monthly check up and each time he was asking the doctor if the drugs could now be tapered off to be finally eliminated. A firm NO from the doctor kept him going but he was slowly becoming lethargic, with aches and pains all over and no energy to do anything at all. He kept pestering his doctor who went on repeating the blood tests and assured him that all his parameters were within normal limits and he does not have to worry. But worry he did because he was not able to walk even for ten minutes while he was an obsessive morning walker for several miles earlier! When he saw me he told me that he was not able to go for a walk at all, although his doctor has been goading him on each visit to walk daily lest his new found diabetes should worsen. Mr Singh, however, kept reminding the doctor that he was NOT ABLE to walk and do any work.
This is a new syndrome, which has not been described in textbooks of medicine as it is of recent origin. The present therapeutics encourages doctors to give multiple drugs all together for most, so called lifelong diseases. Mr Singh has been on a sugar pill, three blood pressure lowering pills of different castes, the universal drug for all people who see doctors today, the (in) famous STATINS, a couple blood thinners like aspirin, to counter the gastric irritation with all these a powerful proton pump inhibitor, ranitidine, another calcium channel blocker to prevent a future dizzy spell in cinerazine and a few vitamins and minerals.  Each one of these drugs has undergone controlled trials in isolation under ideal circumstances. Alas, there is no study to show what happens when they are combined and given to the same patient. This is what we call evidence based medicine of twenty-first century. Each combination could throw up a new ADR syndrome which can never be predicted by the Pharmaceutical representatives that educate doctors these days. Whoever could have dreamt that Thalidomide, such a nice tranquiliser, given to pregnant ladies for sound sleep could bring forth monsters?
 If one wants to suppress the production of human healthy cholesterol in the liver with statins, one is also suppressing other liver functions through the same enzyme that statin tries to suppress! One of the vital chemicals needed for healthy human system is Mavalonic acid which is also produced in the liver in the same pathway as cholesterol. When statin is given to patients it would also suppress Mavalonic acid production. Children born with congenital mavalonic acid defect look like old ghosts at the age of two to three years and do not live long. Think of the same defect being brought on by drugs in adults. Statins also damage muscles universally in all recipients (biopsy proven) although some might not be symptomatic, or even get their muscle enzyme levels increased! But when a patient who is intelligent keeps on complaining that he cannot walk for more than a few minutes he needs immediate intervention to see what is happening. Most of the time this is one of the ADR syndromes. Concurrently Mr Singh’s most of the vital systems are knocked off by beta-blockers, ACE inhibitors, calcium channel blockers, proton pump inhibitors and even alpha blockers and H1 blockers.  I do not think that any of his vital systems is functioning at its best, imagine at age 77. I was surprised that he is still on his feet and has the courage to come to lecture for one hour! He must be a lot better now with very few of those deadly drugs.
The new doctrine should be to intervene when patient bitterly complains repeatedly while on drugs. But do not forget Osler’s dictum of NOT interfering when patient is doing well. Patient’s story is a better judge compared to laboratory reports.