Why does common sense go out the window?

A 75-year-old retired chemical engineering researcher came to see me to confirm his diagnoses of primary aldosteronism and pheochromocytoma.

His saga began when he had an acute myocardial infarction about six months prior to the clinic visit. While on a monitored bed, he was noted to have marked hypertension, 210 mm Hg/105 mm Hg, at about 1 a.m. When he was woken up by the nurse, his only complaint aside from being woken up was severe tinnitus — a complaint that he had lived with for many years and controlled somewhat by a tube in each ear. He was given the diagnosis of "nocturnal hypertension," a syndrome that I had not heard about previously. Recovering at home after discharge, he developed the habit of checking his blood pressure at 1 a.m. each morning, getting three readings over a five-minute period to check for accuracy. Most times it was elevated and he had difficulty getting back to sleep. His wake-up blood pressures were in the 150 mm Hg/90 mm Hg range, and he was started on appropriate therapy for hypertension, but this had little impact on his nocturnal blood pressure.

Over the next several months, he went from doctor to doctor (primary care, internal medicine specialist, holistic, homeopathic, nutritional/bio-identical) trying to find a diagnosis and a cure. With each successive visit, he had additional blood work — both standard and tests of which I had never heard — and came away with additional medications. He was taking 14 different “medications” when I saw him.

Most of his labs, including electrolytes and catecholamines, were normal, but the validity, particularly of the catecholamines, was very questionable because he was on medications that were likely to interfere with the assay. His dihydrotestosterone, a test infrequently ordered by endocrinologists, was elevated and this too troubled him. Total and free testosterone were both normal, but sex hormone-binding globulin and gonadotropins were never measured. Free thyroxine was 1.2, thyroid-stimulating hormone was 4.1 — both measured while he was taking a thyroid preparation provided by his nutritionist.

After listening to his story for about 45 minutes, I turned the tables on him and asked if he would have conducted any of his research experiments this way. He needed some explanation of the question. If he had a chemical engineering problem to solve, would he continue to add different approaches to his work, or would he take a more reasoned approach of altering the experimental design with each miss step?

All too often in medicine when our initial therapeutic approach does not produce the desired result, we simply add another medication without discontinuing the ineffective one. In some circumstances, hypertension being a good example, this stepwise approach had been carefully studied and documented to be effective in clinical trials. However, in most circumstances, particularly when an etiologic diagnosis is not forthcoming for a set of symptoms or abnormal test findings, such studies have not been conducted. But each new consultant is reluctant to recommend discontinuing a medication prescribed by the last consultant. My most recent example before this patient was an older woman prescribed 29 tablets a day (not all different medications of course) by four consultants and her primary care physician.

We are all guilty of this — but what is the common sense alternative? I can think of a couple of approaches, but the practicality still escapes me.