My Patient's Sky-High Blood Pressure And 'The War On Science'
Madame Laurent came to my office one day last year with bloodshot eyes and a two-day headache. She’s well known in our clinic – kind to all the staff and always smiling even when she’s in pain. Despite a stroke a few years ago, she is mentally sharp, often able to read what I want to say before I can say it – an impressive feat considering that she only learned English late in life after immigrating from Haiti.
That day, her blood pressure measured 190 – a dangerous level when normal is below 140. It was probably causing her headache, I knew, making it even more dangerous. Before sending her to the emergency room, I asked her why she thought it was so high. The answer: While she’s prescribed four different medications for blood pressure, she hadn’t taken any of them for the past two days.
She told me she thought her medications were making her sick, and a friend suggested she should stop taking them. It mystified me: She was a clearly intelligent woman who knew her medications were vital to keeping her blood pressure low and helping prevent another stroke. How could she think stopping her medications would solve her problem without creating others?
My visit with Madame Laurent (not her real name) came back into my mind recently while I was reading Shawn Otto’s new book, "The War on Science: Who’s Waging It, Why It Matters, What We Can Do About It." Written during the presidential primaries, it has become even more relevant after the election.
Otto, the founder of ScienceDebate.org, an organization committed to including questions about science in presidential debates, has deep knowledge of the current battle lines in what he and others call a "war on science" – a war waged in the political arena but that influences which sources we trust for information about science and our health.
He sees the war being waged on three fronts, each with their own motivations:
• Industry powers that undermine climate change findings and other science to further their economic interests
• Evangelical Christians who question evolution because it contradicts church teachings
• And post-modern journalists who believe there is no objective reality, that scientific facts are only perceptions and have no greater claim to objective truth than any other.
According to Otto, few are blameless in this war. He accuses journalists of being too steeped in post-modernism and writing articles that falsely balance the fringe opinion of climate skeptics against the thousands of studies that have led to a strong consensus on climate change. He criticizes scientists in their ivory towers for not reaching out to communicate science to the public. He laments how politicians benefit from fanning the flames of partisan warfare to motivate misinformed constituents. He even takes science itself to task in heralding magic-bullet technological solutions like DDT that not only disappoint such high expectations but occasionally have devastating unintended consequences.
The result, he claims, is a weaker democracy that relies on individual voters to effectively weed out opinion from highly complex and technical facts. Yet, with so much information, all of us seek out trusted sources to do that work for us. It is no surprise that these sources help shape our opinions on medical and scientific topics – claims of a vaccine-autism link, evolution, and, as Otto covers most extensively, climate change.
But he is not encouraging blind belief in scientists or other elites. Otto points out that, aside from political dividing lines, we’re also separated by how we digest new information. Do we question our sources and ask for their data so we can evaluate it ourselves and come to our own conclusion? Or do we put our trust in the authority of the source?
I see this daily as a physician. Some patients want me to just tell them what to do and they’ll do it. Others want to understand the mechanisms and data behind why I think a medication or surgery will help them.
I might never convince some as their family or friends have already diagnosed them and they just want me to prescribe a treatment. Madame Laurent followed her friend's advice on what to do about her medications. Often, my work is less about providing detailed and confident answers to every question than about building trust through the process of talking through the uncertainties.
But misconceptions can have dangerous consequences, as with Madame Laurent. And countering them is no easy task. Madame Laurent knew she had high blood pressure and diabetes, that she needed medications to reduce the risk of a heart attack or another stroke. To help, I couldn’t just tell her: “Take your medicine!” and expect that to solve the problem. I had to understand why she stopped taking them.
She told me she would take all four medications in the morning then feel tired and dizzy all day afterwards. While she was correct in her assessment – taking all four pills at once was likely leaving her sapped of energy all day – her solution caused more harm than good. So she ended up in the emergency room.
In health, as in politics, empathy only goes so far. Like Madame Laurent, voters sometimes make choices based on a misunderstanding of the problem or misinformation from friends and family. Post-election calls to empathize with voters have generated new interest in books that offer a window into the widespread feelings of resentment people in the Midwest and South harbor as they perceive coastal elites looking down on them.
These books are worth reading. But, sometimes, the crux of the challenge is that people in them are misinformed. To quote one example, Katherine J. Cramer recently wrote in "The Politics of Resentment":
“[People in rural Wisconsin’s small towns] thought that they didn’t get their fair share of tax money. To them, too much of it went to the cities, to “underserving” people. The undeserving included racial minorities on welfare but it also included lazy urban professionals like me working desk jobs and producing nothing more than ideas.”
But even if we empathize with the people of Wisconsin who feel this way, even if we see and understand their perspective, how can we reconcile their arguments if they contradict established knowledge?
In some cases, we can’t. Sometimes, like Madame Laurent, people have misconceptions.
From that same article:
“According to my analysis of state and federal 2010 dollars, rural counties in Wisconsin do not receive fewer dollars per capita than do urban counties, and they don’t receive a lower share of what they pay in taxes than do urban counties.”
The more important question then becomes: How can such misinformation and misconceptions persist despite the evidence? And what can we – as doctors, as citizens – do to help counter misinformation?
Otto suggests engaging individuals, walking through the methods of how we know what we know, emphasizing the scientific process. “Digging into just how we know things pulls away the curtain…it opens up the conversation and invites people in, to participate with science.”
In other words, yes, we should empathize and understand each other, but the focus should be on the process of inquiry, of believing evidence and using that to ask more questions.
Madame Laurent and I opened that conversation. I told her I understood that she trusted her friend's recommendation to stop taking the pills, but explained to her that numerous studies in medical journals found that medications like hers save lives because high blood pressure is associated with a higher risk of strokes.
We then moved on to negotiating a solution to lower her blood pressure but not leave her drained of energy. We agreed that she would try taking two medications in the morning and two at night. But I stressed that if she ever thought her medications were causing her problems again, she should call my office first so we could find another suitable solution, together.
I could understand her perspective, but I also had to provide a gentle reality check to help correct her misconception that stopping her medications would solve the problem without causing others. Otto’s suggestion for dialogues like this may just be a prescription for both healthier patients and a healthier democracy.
David Scales, M.D., Ph.D., is an internal medicine physician at Cambridge Health Alliance and an Instructor at Harvard Medical School.