The Dilemma Between the Doctor, the Patient and the Drugs They Take

 

 A friend of mine, Dr David Teh, a Senior Consultant Orthopaedic Surgeon in our WhatsApp chat group recently sent us two articles:

Salt substitute with potassium reduces risk of hypertension.

https://www.medscape.com/viewarticle/salt-substitute-reduces-risk-new-hypertension-2024a100031q

He also sent us another article on plant-based diet and prostate cancer here:

https://www.medscape.com/viewarticle/plant-based-diet-boon-men-prostate-cancer-2024a1000342?ecd=wnl_tp10_daily_240214_MSCPEDIT_etid6311019&uac=17750BG&impID=6311019

But let us deal with only the first one on salt intake and hypertension which affects and is common on both males and females, whereas prostate cancer affects only males. So, we shall not discuss the second article else it shall be very lengthy. Here’s my view:

First, all we know is that vegetables are rich in potassium. We know that potassium lowers blood pressure by counteracting the effects of sodium.

A diet high in sodium causes water to be retained in the body, leading to an increase in the hydrostatic pressure and thus a higher blood volume, just like inflating excessive air into a tyre till it burst similar to a haemorrhagic stroke in a blood vessel in the brain due to high blood pressure. 

Second, we also know that potassium reverses the action of sodium by excreting excess sodium through urine.

Third, potassium relaxes the blood vessel walls, improves blood flow and reduces the strain on the cardiovascular system. Adequate potassium intake is crucial for maintaining this delicate balance and supporting overall cardiovascular health. This is a simple understanding of nutrition and medicine.

On this note, I think the first line management for those with high blood pressure is to advise the patient to reduce his salt intake, excessive eating, reduce his body weight and also to change his dietary lifestyle from meat eating to a vegetarian diet. But is the patient willing to change his dietary lifestyle and compile? This is a very big problem in health care.

This leads me to pen further about doctors and patients attitudes about drugs and medicines.

For the patient It is far easier for him to pop in a pill a day, twice or three times a day than to change his eating habits or his lifestyle. This is the greatest problem in the practice of medicine. 

There is no use keep giving all those antihypertensive drugs like beta blockers, ACE inhibitors, calcium channel blockers, vasodilators, renin inhibitors, atenolol to patients   with high blood pressure and ask them to come back again  in 3 months’ time for the next  refill of the same medicine at higher dose or change  the drug if not effective or cause  side-effects when simple dietary adjustment would suffice.

However, drugs are still very lifesaving in a medical emergency, and I have written at length on them.

But the medical life and death crisis is comparatively rare. We can clearly see that there are very few cases such as trauma, accidents, near drowning, myocardial infarction etc, sent to the triage red zone, in an emergency department of any hospital. These cases require instant intervention.

But I believe over 75 % of the patients who crowd hospitals these days are those with chronic cases like diabetes, high blood pressure, cardiovascular, renal, respiratory cases like COPD, arthritis, gout, digestive problems, coughs and cold, and so on.  

Even the common cold is quite common but there is no cure for it. It just resolves itself within a week in most cases.  So does simple coughs even without the use of a mucolytic agent called an expectorant like diphendryl to cough out the phlegm easily. 

The body has tremendous ability to heal itself if only patients are willing to remove the root causes such as overeating, obesity, smoking, unnecessary stress, inadequate rest and sleep or exposure to harmful chemicals or to the environment such as keeping and feeding pigeons whose excreta can cause respiratory diseases. But how do we explain these to the patients? 

All they are interested in is just to swallow some pills to suppress the symptoms the quick and easy way so that they can go about their business.

It is often difficult to deal with patients. They don’t comply, and compliance by the patient is one of the problems in the practice of medicine. For instance, even asking them to take their medicines regularly is a problem. They take them at any time they like, or not at all, or as they wish.  But clinicians must also understand them. They have their own reasons. They may have social, economic, or behavioural reasons for not wanting to listen. Sometimes they forget or have no time or take them at odd times when they have the time and are not preoccupied by something else.  So, they may not comply.  

Sometimes they find intolerance to certain drugs, or they may already be on some other medication that they find more suitable. Most often the doctor may not even ask if the patient has an allergic reaction to certain drugs or foods. They assume the medications they give are always suitable, and that the patient must comply, not forgetting patients have the right to refuse too as given in the Patients Charter based on the principle of mutual respect.

 

This is not just a medical issue but a social problem too. So how do clinicians deal with this problem on patients' right to refuse treatment or to listen to advice?  Yet they still crowd the hospitals hoping for some quick fix.

Often, we are aghast to see the number of medicines the patient is asked to take. They crowd in the hospital pharmacies with grocery bags that become larger and larger to contain all those medicines at each follow-up visit with their doctors.  

Clinicians with a conscience need to ask, would all these medicines interact with each other and poison the patient instead of "curing" him?

If clinicians understand pharmacology well, they will go to the literatures published by the drug companies that gives instructions on the drug pharmacology, indications, contraindications, adverse drug interactions, side effects if they are safe or suitable in certain conditions such as in pregnancy or in children under certain age, or if they have any liver disorder or renal impairment when the drug is contraindicated.  All these instructions are clearly printed in black and white by the pharmaceutical companies for the prescribing doctor.   

 Unfortunately, pharmacology itself is a very highly technical field that requires a very high level of complicated biochemistry and chemistry to understand which itself is a 4-year structured university degree course, and we don’t expect any medical doctors to understand complex biochemistry or pharmacology well except for routine applied clinical settings.

Before becoming a medical doctor, medical students studying pharmacology as part of their curriculum typically cover a broad range of topics related to drug actions, mechanisms, and applications. The depth of understanding in fields like biochemistry, chemistry, molecular biology, and other related sciences can vary based on the curriculum of the medical school. However, a solid foundation in these sciences is often necessary for a comprehensive understanding of pharmacology.

Medical students before graduating as doctors are generally expected to grasp the fundamentals of pharmacodynamics (how drugs exert their effects) and pharmacokinetics (how the body processes drugs), dosage calculations, and the clinical applications of various drugs. Understanding the molecular and biochemical mechanisms behind drug actions, as well as potential adverse effects, contraindications, and drug interactions, is important for making informed clinical decisions.

While the amount of information may seem overwhelming, the goal is often to provide students and the clinician with a well-rounded understanding of pharmacology that can be applied in clinical practice. The emphasis is usually on the practical aspects relevant to patient care rather than memorizing every detail. Medical professionals may also refer to resources, guidelines, or consult pharmacists when specific drug-related questions arise in their practice.

In other words, clinicians need a strong foundation in relevant sciences to understand pharmacology, the focus is often on the practical application of this knowledge in clinical settings rather than memorizing an exhaustive list of details which I don’t think I would be able myself, and I don’t think even a well-qualified pharmacologist, or a pharmacist can remember or need to

Furthermore, there are so many drugs and dosages to remember, let alone so many drug interactions with each other that it is almost impossible for any doctor to remember. Doctors are not computers that can store in vast amounts of information Even pharmacologists who know most about drugs than anyone else including pharmacists are at the loss trying to grapple all these drug pharmacodynamics (what the drug does to the body) and their pharmacokinetic (what the body does to the drug) – to put this in the simplest way.   

Hence, we don’t expect clinicians to try to understand, let alone remember all those horrendously complicated biochemistry, molecular biology of drugs on the body.

Furthermore, there are also individuals who are intolerant to certain medications that he / herself was not aware of till he /she took the drug.

Hence, we do not expect clinicians to know everything about the drugs they prescribe, and what they prescribe is always safe for everyone.

I think the pharmacists who know much more about drugs and their interactions should block some of the doctors’ prescriptions or refer to the doctor concerned again especially on scheduled drugs that need to be countersigned by a specialist before the pharmacists can dispense them to the patients.

Unfortunately, these problems are seldom considered in the prescription. Doctors merely assume everyone is the same and the patient needs to comply.

It is not only these issues.  We also have another problem here with patients with multiple disorders, especially the elderly. These categories of patients tend to see so many kinds of specialists, one for their eye disorder perhaps, another for their ear, another for their heart and cardiovascular problems, another for their urological disorder, or separately for their kidney problems and yet another for their arthritis or liver problem. Others for their neurological disorder and so on.  It never ends with their constant and regular visits to their specialists.

Then each specialist gives their own “special medicines" without bothering what the other specialist gave or asking what the patient has been taking

With all these multiple drugs interacting with each other, they tend to poison the patient together with the patient’s own multiple disorders till the patient finally dies of multiple organ failures due to one or the other.

I think it is time for doctors to specialize in social, preventive and lifestyle medicine as is now implemented in the United States and other advanced countries so that patients depend less on drugs and medicines to support their disorders. We shall talk more about lifestyle medicine later.

I think we need accept truthfully that a disease arises not because the body is deficient in drugs or medicines. Right now, as I think and type, there are several diseases that the body is unable to produce these “natural drugs” to function, and most of them are hormones that need to be replaced exogenously (from outside the body) and these are:

Hormonal replacement therapy (HRT) is a medical treatment that involves replacing or supplementing hormones that are deficient or not produced in sufficient quantities by the body. While HRT is commonly associated with menopause and the treatment of symptoms related to oestrogen and progesterone deficiency, there are several other conditions and diseases that may require hormonal replacement therapy. Here are some examples:

1. Menopause: HRT is often prescribed to relieve symptoms such as hot flashes, night sweats, vaginal dryness, and mood swings that occur during menopause. Oestrogen and sometimes progesterone are commonly used in menopausal HRT.
2. Hypogonadism: This condition involves the underproduction of sex hormones, such as testosterone in men and oestrogen in women. HRT can be used to replace or supplement these hormones.
3. Primary ovarian insufficiency (POI): Also known as premature ovarian failure, POI occurs when the ovaries stop functioning before the age of 40. Hormonal replacement therapy, typically involving oestrogen and sometimes progesterone, may be used to address hormonal deficiencies.
4. Hormone deficiencies in men: Testosterone replacement therapy (TRT) is used to treat low testosterone levels in men, a condition known as hypogonadism. It can help alleviate symptoms such as fatigue, low libido, and mood changes.
5. Thyroid disorders: Hormonal replacement therapy may be necessary for individuals with thyroid disorders such as hypothyroidism (underactive thyroid) or hyperthyroidism (overactive thyroid). Thyroid hormones (levothyroxine for hypothyroidism or antithyroid medications for hyperthyroidism) are commonly used.
6. Adrenal insufficiency: Conditions like Addison's disease, characterized by insufficient adrenal gland function, may require hormonal replacement therapy with glucocorticoids and mineralocorticoids.
7. Transgender hormone therapy: Individuals undergoing gender transition may undergo hormonal replacement therapy to align their secondary sex characteristics with their gender identity. This may involve the use of hormones such as oestrogen or testosterone.

Besides hormonal deficiencies that need to be replaced, what is even more important are all those long lists of nutritional diseases caused by nutritional deficiencies anything from retinol (vitamin A), thiamine, riboflavin, niacin, ascorbic acid (vitamin C), tocopherols (vitamin E), folic acid and cyanocobalamin (vitamin B12), iron, calcium. all the way down to the various trace elements, let alone the proximal principals - carbohydrates, proteins, fats.

 All these are totally complete and perfect natural medicines for all living life on Earth, without which none of us would survive. Without food as medicine, all humankind will run into nutritional deficiency diseases first, before dying, whether with or without medicine.

A summary of these nutritional diseases without going into the clinical details are:

1. Scurvy: Caused by a deficiency of vitamin C (ascorbic acid). Symptoms include fatigue, swollen and bleeding gums, joint pain, and anaemia.
2. Rickets: Caused by a deficiency of vitamin D, calcium, or phosphate. It can result in soft and weak bones, skeletal deformities, and growth retardation.
3. Beriberi: Caused by a deficiency of thiamine (vitamin B1). There are two main types: wet beriberi affecting the cardiovascular system and dry beriberi affecting the nervous system.
4. Pellagra: Caused by a deficiency of niacin (vitamin B3). Symptoms include skin rashes, diarrhoea, and neurological issues.
5. Night Blindness: Caused by a deficiency of vitamin A. It can result in difficulty seeing in low-light conditions and can progress to more severe vision problems.
6. Anaemia: Various types of anaemia can result from deficiencies in iron, vitamin B12, or folic acid. Iron-deficiency anaemia is one of the most common forms.
7. Kwashiorkor: A severe form of malnutrition, often associated with insufficient protein intake. It can lead to oedema, skin lesions, and liver damage.
8. Marasmus: Another severe form of malnutrition, resulting from inadequate intake of both calories and protein. It leads to severe wasting and weakness.
9. Osteoporosis: While not exclusively a deficiency disease, inadequate intake of calcium and vitamin D can contribute to the development of osteoporosis, characterized by weak and brittle bones.

Nutritional deficiencies can lead to various health conditions, and several diseases are associated with specific nutrient deficiencies. It is best to discuss and consult a nutritionist rather than a doctor about them. Nutritionists are specialists on nutritional disease who know more about them and are able to diagnose them than a doctor.  They undergo postgraduate Master’s and Doctoral degrees after getting their medical degrees like MD or MBBS.  

Back to lifestyle medicine as briefly mentioned earlier. But where do we get these specialists in Malaysia? This branch of medicine is very time consuming, daunting, and not lucrative at all to any doctor.

They don’t bring in much income to the specialists or to the drug companies let alone if the patients are willing to change their exposure, their lifestyle especially nutrition and dietary lifestyles.

Some take drugs like taking sweets or honey but even sweets are a poison causing a host of metabolic and heart disease instead of changing their dietary and other lifestyles

All drugs are chemicals but hidden under the glorified name as 'medicines'. All drugs have a chemical formula, a molecular mass and all of them react with each other and interfere with the normal or pathological chemistry of the body by either blocking, Inhibiting, replacing whatsoever these chemistries

What can we do when drugs, disease and death is no respecter of any person, and when all drugs are poisons.  Even King Charles has cancer and is undergoing devastating chemotherapy.

In summary, food, air, and water are the only “medicines” that support life.

If only we have just air, water, and food, then none of the chemical drugs produced by the rich, powerful, and influential pharmaceutical industry would be needed.

Interestingly, Yukie Niwa, MD, DMS, PhD who is the Director of the Niwa Institute of Immunology in Tokyo published a book:

“Drugs Do Not Cure Disease”  

 Dr Nima believes free radicals are the cause of disease. So do I believe that free radicals lead to shortening of life span here:

“The Role of Free Radicals in Human Life Spans”

https://scientificlogic.blogspot.com/2024/02/the-role-of-free-radicals-in-human-life.html

Incidentally, An Indian lady medical doctor colleague of mine when we were working together with other doctors years ago in medical research told us that when she was sick, she would not give herself any drug or medicine. She told us in our usual chit-chat that she would use other alternative modalities to treat herself. She told us that she only prescribes drugs for her patients, but not use them on herself. Another doctor colleague of ours after he resigned to join private practice has been using alternative methods of diagnosis and other alternative therapies to treat his patients or he would combine all the therapeutic modalities, drug and non-drug based. In fact, he once explained to me an alternative diagnostic method which I could not quite understand. 

One of Dr Niwa profile is here:  

https://miwakovonplanta.com/drniwa-en/

“Let Food Be Thy Medicine”

(Hippocrates, Father of Medicine)