DR DELBANCO: Mr R is a 41-year-old African-American man with a long history of hypertension, first discovered in the early 1990s. Over the years, Mr R has had difficulty adhering to suggested medication regimens, and his blood pressure has been poorly controlled, despite the efforts of multiple doctors at a number of different institutions.
With blood pressures as high as 240/180 in the past, Mr R’s medical history is remarkable for episodes of epistaxis, headache, and occasional palpitations. Hospitalized for accelerating hypertension in 1994, he has been troubled over the years by side effects from a number of medications. Hydrochlorothiazide interfered with his sexual function, and beta blockers made him feel “sluggish mentally.” He tried acupuncture, but found it unhelpful.
A self-employed business man, Mr R has commercial health insurance that partially covers the costs of his medications. He works long and irregular hours. He is a single father with two children, one of whom lives with him. He has never smoked and uses little alcohol. The CAGE questionnaire,1
a screening test for alcohol abuse, was performed and was negative. He is physically fit and exercises intermittently. His mother has hypertension, but his siblings do not.
On recent physical examination, Mr R looked well. His blood pressure was 146/74 in the right arm and 144/72 in the left arm. His pulse was 64 and regular, respirations 10. He weighed 210 lbs, and his height was 72 inches. His eye grounds were unremarkable, lungs clear, veins flat. Carotid arteries demonstrated normal pulsations and no bruits were heard. Cardiac exam revealed a grade 2/6 holosystolic murmur at the base, accentuated with a Valsalva maneuver. There was no heave, rub, or gallop. Abdominal exam revealed no organomegaly, bruits, or hepatojugular reflux. He exhibited no peripheral edema or neurologic abnormalities.
The CBC, electrolytes, creatinine, BUN, and a random glucose were normal. Urinalysis and PSA were normal. A fasting, calculated LDL was 104 mg/dl. An electrocardiogram revealed voltage criteria and St-T changes compatible with left ventricular hypertrophy. A chest film revealed mild cardiomegaly, with left ventricular predominance, as well as a tortuous or dilated ascending aorta, for which further evaluation was scheduled.
Mr R was prescribed lisinopril, 10 mg, once daily, and nifedipine, 90 mg, extended-release, once daily by his physician. His level of adherence to these medications is unknown.
MR R: My boss noticed blood dripping on the paperwork, and he said, “Go to the hospital.” So I went to the emergency room. This was the early ‘90s, and I don’t think there was a lot known about blood pressure at that time. The doctor gave me some medication and sent me back to work. I pretty much ignored the problem from there.
I know that high blood pressure is a silent killer. You really don’t feel the effects—I didn’t. I think my body has adjusted to it. There are times when I have come into the hospital and I’ve felt very good, but my blood pressure was off the scale. To a certain degree, it scares me that I can feel good walking around. I feel pretty strong, but I'm like a walking time bomb. So I guess, in a sense, I’ve developed a proclivity for self delusion when it comes to high blood pressure. I don’t look at it as a disease. When I think about a disease, I think about cancer or HIV, those types of things that you can readily see and feel. High blood pressure: you don’t see it; you don’t feel it.
The problems that I had early on with the treatments were that they seemed to be inconsistent. I believe, back in ’98–’99, within a one-year period, I must have been given at least 30 different types of medications.
I was referred to an acupuncturist, who told me that sooner or later, all the medications that I have been taking are going to have an adverse effect on my health. So that put me in a stymie: “Do I believe this doctor, or that doctor? Are they giving me medication? Is it just to throw them at me, hoping for a cure?”
You ask yourself, “Why are you taking the medication?” So you kind of slack off. You don’t feel well. You go back to the doctor and say, “I’m not feeling well.” He gives you another bunch of medication. You take that. So it’s an ongoing problem. You’re always constantly searching for answers, but you don’t know where to find them, necessarily.
I don’t eat right. I don’t cook. I don’t know how to cook. I don’t plan on learning how to cook. I like McDonalds, Burger King, Wendy’s, you name it. So I know I have to eat better. And I’ve been trying. I know I have to exercise, and I don’t have a problem with that.
I have not checked my own blood pressure. I bought the kit, and I find it difficult to monitor it. I don’t think I read it correctly. And I don’t think the electronic models they sell in stores work properly. I used to go into the little blood pressure capsules in CVS, and I always got an error back. That made me nervous, because a person went right after me, and the blood pressure machine worked just fine for them. So I don’t do that any more.
As far as a racial guideline, in regards to how a doctor looks at a patient of another race, I’ve never been treated unfairly or differently. I guess the confusing part is that I see people as being the same. So, when you say one disease is more prevalent in an African-American than in a Caucasian-American, I get confused. I’m always saying to myself, “Why? We are all supposed to be the same inside and outside.”
DR W: I’ve tried to get an idea of how my patient looks at his blood pressure, and it’s somewhat difficult to say. He’s a very smart man. He certainly has good insight into a lot of parts of his life. And he knows he needs to take medication on a regular basis. But when he comes into the office, frequently he’ll have gone through a long period of time when he has not taken his blood pressure or has not been seen by a physician. And he can do this for many months. He often has side effects, and that is a primary concern, but I often do wonder if there’s something else that either he hasn’t told me or that I’m not understanding.
There was a period when my patient went a year without seeing me. I really would love to see a system where the pharmacy let me know that he was not filling his medications. I would love to have a nurse or someone else who could call him to tell him it has been more than 3 months since his last visit.
I think it is more difficult to manage someone from a different culture. They may have different values. They certainly have different ways of interpreting medications. Being Jewish—and there’s a long line of Jewish doctors in my family—we tend to listen to a doctor and take what they say more word for word. We’re more likely to go to a doctor, more likely to take what medications we’re given. So in a lot of ways, it is much more difficult.