The History and Future of Hypertension

In an interesting essay, Dr. Marvin Moser writes that “as late as the 1950s, elevated blood pressure was considered by many experts to be necessary for adequate perfusion of vital organs.”[1] The eminent American cardiologist Paul Dudley White suggested in 1937 that “hypertension may be an important compensatory mechanism that we should not tamper with even if we were certain we could control it.”


In 1937, 54 year old Franklin Roosevelt’s blood pressure was 162/98. But in accordance with medical opinion of the time, his personal physician did not prescribe medication to lower it. By 1941, a reading of 188/105 was recorded and finally a barbiturate and massages were prescribed. In 1944, a cardiologist examined Roosevelt and was appalled at what he found. Many of the now well-understood results of untreated high blood pressure were present. A chest x-ray showed fluid in his lungs and an enlarged heart from congestive heart failure. His urine showed protein due to kidney damage. The cardiologist recommended digitalis (a medication to treat heart failure) and a low salt diet. By the time Roosevelt attended the Yalta conference his blood pressure was recorded at 260/150. Seeing Roosevelt at the conference, Winston Churchill’s physician Lord Moran noted that “Roosevelt looked straight ahead with his mouth open as if he were not taking things in.” In 1945, while sitting for a portrait, Roosevelt complained of a headache and suddenly lost consciousness. His blood pressure was measured at over 300/190 and he was later found to have a cerebral hemorrhage.


In the late 1950s, thiazide diuretics were identified as the first well tolerated and effective medication for treating high blood pressure (hypertension). In the 1960s and 1970s, new blood pressure medications became available and a consensus on the importance of treating hypertension solidified.


It is now clear that treating hypertension early can prevent heart attacks and strokes, as well as heart and kidney failure. But until recently, there has been debate about how low we should aim to get the pressure. In November of this year, a landmark study called SPRINT (Systolic Pressure Intervention Trial) offered tremendous insight into this issue. The study took people 50 years and older with hypertension and randomized them to aim for a systolic blood pressure of either a) less than 140 or b) less than 120. The study was stopped earlier after 3.3 years when it became clear that the people with tighter blood pressure control were experiencing clear benefits. There were significantly less bad outcomes such as heart attacks, congestive heart failure, strokes, and death in the group with the lower blood pressure.


My takeaway from this study is to aim for a systolic blood pressure closer to 120 in patients I treat for hypertension. The trial provides firm evidence that doing so lowers the risk of having a heart attack, stroke, and congestive heart failure. Nonetheless, a person’s individual situation must be taken into account. As people age, the ability to compensate when standing up can be compromised, making them prone to fall if blood pressure is lowered too aggressively. In addition, decreasing blood pressure below a certain level in some people can cause fatigue and a poor quality of life. It takes more medications to achieve a lower blood pressure and these can sometimes have side effects. So patients and their doctors should work together to find a combination of medications and behaviors (such as exercise and diet) that fits their unique situations.

[1] Historical Perspectives on the Management of Hypertension

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Posted by on December 9, 2015 in Uncategorized


Boxing and Parkinson’s Disease

Although I’m not a neurologist, I’ve seen firsthand how devastating Parkinson’s Disease can be.  Parkinson’s does not just consist in tremors. It is a progressive neurological disorder than can ultimately take away essential capacities such as walking, writing, and swallowing.  Research into Parkinson’s has yielded impressive therapeutic interventions such as deep brain stimulation.  Nonetheless, the human brain is the most complicated structure in the known universe, so that our current understanding and treatment of Parkinson’s is limited.

I am moved by the courage people with Parkinson’s, as well as their loved ones, display in living with this disease.  CBS Sunday Morning recently had a segment that was particularly inspiring.  CBS correspond Leslie Stahl reports on how her husband and other people with Parkinson’s have found some hope and healing in an exercise program that uses boxing techniques.  In the segment, a researcher says a  study of the program showed it offers people with Parkinson’s genuine clinical benefit.  I highly recommend watching the segment  linked below (it starts with an advertisement that quickly passes).  Whatever challenges you face might seem less daunting after witnessing such bravery.


Posted by on November 25, 2015 in Uncategorized


The Nuclear Option

Here’s an article I wrote on a reproductive method that uses DNA from three different people to prevent mitochondrial diseases. The technique raises challenging ethical questions.

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Posted by on October 27, 2015 in Uncategorized


A Higher Vision

While I feel privileged to practice medicine, from time to time I find myself becoming burned out and discouraged. Spending the time needed to care for a person at their clinic appointment without falling behind in the day’s schedule, angry calls from patients about their insurance no longer covering the medications they’ve been on for years, the sheer volume of labs to respond to and paperwork to review–all of this can leave a physician feeling like Sisyphus pushing the boulder up the endless mountain.  When I feel this way, the writing of Daniel Sulmasy helps me to regain perspective. Sulmasy is an internist, palliative care physician, bioethicist, philosopher, and former Franciscan friar who serves on the Presidential Commission for the Study of Bioethical Issues.  I had the chance to meet and talk with Sulmasy for a while at a conference a few years ago and found him to be kind, gracious, and humble.

Here are a couple of passages from his book The Healer’s Calling. It should be noted that Sulmasy is a Christian and these passages reflect his spiritual tradition:

“For the health care professional, love for one’s patients alone will not ultimately satisfy. Patients can be very fickle. They can bring frivolous lawsuits against those who did their best in love to help them, and this can be deeply hurtful. Patients can be demanding at times. The relationship to the patient will not be a full healing relationship if one cannot see it in the context of one’s relationship with God–one’s spirituality.  If a health care professional is not careful to cultivate a spiritual life, he or she will quickly end up becoming cynical about patients. No physician or nurse will last very long in health care looking to patients themselves for personal satisfaction. Patients can only be the point of departure. They are not the source of satisfaction, but signposts that point the way to satisfaction. Physicians and nurses are really doing their jobs when they see each patient as a precious being swept up into the mystery of God’s love. . . No matter how sophisticated the technology of healing gets, true healing will involve three very simple human elements: compassion, touch, and conversation.”

Sulmasy’s words are lofty and well beyond what I achieve except in my very best moments. Nonetheless, he offers a noble vision of medicine that calls health professionals to strive toward something higher amid the daily stress and frustrations of clinical practice.


Posted by on October 22, 2015 in Uncategorized


Advice for Aspiring Physicians

Tonight I spoke with UT’s Plan II Pre-Medical Society, answering their questions about what it’s like to become and be a doctor. Here’s some of the advice this old man shared with the youngsters.

Embrace Your Gifts and Passions

Early in his career, the late physician and author Oliver Sacks badly wanted to be a neuroscientist. The only trouble was he just wasn’t very good at it. After a number of mishaps in his attempts to do research, his supervisors firmly told him his future was not in the lab. Instead, he was sent to work with patients with severe degenerative neurological diseases living in a long-term care facility. While his contemporaries saw this kind of work as a dead-end, Sacks found it very much to his liking. At the nursing home, he was able to spend long hours with patients learning their stories.  Out of this experience, he discovered his gift for writing about what it’s like to live with a serious neurological condition. Sacks’ books and articles have evoked empathy and interest in people who would otherwise be overlooked. He has drawn medicine’s attention to the patient’s experience of illness, rather than simply studying and addressing disease. As Nobel Prize-winning scientist Eric Kandel wrote, Sacks “transformed the view of the mind for millions of people in a way that is both insightful and entertaining.” Imagine how much the world would have missed if Oliver Sacks had insisted on being a neuroscientist instead of embracing his gift for hearing and writing patients’ stories.

Be Curious

I recently saw a patient with symptoms I simply could not make sense of.  As I asked her questions about what she was feeling, more and more interesting details about her life came forth. I followed my curiosity and soon we were discussing changes in her most important relationships and transitions that were taking place. And then the cause of her symptoms became clear. Just by following my curiosity, rather than directly trying to figure out what was wrong.

It is also important to be curious about systems, customs, and institutions. Medical students should embrace the naivete they bring to their work. Medicine’s pedagogical method of apprenticeship leads it to honor tradition and hierarchy. It is slow to embrace change and question itself. While students are learning the culture and methods of medicine, I encourage them to also respectfully question why things are the way they are.  This is how breakthroughs and innovation happen. The disciplines of hospice and palliative care emerged when people looked at how patients were spending the end of their lives and asked if there could be a better way.  Was it really necessary to die in an intensive care unit connected to tubes and wires, surrounded by strangers and beeping machines? Or might it be much better to die at home in your own bed with family at our your side?

Seek Balance

There is more to life than medicine Keep up your relationships with your friends and family. Exercise. Take time to do what recharges your battery–music, books, writing, sports, travel, being outdoors. What good is it if you become a doctor, but in the process are transformed into a miserable, boring person?

Anyway. I hope the students gained something out of our time together. I enjoyed being with them and sharing what I’ve learned.



Seek Balance


Posted by on October 15, 2015 in Uncategorized



In a wonderful essay, physician and educator Faith Fitzgerald writes about the importance of curiosity in health care. As dean of students at UC, Davis’ School of Medicine she sometimes heard complaints from politicians about medical students being “insensitive, mechanistic, technocratic, inhumane brutes.” After a good deal of research, she asked herself, “What is kindness as perceived by patients?” Her answer was

“Perhaps it is curiosity: ‘How are you? Who are you? How can I help you? Tell me more. Isn’t that interesting?’ And patients say, ‘He asked me a lot of questions’; ‘She really seemed to care about what was going on with me.’ Is curiosity the same, in some cases, as caring?”

Fitzgerald writes that

An endowed lectureship at my medical school allows us to invite Nobel Prize-winning scientists to visit and lecture for several days. What impressed me most about my conversations with these luminaries was their extraordinary broad range of interests, their enthusiasm, and their thought patterns. One thinks science has a sequential and controlled pattern of logical ideas, firmly grounded in antecedent principles and constantly cleansed of intellectual debris by the abrasion of skepticism. Listening to Nobel laureates in medicine was revelatory. . . The scientists seemed oblivious to intellectual constraints and unconcerned about seeming naive or unknowledgeable. . .”

She then asks

What does curiosity have to do with the humanistic practice of medicine? Couldn’t it just convert patients into objects of analysis? I believe it is curiosity that converts strangers (the objects of analysis) into people we can empathize with. To participate in the feelings and ideas of one’s patients–to empathize–one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past and social surrounds. Truly curious people go beyond science into art, history, literature, and language as part of the practice of medicine.  Both the science and art of medicine are advanced by curiosity.”

Fitzgerald writes that efficiency and time often undermine curiosity. For instance,

One senior resident once presented a patient in morning report and, as part of the physical examination, mentioned a scar in the patient’s groin. When I asked how the scar had been acquired, she said, ‘He told me he was bitten by a snake there.’ ‘How did that happen?’ I asked. ‘I don’t know,’ she said.

How could that be? How could one not ask? The imagination runs riot with the possibilities of how this man got bitten by a snake in the groin. But the resident was too busy (or not curious enough) to ask!”

Fitzgerald asks

“What is the reward of curiosity? To the patient, it is the interest and physical propinquity of the physicians, which is therapeutic in and of itslef. To the physician, curiosity leads not only to diagnoses, but to great stories and memories, those irreplaceable ‘moments of medicine’ that we all live for.”

You can read the entire essay through the link below, and I recommend you do–especially because the story she ends it with is very good.

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Posted by on August 4, 2015 in Uncategorized


Aid in Dying in Belgium

As I’ve written elsewhere “physician-assisted suicide (PAS) laws in Oregon, Washington, and Vermont permit doctors to prescribe a life-ending medication to adults who are found to have decision-making capacity and a terminal illness that will lead to death within six months. But now groups such as the Society for Old Age Rational Suicide (SOARS) are advocating that people without terminal conditions also be granted means for committing suicide.” A recent New Yorker article describes how this is already happening in Belgium. With the Britney Maynard case sparking a movement to give people more autonomy end to their lives, it’s worth examining how this is playing out in the European countries that are doing so. Here’s the link to the New Yorker article.




Posted by on June 18, 2015 in Uncategorized


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