Perspective: Broken Medicine

Here is a question for you:

A 55 y old male with HTN is here for follow up.  He has no other medical problems.  Medications include losartan, metoprolol, amlodipine, and HCTZ.  Blood pressure is 160/100 mm HG.  What is the next best step for his blood pressure control?

A.      Dietary history

B.      Check Renin/Aldosterone levels

C.      Check secondary workup

D.      Make sure the patient is taking all medications properly

E.       Obtain a 24 hour ABPM

Any of the above or all of the above would be good choices and one can start with either one. Here are the real world choices…

A.      Obtain Renal consult

B.      Obtain Endocrine consult

C.      Obtain Cardiology consult

Here is where the fragmentation begins. Why does this happen?

Here are the top reasons in my opinion

Not enough time to think
Inertia to think
Patient satisfaction( I want a HTN specialist)
Training not adequate
Trainers were not master clinicians and hence they believed in panconsultemia as well

Once consults are obtained: - more confusion as cardiology and nephrology don’t agree on drug choices. Endocrine wants more tests. Now more accidental findings…. And it continues. 

Welcome to medicine in 22^st century.
Let’s please stop this madness!!