This breakdown of measurement protocols shows how technical rigor directly impacts diagnsosis. The cascade from mismeasurement to polypharmacy is alarming because each step seems rational in isolation. I've seen this play out with elderly relatives who suddenly had a medicine cabinet full of pills, and now I'm wondering how much started from bad baseline data.
Exactly. I just saw something about how a rather substantial chunk of people diagnosed with asthma don't actually have it.
And I do some medical coaching and it's a question I have with some frequency. People have been diagnose with some condition and "treated" for it for decades sometimes, but I see that their diagnosis was far from definitive.
There is almost always a piper to pay with any drug. So many drugs, many pipers.
One of the things I'm going to focus in posts here is ways to instill habits—ways that prepare us to act in ways that will help us create and stick to habits. We need that foundation, the preparing us to act.
It’s in there! And I tell you why using “white coat syndrome” as a reason to get a second read is probably the most effective option you have.
From the post: “A possible perp—right out of the medical literature? ‘White coat syndrome’—being freaked out at getting your blood pressure taken (due to what that could mean for your health) or just being at the doctor’s office.”
That’s really terrible. Accuracy, not convenience, should be the driving factor here!
I try to avoid them ever taking my blood pressure. It’s an opportunity for it to be wrong. And recorded my chart that way.
The “white coat syndrome” thing worked with my primary care doctor. He just nodded and I think left it out of my chart. It does seem to be a sort of magical term in terms of we as patient having some control.
I went through medical school over 50 years ago. Way back then we were initially taught the correct methods as you have outlined. Then ever afterward we seldom if ever checked our patients with the recommended methods. One thing I think you left out, which can be highly significant. Initial contact with a caregiver must always include measuring BP in both arms several times in the initial encounter. We were also taught this at the beginning and virtually never did it in reality. Measuring / comparing BP: in both arms is the easiest way to detect a patient with an obstruction in one of the arteries supplying each arm. I have an elderly cousin who went 40 years with a undiagnosed significant obstruction in her left subclavian artery that made her left arm BP about 30 mm Hg lower than the right arm BP. She did actually have high blood pressure, but recommendations for treatment varied (seemingly at random, but not actually so) depending on which arm was measured. Decades ago she had had a left carotid endarterectomy to clear out an atherosclerotic obstruction there. She saw what the surgeon had removed, and said it resembled a tube of pure white fat. It wasn't until she got her own BP cuff, tested herself at home, and determined she had a constant marked and durable lower BP in the left arm every time she did both arms in one sitting. She was then referred to a vascular surgeon who agreed with the diagnosis but said she, being 80 years old by then, would not be helped by surgery to clear the obstruction. I have talked to several dozen people with diagnosed HBP, only a single one ever had their caregiver measure both their arms during an initial visit.
For those who can measure their own BP at home, I recommend the following before any visit to a primary care physician. Measure your own BP at home 3x before you go to the physician an hour or two before your appointment. Thus you will have a baseline measurement which is likely to be more reliable than what will happen in the office. Write the measurements down, date and time them. Bring your written measurements to the office and show them when they measure you there.
I wonder if you have any advice for the situation of past diagnosis of high BP & prescribed drugs. This person has made so many positive lifestyle changes over the last 15-20 years, including retiring from a high stress job, now having a supportive and loving domestic partner, clean diet, and active not sedentary lifestyle (healthy weight). But the hypertension drugs remain: sometimes reduced, sometimes changed, recently a new one added.
Starting from here, how can we hope to get out of the 'controlled' disease category? Is there any way to get an idea of a current accurate baseline of 'normal' BP with all of these lifestyle changes? It would be great to reset and determine how much of which meds could be the minimal intervention.
Thanks for this really clear explanation of so many factors and influences that can help us be appropriately vigilant when interacting with the medical-industrial complex.
I have to be very conservative and careful here. I am those things anyway, but I just want to let you know that this is going into my reply.
I’m asking this is if you are the person you’re describing. Just in case you are. But I’m guessing maybe you’re the partner! And if so, yay. What a beautiful thing to truly partner with someone in all the ways that matter.
How high was your blood pressure when they put you on drugs?
Which drug or drugs do they have you taking?
And how great that you made all these positive lifestyle changes. That never ceases to excite me when I see people taking their health in hand.
Doing everything we can to be in the most robust health we can is the way we seize life—throughout our lives—and and make it more likely that we can live without suffering horribly.
And if you do get injured, being a robust health gives you your best hope of possibly healing. Or healing more than you would if you hadn’t taken care of your health.
• It's been many years since I've had a GP doctor who insisted on wearing a white lab coat. The few exceptions have been surgeons, particularly if they were affiliated with a teaching hospital. That doesn't obviate the many other cues present with a visit to see a doctor. Just wanted to note that, in general, the practice of medicine has become more aware of the impact of these cues and attempts to remove them.
• I learned about autonomic hyperreflexia when working at a spinal injury rehab hospital. My takeaway was the degree to which multiple small physical discomforts can collectively contribute to higher blood pressure.
• I've been taking blood pressure reading twice a day (AM & PM) for over 7 years using two different devices, taking the average of three reading per device. (This is also the only two times I check email, so it's time efficient.) Many devices on the market will do this automatically. What I've learned is that the first reading is almost always a throw-away unless I've sat and rested for about 5 minutes before taking a reading. Often, at the doc's office, they take a BP right away, just after I've been driving in traffic, walking up stairs, etc. It's always 10 clicks or more higher than the running average from readings taken at home. I've also had some surprises about what affects my BP in either direction, beyond the obvious ones like stress and physical exertion. Added benefit is that I've become sensitized to the other physiologic signs that tell me if my BP is running high or low. There's a lot more to this, which I write about here: https://remnantsway.substack.com/p/health-and-well-being-part-2-the
• The BP recommendations are a one-size fits all so unless your body composition (and age) matches what science has decided is "normal," it's important to adjust accordingly. For example, I'm 6'5" and a BP of 110/70 has me light headed and at risk for falling. My sweet spot seems to be around 125/85. My cardiologist, who's hip to these variables, agrees.
• I am on medication for BP, which has helped. It runs in the family. The twice daily BP measurements have been a critical factor in working out which medication and dosing.
A suggestion for future article: Body Mass Index (BMI.) A useful metric for populations, but a completely useless metric for individuals. Nonetheless, docs still rely on the BMI to make decisions regarding individual patients. Worse, so do the insurance companies. The Body Roundness Index (BRI) has been around for 13 years and is a better, but still not great, index to follow. The doc offices fail on this measure, too. So much so, I refuse to step on their scales as I'm fully dressed when I do. They subtract a few pounds for clothes. Hell, that's what my shoes alone weigh.
This breakdown of measurement protocols shows how technical rigor directly impacts diagnsosis. The cascade from mismeasurement to polypharmacy is alarming because each step seems rational in isolation. I've seen this play out with elderly relatives who suddenly had a medicine cabinet full of pills, and now I'm wondering how much started from bad baseline data.
Exactly. I just saw something about how a rather substantial chunk of people diagnosed with asthma don't actually have it.
And I do some medical coaching and it's a question I have with some frequency. People have been diagnose with some condition and "treated" for it for decades sometimes, but I see that their diagnosis was far from definitive.
There is almost always a piper to pay with any drug. So many drugs, many pipers.
One of the things I'm going to focus in posts here is ways to instill habits—ways that prepare us to act in ways that will help us create and stick to habits. We need that foundation, the preparing us to act.
Don’t forget white coat anxiety!
It’s in there! And I tell you why using “white coat syndrome” as a reason to get a second read is probably the most effective option you have.
From the post: “A possible perp—right out of the medical literature? ‘White coat syndrome’—being freaked out at getting your blood pressure taken (due to what that could mean for your health) or just being at the doctor’s office.”
Interesting.
Thank you. Excited about the next one in this series that I’m writing now. Hope you will be, too!
And people reading here should feel free to ask me questions or suggest stuff you want me to cover.
I have a bunch of ideas in the pipeline but I’d love to get some requests!
They take my blood pressure when I have been fasting for blood work. I'm starving, it's up.
That’s really terrible. Accuracy, not convenience, should be the driving factor here!
I try to avoid them ever taking my blood pressure. It’s an opportunity for it to be wrong. And recorded my chart that way.
The “white coat syndrome” thing worked with my primary care doctor. He just nodded and I think left it out of my chart. It does seem to be a sort of magical term in terms of we as patient having some control.
I went through medical school over 50 years ago. Way back then we were initially taught the correct methods as you have outlined. Then ever afterward we seldom if ever checked our patients with the recommended methods. One thing I think you left out, which can be highly significant. Initial contact with a caregiver must always include measuring BP in both arms several times in the initial encounter. We were also taught this at the beginning and virtually never did it in reality. Measuring / comparing BP: in both arms is the easiest way to detect a patient with an obstruction in one of the arteries supplying each arm. I have an elderly cousin who went 40 years with a undiagnosed significant obstruction in her left subclavian artery that made her left arm BP about 30 mm Hg lower than the right arm BP. She did actually have high blood pressure, but recommendations for treatment varied (seemingly at random, but not actually so) depending on which arm was measured. Decades ago she had had a left carotid endarterectomy to clear out an atherosclerotic obstruction there. She saw what the surgeon had removed, and said it resembled a tube of pure white fat. It wasn't until she got her own BP cuff, tested herself at home, and determined she had a constant marked and durable lower BP in the left arm every time she did both arms in one sitting. She was then referred to a vascular surgeon who agreed with the diagnosis but said she, being 80 years old by then, would not be helped by surgery to clear the obstruction. I have talked to several dozen people with diagnosed HBP, only a single one ever had their caregiver measure both their arms during an initial visit.
Thank you. I read that in the literature and should’ve included it. So appreciate your comment here! Please keep coming back and commenting!
For those who can measure their own BP at home, I recommend the following before any visit to a primary care physician. Measure your own BP at home 3x before you go to the physician an hour or two before your appointment. Thus you will have a baseline measurement which is likely to be more reliable than what will happen in the office. Write the measurements down, date and time them. Bring your written measurements to the office and show them when they measure you there.
Thank you— really excellent suggestion.
I wonder if you have any advice for the situation of past diagnosis of high BP & prescribed drugs. This person has made so many positive lifestyle changes over the last 15-20 years, including retiring from a high stress job, now having a supportive and loving domestic partner, clean diet, and active not sedentary lifestyle (healthy weight). But the hypertension drugs remain: sometimes reduced, sometimes changed, recently a new one added.
Starting from here, how can we hope to get out of the 'controlled' disease category? Is there any way to get an idea of a current accurate baseline of 'normal' BP with all of these lifestyle changes? It would be great to reset and determine how much of which meds could be the minimal intervention.
Thanks for this really clear explanation of so many factors and influences that can help us be appropriately vigilant when interacting with the medical-industrial complex.
Hi, @bellingthecat,
I have to be very conservative and careful here. I am those things anyway, but I just want to let you know that this is going into my reply.
I’m asking this is if you are the person you’re describing. Just in case you are. But I’m guessing maybe you’re the partner! And if so, yay. What a beautiful thing to truly partner with someone in all the ways that matter.
How high was your blood pressure when they put you on drugs?
Which drug or drugs do they have you taking?
And how great that you made all these positive lifestyle changes. That never ceases to excite me when I see people taking their health in hand.
Doing everything we can to be in the most robust health we can is the way we seize life—throughout our lives—and and make it more likely that we can live without suffering horribly.
And if you do get injured, being a robust health gives you your best hope of possibly healing. Or healing more than you would if you hadn’t taken care of your health.
A few thoughts...
• It's been many years since I've had a GP doctor who insisted on wearing a white lab coat. The few exceptions have been surgeons, particularly if they were affiliated with a teaching hospital. That doesn't obviate the many other cues present with a visit to see a doctor. Just wanted to note that, in general, the practice of medicine has become more aware of the impact of these cues and attempts to remove them.
• I learned about autonomic hyperreflexia when working at a spinal injury rehab hospital. My takeaway was the degree to which multiple small physical discomforts can collectively contribute to higher blood pressure.
• I've been taking blood pressure reading twice a day (AM & PM) for over 7 years using two different devices, taking the average of three reading per device. (This is also the only two times I check email, so it's time efficient.) Many devices on the market will do this automatically. What I've learned is that the first reading is almost always a throw-away unless I've sat and rested for about 5 minutes before taking a reading. Often, at the doc's office, they take a BP right away, just after I've been driving in traffic, walking up stairs, etc. It's always 10 clicks or more higher than the running average from readings taken at home. I've also had some surprises about what affects my BP in either direction, beyond the obvious ones like stress and physical exertion. Added benefit is that I've become sensitized to the other physiologic signs that tell me if my BP is running high or low. There's a lot more to this, which I write about here: https://remnantsway.substack.com/p/health-and-well-being-part-2-the
• The BP recommendations are a one-size fits all so unless your body composition (and age) matches what science has decided is "normal," it's important to adjust accordingly. For example, I'm 6'5" and a BP of 110/70 has me light headed and at risk for falling. My sweet spot seems to be around 125/85. My cardiologist, who's hip to these variables, agrees.
• I am on medication for BP, which has helped. It runs in the family. The twice daily BP measurements have been a critical factor in working out which medication and dosing.
A suggestion for future article: Body Mass Index (BMI.) A useful metric for populations, but a completely useless metric for individuals. Nonetheless, docs still rely on the BMI to make decisions regarding individual patients. Worse, so do the insurance companies. The Body Roundness Index (BRI) has been around for 13 years and is a better, but still not great, index to follow. The doc offices fail on this measure, too. So much so, I refuse to step on their scales as I'm fully dressed when I do. They subtract a few pounds for clothes. Hell, that's what my shoes alone weigh.
Some really insightful remarks here. I’m going to reflect on them but I didn’t want to let your comment go on unremarked now. Thank you.