Feeling the Pressure

It has occurred to me that this is a terrible idea.

In fact, it’s possibly the least beneficial thing for the general health of a population to have gained momentum in recent years. I’m not discussing cigarettes or e-cigarettes or low-yield cancer screening procedures. I’m not talking about diet drinks or sugary drinks.

I’m talking about home blood pressure monitoring.

It’s a terrible idea.

Okay, I get it. The idea sounds benign. Buy your own cuff. Monitor your blood pressure at home. Why? Well, it might be high. And, we need data. Lots of it. So, monitor away.

Of course, it’s never really about an idea or its intention. It’s about results. And, how this concept currently gets implemented is the number one cause of preventable panic attacks in my area.

You think breast cancer screening is inflicting unnecessary angst on the general public? It’s nowhere even close to blood pressure monitoring. I’ve even found this practice to occasionally worsen the disease state of hypertension. Yes, it literally makes some people’s blood pressure get worse!

Very soon, I may give up recommending the idea to anyone. In fact, I currently tell MORE and MORE of my patients to check it LESS and LESS at home.

I’m really not trying to offend anyone involved with the patient-empowerment movement. These are the people laser focused on proving medicine’s paternalism has long been the problem with healthcare. They claim the “asymmetry of information” between the doctor and the patient must be eradicated. We must democratize medicine. Patient’s should own their medical data, be informed of all potential outcomes, and be equal participants in deciding upon medical therapies they know far less about.

And, let me tell you, I’m all for the dispersion of power. I’m fine with you believing this will improve your health. But, I just see so many people supporting this kind of thing who really have no clue what they are supporting.

Good intentions begone, what matters are results. And, the results of this ongoing home blood pressure project are a disaster.

I’m “on call” an average of 1 out of every 4 days all year long. People who aren’t in medicine really have no clue what it’s like to be on call. And, that’s okay. I have no clue what it’s like to be an astronaut. I just know that on many call nights, I’d rather be on the moon. Somewhere far away from call.

When I’m on call, I do my job. I manage emergencies that arise in my specialty at the hospitals nearby. I also take personal calls from patients who think they are having “emergencies” at home. These calls get patched into my phone from our office answering service.

If you are one of my patients, please don’t think that I don’t want you to call me when you need me. That’s why I’m on call, to help you in a time of need. Call me! But, just know that the human race is all over the place, and this is never more apparent than call nights.

I tell you more about my lifestyle in Finding Truth in Transparency, so I’m not going to repeat all of that here. But, I will tell you this. I drive a truck. Maybe, it’s outdated, but it has one light that comes on when it needs to be “serviced.” It doesn’t tell me what to do. It doesn’t tell me the radiator coolant needs flushing.

“Just bring her in,” it says.

And, for me, this seems to work fairly well.

You may presume monitoring blood pressure is an easy thing. Just give people a simple algorithm to follow that works. I haven’t found one. Doesn’t matter what I say in the office, the situation explodes out of control whenever people get home. Suspect the same thing would happen to me if I left the dealership with an air compressor.

I get calls frequently at 2 AM because, for whatever reason, the electronic home blood pressure monitor won’t turn on. People are literally stricken with panic, not sure what they should do.

I get calls in the middle of the night because someone without symptoms found his diastolic blood pressure (the bottom number) to be 45 mmHg. A neighbor told him that this number wasn’t compatible with life. Of note, this guy lived.

Patients frequently call after midnight with blood pressure readings to ask if they should go the emergency department. Who checks it then, you ask? On many nights, it seems like almost everyone. One person told me the insurance company instructed her to do it.

The first blood pressure may be 152/82 mmHg, which, not surprisingly, increases to 160/90 mmHg when checked five minutes later, and then increases again to 168/95 mmHg when checked a few minutes after that.

“What should I do?” people ask.

“Go to sleep,” I commonly say.

This movement has gotten out of control. I’m sure someone sitting behind medicine’s curtain of Oz will study this practice and find it to be helpful. I’m studying it now, and it’s not.

This post isn’t intended to provide medical advice. But, I’m just not certain there is much utility for an asymptomatic patient, feeling normal, to take a routine blood pressure before going to the bathroom in the middle of the night.

Yet, plenty of people think we need more of this patient participation and not less. Almost to the point that patients feel they are doing something wrong if they choose to be managed entirely by the discretion and expertise of a doctor, someone who (at this point) is still a human being capable of using judgement (despite a myriad of government mandates that appear less focused on incentivizing it).

Yes, we have apps on our phone that measure heart rate. The rhythm of our body is viewable on a watch. Consumers can now request any blood test they want to be drawn from a lab on the street corner.

And, I’m not against it. Just be ready for the consequences. They are coming. You think it will save doctor visits or drive more of them?

I’m not here to predict the future. The future of healthcare will take care of itself.

I just think you’ll find that many things are better left for servicing at the dealership.

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SR

I think you’re addressing the culture of “I can control everything” and not have to die. As a born yet recovering worrier, I have learned that almost anything I’ve worried about is not what has caused the most problems. And relaxing and enjoying life (within reason, of course) is highly underrated.
Jawaralal_Schwartz

Doctor Rocky,

I have my GP’s cell no. but work hard not to call it–only twice in 20 years, and that was during lunchtime on workdays. You are extraordinarily dedicated to be so accessible. All your stories are plausible. My guess is that in person you look healthy, and probably are in good shape. But your BP is likely zooming up as you get into this subject, perhaps even more than when you are dispensing a feverish rant against regulation. You might try being less accessible. Even docs on call can leave patients with a message to go to the ER, or just don’t take the call. I know of quite a few cardiologists (of friends and acquaintances) who don’t. My next guess is: their patients probably have the same survival rate as yours. Finally, I have a nifty BP meter attachable to my iPhone (the Withings product). I can send my cardiologist long runs of triple-measurements, all in pretty graphs and charts. I’ve noted, though, that he spends about a nanosecond on them and only refers to the measurements taken in his office. Hope you get to relax more….
Scott Vasconcellos

Such a perfect corollary that I needed to share:
I read with great interest your post of October 19 “Feeling the Pressure” (That’s my peer-reviewed journal speak). It was 2:23 this am when I picked up my iPhone to read your post. I had been staring at the ceiling fan spin in the dark for some time prior, finally realizing that I wasn’t falling back to sleep. My VF arrest patient had simmered back to a toasty and lucid 98.6 degrees this week and I was perseverating on how I would balance his ICD upgrade today, a full clinic, hospital rounds, and whatever else happens.
Unfortunately, your post didn’t put me back to sleep. I went downstairs to login to our “clunky” EMR and check my clinic schedule for the day. There was a new “Telephone Encounter” waiting for me. Apparently, my partner had fielded a call from one of my patients at 10:54 last night worried that her pacemaker was not working. She had become alarmed because I had previously informed her that her pacemaker was set to not allow her heart rate to fall below 60 beats per minute; But her home BP monitor was reporting a heart rate of 59!! I promise I’m not making this up for effect. The requisite reassurance was conveyed and I hope she is sleeping soundly now as I write this.
My ultimate point is that different strategies have a role for different people, and I do think various forms of home monitoring can be an invaluable tool (for some). I too have told a few of my “worried well” patients to put their home BP monitor in the attic and leave it there – but they will find other reasons to call. Having a better understanding of my own hypochondriacal tendencies has made it a little easier to field these midnight calls. Now more than 5 years removed from fellowship, I’ve realized that my skills as “cardiac psychiatrist” (a la Jim Schmitz MD) might be just a valuable to my patients as my hands in the catheterization lab.
Lastly, let’s not overlook Dr. Bilhartz’s underlying theme with most of his posts and publications. As a healthcare insider, I would stress to readers that recent government-driven change in healthcare has me very concerned. While it’s difficult to ignore the positives (which in my state of CA has been access for those who previously were simply not receiving care due to financial barriers), virtually everyone else has seen their premiums hiked, benefits/provider networks squeezed, and ease of access greatly reduced. That’s without mentioning the degradation of physician-patient relationships resulting from new distractions (mostly created by the mandates for “meaningful use” of EMR technology). With every new regulation and government mandate, it is becoming ever more difficult to provide efficient and individualized care to my patients.
But the train is heavy and moving fast. I would rather it brake than derail.
The opportunity to say “We told you so” isn’t very appealing either.
DrRajHealth

I agree having a home medical device with the public not being aware of the limitations of the technology and not knowing physiologic variances creates tremendous anxiety. For instance, a weight lifter doing maximum load squats may have a spike in systolic blood pressure in the range 200 – 300 mmHg during concentric muscle contraction which is a normal physiologic response.

I have experienced similar issues with home pulse oximetry. DMEs (medical equipment sellers) are up-selling these devices to patients with lung disease without explaining to them that the devices are prone to tremendous signal dropout and artifact. So, I get calls day and night with concerns of, “doctor, my oxygen level is 82. What should I do?”

Most docs who work in hospitals know how problematic getting an accurate pulse oximetry reading is in the inpatient setting with hospital-grade equipment. Indeed, the brand of pulse oximetry used at a facility where I work has a sensitivity and specificity of 65% and 50%, respectively (values closer to 100% preferable). It is subjected to motion artifact and is near useless in low perfusion states. This means, I am not likely to believe an abnormal value in the hospital, and usually there’s a whole rigmarole to correlate whether true or not.

Most of the home finger devices are even worse in their performance (sensitivity as low as 20% with patient motion reported for one device). By comparison, home pregnancy tests sold over-the-counter have a sensitivity and specificity of >99% at seven days after embryo implantation.

For you to know if a value from any pulse oximetry is “true”, you would have to know device specifications such as it’s sampling rate, it’s formula for pulse averaging, limits of performance within usual physiologic variances, etc. What happens if your hands are cold for example? What if you are anemic? What if you are using it whilst walking? Does the device check for a signal 20 times per minute or 90 times per minute?

If you are going to use such devices at home, trends rather than individual measurements are more meaningful. Which means you have to collect many, many individual readings and plot them out to understand the trend. This requirement is likely to create significant anxiety and dissatisfaction. I don’t know of many who find it a joyful endeavor to sit perfectly still and quiet all day long taking medical measurements.

For all the patients I have with chronic lung disease, I’ve never once asked what their home pulse oximetry reads were. Yet, these devices are being sold like hotcakes. Until many home diagnostic devices reaches the level of performance of that of home pregnancy testing, it may be reasonable to use them with great discrimination.

(Disclaimer: Image indicated as “Labeled for Reuse” by Google Image’s usage rights filter)

Further reading if curious:
There are three common forms of blood pressure measurement–auscultation, oscillometry, and resonance. Auscultatory measurement is when a cuff is inflated with listening by stethoscope for certain sounds (korotkoff sounds). Some limitations of measurement by auscultation is that Korotkoff sounds occur at the threshold of human hearing (near deafness) and the measurements are not useful if the blood pressure is low. So the environment has to be completely quite, patient blood pressure normal to elevated, and the provider’s hearing has to be perfect. Measurement by oscillometry is machine performed by a blood pressure cuff (used most commonly today). Limitations of measurement by oscillometry is that the systolic number (top number) can have significant variation while the MAP (mean arterial pressure) is more likely to be accurate. Measurement by resonance is when the doctor does measurement directly by a catheter inserted into your artery. Measurement by resonance has potential limitations as well but, as with oscillometry, the MAP is more likely to be accurate.

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