Some Issues About Evaluating Blood Pressure

A new report by an expert "guidelines committee" has shifted blood pressure norms for people over 60 years of age up to 150/90 from the previously accepted level of 140/90.  This has huge implications for many individuals presently taking anti-hypertensive medications, many of which have decidedly negative side effects.

This blog is not meant to evaluate the validity of this conclusion but to educate individuals about possible errors in blood pressure measurement.

Blood pressure is most often measured by using an inflatable cuff wrapped around the upper arm, a manometer (either a column of mercury, or a clock-face dial with a needle) and a stethoscope with which the examiner listens for the appearance and disappearance of pulse sounds in the crease of the elbow.  The blood pressure can vary based on a number of factors that affect these elements. Techniques used to record blood pressure in a doctor's office are "indirect."  The only true,"direct" method of measuring the pressure in a blood vessel is to attach a measuring device to the blood vessel directly - a procedure normally performed only in emergency rooms and hospital settings.

There is room for variability and some differences when the indirect measure of blood pressure is used. For instance:

1. The cuff may not be appropriately sized for the circumference and length of the upper arm - cuffs that are to short, or do not comfortably fit around the arm are apt to give falsely high pressures.  The reverse is true of cuffs that are too loose or to large.  The cuff must also be properly applied to the arm so that the bladder inside the cuff covers the brachial artery (the large artery in the upper arm.)
2.  Blood pressures are determined by the appearance and disappearance of sounds the blood makes as it moves under the stethoscope for which the examiner listens.  Clearly the auditory acuity of the examiner means something here. The ability to hear the initial and final sound depends not just on the examiner's ears, but also on the rate at which the air is released from the inflated cuff.
3.  Blood pressure may vary with body position.  It may also differ from one arm to the other.

Given the variables involved in the indirect recording of blood pressures, using absolute numbers as guidelines is fraught with the potential for error.  A blood pressure recorded as 154/90 could easily be an inaccurate reading of a pressure which may actually be 148/86, or even 158/94.

It would be more helpful to provide a "range" of normal (or abnormal) rather than an absolute number, given the variables discussed above.  And remember, one blood pressure recording is never enough to make a diagnosis of hypertension - there should be at least three such recordings over a period of a few weeks before a diagnosis is confirmed.

Children with Down Syndrome - How Times Have Changed

Susannah Meadows's book review in the Dec. 17 NY Times Science Section (Raising Henry, by Rachel Adams) discusses how the attitude towards children with Down Syndrome (also known as Trisomy-21) has changed.  Ms. Adams, a professor of English and American studies at Columbia University declined the amniocentesis which would have made a pre-natal diagnosis.  In describing Henry, who is now six years old, she makes the following heartwarming comment about what is described as Henry's essence:  "I couldn't have ever known about his great sense of humor or the sound of his infectious laugh.  Or the smell of his hair.  The delight he gets from singing along with music or pouring bathwater from one cup to another."  Her son is "separate from the diagnosis," she writes.

Ms. Adams goes on to describe the "abysmal" bedside manner of her physicians - the OB-GYN resident who "sewed her up"then "sprints out of the room," the pediatric geneticist who used Henry as a "teaching prop," without a word to Ms. Adams, and her obstetrician who assured her that "I wanted to make sure I didn't miss anything so I showed your records to my colleagues, and everyone agreed there was nothing."  So many doctors remain poorly trained in "people skills."  Medical schools must begin to realize that their job is to graduate not just physician-scientists, but physician-healers - doctors adept not just in the science of medicine, but in the art of healing as well.

When I was a young pediatric resident, Down Syndrome was often termed "mongolism" because of the "Asian" appearance of these children.  My chief of pediatrics routinely advised all parents of such children to institutionalize them immediately lest they adversely affect the family dynamic.  His "advice" frequently sounded more like a requirement and was, to the best of my recollection, most often followed.

Statistically 50% of children with Down Syndrome have congenital heart deformities, often rather severe forms, unfortunately.  When I was a trainee in pediatric cardiology, our team routinely declined to offer cardiac corrective surgery to these children, feeling that such treatment was far too involved for patients with Down Syndrome and that their lack of co-operation during the post-operative recovery period would add greatly to the risk and preclude a satisfactory outcome.

Attitudes have clearly changed.  No one is routinely institutionalized.  Surgery is no longer denied, and outcomes are excellent.  It has been a lifetime of change for me, especially as a pediatric cardiologist.

But one must remember that not all children with Down Syndrome have Henry's essence.  Some are extremely difficult to manage and very delayed developmentally - but so are some children without Down Syndrome.  And, finally, one needs to remember that children with Down Syndrome will become adults with Down Syndrome - and that is another issue altogether.

Should We Mess With Aging

Studies on aging are primarily concerned with controlling the process rather than coping with the process.  A recent article discussed the frequent features of the aging male - namely the development of the "pot belly," loss of muscle mass and a decrease in sexual desire.  These processes of growing older are mediated in large part by a fall in the level of testosterone.

Articles describing research in the field of aging refer to this change in testosterone level as a "decrease in the normal level of testosterone."  But it is not a decrease in the normal level of testosterone -  it, in fact, is a normal level of testosterone commensurate with the aging male.

Studies directed towards reversing the aging process by abnormally increasing a level of a hormone, be it testosterone, estrogen, or some other such agent, are concentrating on converting us from the normal aging process to an abnormal one.

Anti-aging research continues.  Why?  Are we truly interested in extending life expectancy to 150, or perhaps even further?   Is government expense for research to provide us with the proverbial "fountain of youth," - to control the aging process whereby we will live far longer, but at a great human and economic cost to society -  treasure well spent?

As Daniel Callahan (age 83), emeritus president of the Hastings Center, recently wrote in a NY Times Op-Ed article (Dec 1):  "We may properly hope that scientific advances help ensure……that young people manage to become old people.  We are not, however, obliged to help the old become indefinitely older.  Indeed, our duty may be just the reverse: to let death have its day."

The Three Considerations in Medical Care

Your health care requires three significant considerations and decisions on your part (not in any particular order).

1.  Cost and availability
2.  Expertise of providers
3.  Whether treatment is really required.

The Affordable Care Act is primarily, if not solely, concerned with the first of these.  It's intent is directed at making health care "affordable," as is clearly stated in its title.  I am not getting into the pluses and minuses of the act, except to say that I feel very strongly that everyone is entitled to basic health care, and it is the responsibility of a government to insure that such care is available to all citizens - as it is for the availability of a citizen's personal security (police and military "care") or the security and safety of his body and property (fire and safety "care").  Though military, police, and fire services are expensive, the cost is not borne by the individual directly, but indirectly via the tax structure.  Therefore the expense is not "felt" as is the case in medical care.  For the record, I am in favor of a form of single payer system, so common in most other developed countries, but available in our country only for people who have reached a certain age, or are below a certain income level.

The Affordable Care Act does not help you determine the expertise of the providers.  Medicine, is a provider-based service, not a product.  Various agencies, governmental or private seem to regard it as a product and wish to furnish you with the "product" at the lowest possible cost.  But there is variability in the expertise of the medical providers, which is just as important, if not more important than cost and availability.   Is your physician skilled at recording your medical history and performing your physical examination?  Does he know which tests to order and, perhaps more importantly, which tests not to order?  Is your surgeon skilled at the surgical procedures he may be advocating?  Additionally, much of medical practice today is guided by evidence-based medicine - recommendations for management of sundry medical diagnoses after evaluation by committees of universally regarded experts.  Physicians should be aware of, and should be following these recommendations, which are based on numerous well-researched published studies.

Lastly, and perhaps most importantly, is the question of whether or not the advocated treatment is really necessary?  A patient should be properly informed of the risks and benefits of the advocated therapy as well as the risks and benefits of no therapy.  Not everyone who is referred for heart surgery actually requires it.  Not everyone who is told to have a colonoscopy really needs it.  Not everyone is informed that surgery is not always the solution to a back problem.  Be aware that medical errors leading to death may befall some 400,000 patients a year,  according to a recent study in the Journal of Patient Safety.

Get all the information you can about cost, expertise and necessity.  If you feel uncertain, find someone to guide you.  Provide yourself with some basic knowledge of medical statistics to help you ask the appropriate questions when visiting your physician.  And try to have someone accompany you to help you understand what you are being advised to do and why.

Michael R. Bloomberg has just been awarded the first "Genesis Prize," a prize that the organizers are terming the "Jewish Nobel Prize."  The NY Times (Oct 21) explains that the prize "aims to honor 'exceptional people whose values and achievements will inspire the next generations of Jews.'"

The prize was created by a group of Russian-Jewish oligarchs and is administered in partnership with the government of Israel.  The Times goes on to say that this award "is open to those who have succeeded in various fields, including science, the arts, business and diplomacy."

Although not specifically stated, it appears that only Jews are eligible to receive this award.  Or are there, perhaps,  non-Jews who may be meet the criteria of "exceptional people whose values and achievements will inspire the next generation of Jews."  I certainly hope so.  As a Jew I can easily declare that I was inspired by the "values and achievements" of many non-Jews and went on, hopefully,  to do the same for both Jews and non-Jews.

Jewish success in science, arts, business, etc. is not restricted to inspiration from other Jews!  

The Unnecessary Annual Physical

Danielle Ofri, ('Doctors' Bad Habits', Sunday Review October 6) after evaluating data that pointed to the lack of benefit in performing annual physical exams on young, healthy, asymptomatic patients, concluded that they were still worthwhile - at least for her.  Without citing any data of her own, the doctor concluded that an annual visit "establishes a solid doctor-patient relationship." We are not told, however, what her patients think about this medically unnecessary visit.  After all, they are asked to come to see her for no medically established reason, and in the process may be losing a day's work, or having to find someone to provide child care, etc.  I feel quite certain that a fee is involved as well.

Medicine should be practiced using well established guidelines.  Physicians often practice methods taught years ago, or practice by some "grandfathered" idea, if you will, that actually has no basis whatsoever in fact.  Evidence-based medicine is the path that all physicians should follow.  If they feel otherwise they should offer their patients a good explanation before he is asked to give up his time and spend his (or, more of then than not - our) money.

Dr. Ofri has decided that annual physicals are worthwhile despite data showing otherwise.  Why not semi-annual physicals, or quarterly physicals?  Why has "annual" become the standard for Dr. Ofri?  Maybe weekly phone calls would be even more beneficial for the doctor-patient relationship, Dr. Ofri.

Non-MD Medical Providers Performing Abortions in California

We are getting there!  As you, my readers know, The Blog has been a champion of non-physician medical care, knowing full well that properly trained, skilled nurse practitioners and physician assistants are highly qualified to provide such service.

Gov. Jerry Brown of California has signed into law a bill that will permit nurse practitioners, midwives and physician assistants to perform all forms of abortion, including surgical abortions.  Those opposed to abortions are maintaining that the new law will "reduce the medical standards for abortion," thereby "reducing safety."(1)

Ridiculous.  This bill will put the procedure within reach of women who often live in settings where physician-provided abortions are difficult to access, and provide them with skilled practitioners.

You do not have to be a physician to perform an abortion.  You do not have to be a physician to perform many forms of surgery.  You do not have to be a physician to perform many emergency medical procedures. You do not have to be a physician to provided excellent general (or even specialized medical care).

An interesting article in the recent edition of The New England Journal of Medicine (2) concluded that he best surgery is carried out by the physicians with the greatest "skills," not necessarily those with the best training.  "Our study showed wide variation in technical skill among fully trained, practicing surgeons." (2)

Academic training is one thing.  Developing the necessary skills is something else.  And, you know, there are many skilled non-MD practitioners who may be far more skilled than those with MD degrees.  Trust your experienced, skilled non-MD medical provider - your physician often does, the city government does (EMTs, etc.), the armed services do (front-line medics) - and so should you.

1. New York Times, Oct. 10.
2. The New England Journal of Medicine, Oct. 10.