techniques are with the taking of BP when I go into the office. I track my own BP regularly & my least favorite are the electronic cuffs in the office. My own electronic cuff is fine but to have them push the electric cuff 3 separate times…”to get the average” is a new one on this old nurse. It seems arbitrary & by the 3rd time it hurts & I’m kinda pissed. I also had one tell me that he never learned how to take a BP without a machine. Again, without being rude or condescending, I try to point out when they put the cuff on wrong, or it’s too small or large, which is almost every time. Last year I was told not to worry about the consistent 140/90’s that I was getting, this year the new PCP
wants to put me on a 3rd BP med, without looking at my home log. it is exhausting trying to work with a new doctor, as I’ve had 5 PCPs in 3 years who have each to had their opinions..:such
as ,” you know, you’re in my office so of course your BP is going to be higher” after being rushed back & getting the 3 BP in 5 minutes average technique. I’m trying to advocate & save my kidneys as a nurse patient. If I have a migraine “, BP will be high. Thank you for this! I find it so difficult to advocate for myself without feeling labeled as troublesome…we don’t want to be that as 68 year olds who need a doc to prescribe our 3 medications! Otherwise I swear I’d just skip the whole pcp bag all together in this day & age!
Really common problems here! I recall a few studies showing that BP's were highest in doctors' offices, as we are all under the microscope in that moment, techniques are often rushed or less than optimal for logistical reasons, and many people are never taught how to properly check a BP. I'm glad you monitor at home and I would certainly give those numbers more credence than what we get in the office (assuming we've checked your BP monitor against our own "expertise" and validated equipment). I am fortunate to work with a medical assistant who does things properly. Hate to admit this, but it is hard to find a good home base these days...
Hey, it's called a vital sign for a reason. So, it is 'vitally important' to do it correctly. My PA friend tells me he had many Px rushed to ER due to faulty readings and they had normal BP. My own experience with a couple of MA lead me to message my doctor's office. I almost said something but didn't want to disturb the peace. One even took it over my long sleeve t-shirt that I graciously offered to bare. I was told it didn't matter that then didn't even placed the arm in the right position. (OK, rant over)
I had good luck with phlebotomists but a few could have been better.
Did I ever mentioned I had to do blood draw on Callinectes sapidus? (Atlantic Blue Crab). Remind me to tell you about Horseshoe Crabs, very worrisome.
Hi KB - more reasons to partner with people in managing and following their blood pressures... the more readings the merrier, preferably done well, sampled during different times of the day, but with a consistently good technique. And I definitely need to hear that Callinectus sapidus blood draw story?!
If the Horseshoe Crab story is about how they are going extinct, then we are really in trouble, as they have survived hundreds of millions of years before Homo sapiens showed up, right?
Good luck! It's hard to hit all the boxes, especially during rapid visits, but wishing you well. Gently "steer" the medical assistant if needed... and the doctor :)
Yeah, technique really matters if you, like I, rely predominantly on well-done home BP readings for treatment decision.
I've found many patients sent to me with "refractory" hypertension have white-coat hypertension or have not been properly education on technique. One of my first questions is to have them show me how they hold their arm when checking BP. If it. is hanging down I know we can drop their BP 5-8 points without any med changes. If they don't wait 5 minutes while sitting quietly before making a recording, we can drop it another 5-9 mm Hg by waiting.
On the other hand I have had patients who sit and wait until they get a "good" BP, sometimes as long as an hour. That technique underestimates BP.
I've experimented with the clothing on arm and find little to no significant effect on BP with thinnish long sleeve shirts or sweaters. The 10-50 mm Hg alteration in the table you presented seems exaggerated, unless you are taking BP with a parka on.
I found that it does make a difference but it made me ponder more profound things:"
"A recent review identified 7 studies which support the influence of leg crossing on BP.
If leg crossing raises the systolic blood pressure 8 to 10 mm Hg why aren’t we doctors recommending patients sit with leg uncrossed the majority of the time. Personally, I had never heard there were any health complications to sitting with my legs crossed.
Apparently the myriad health information sources on the internet are near unanimous in their condemnation of leg crossing but the hypertensive effect of this maneuver is usually not cited.
My favorite title condemning the practice was “The surprising and inconvenient truth of crossing your legs.”
I must admit since doing this bit of research I have substantially reduced the amount of time I sit with my legs crossed. And I’ve pondered extensively whether sitting with legs crossed makes me feel any different and why I suddenly and seemingly randomly decide to cross my legs.
I’ve also started asking friends and colleagues and medical residents how much of the day they spend with legs crossed.
On teaching rounds one morning recently we tested a volunteer resident’s blood pressure with legs crossed and uncrossed. Sure enough, the systolic BP was 10 mm Hg higher with legs crossed."
Hi Dr. P! Fascinating stories from the trenches, and practices backed by good evidence. I agree the whole bare arm versus measured through a sleeve does not seem to make a big difference, like you said as long as the fabric is thin and the pulse easy to hear.
Such an important and overlooked additional consideration with the legs crossed. I will have to go back and add this, but glad to have it here in the comments, as well as the link to your previous post about it. Over decades this unconscious behavior could add up! I tend to think of this in the context of venous insufficiency/peripheral edema/varicose veins and uncrossing legs in these situations helps take some of the pressure off venous/lymphatic return, right? A good trick when you are standing (i.e. in the OR, which I haven't in a long time) or other situation and start to feel a little lightheaded, crossing one's legs while standing can help prevent presyncopal feelings. But if really feeling that way best to hit the deck and get horizontal! Surgeon taught me this. Maybe I looked green in the OR one day ;)
Always a pleasure to stop by! You are doing great work on Examined, which has become the best source of general medical information available for patients.
"I had a high blood pressure event several years ago. Since then I have monitored my BP at home, sitting with both feet flat on the floor, not eating or drinking, not speaking or moving around, on a chair with a back, and without clothes on the arm being used for the measure. My BP remains normal.
I have never had my BP taken correctly in a doctor’s office. They will do it while I am speaking with the doctor, sitting on an exam table with my legs swinging, with the monitor band over my heavy winter sweater, right after I have sat down. They do not ensure that my arm is supported or at the right height. If I recommend that I take off my sweater, or move to a chair with a back, they tell me that is not needed. I have decided to refuse such measurements. How can they possibly be monitoring my health this way?"
I'm going to restack this quote. Although we don't want people to lose trust or confidence in our office measurements, we also don't want to be dogmatic like we are the only source of reliable data. To the contrary!
And many thanks for the highly generous compliment! As my slogan goes: "If I only had more time..." I could live up to "the best source of general medical information available for patients." But in terms of some of the other sites "ahead of us" on Substack, I think you and I are doing alright by readers!
Always feel free to correct or disagree with me by the way, especially in your field of expertise or when I get off the evidence-based track.
A little late reading this but this all makes sense. I always say, “it’s normal at home and runs high here” (at the doctor’s office). Great information.
I am always amazed at how varied the MA’s
techniques are with the taking of BP when I go into the office. I track my own BP regularly & my least favorite are the electronic cuffs in the office. My own electronic cuff is fine but to have them push the electric cuff 3 separate times…”to get the average” is a new one on this old nurse. It seems arbitrary & by the 3rd time it hurts & I’m kinda pissed. I also had one tell me that he never learned how to take a BP without a machine. Again, without being rude or condescending, I try to point out when they put the cuff on wrong, or it’s too small or large, which is almost every time. Last year I was told not to worry about the consistent 140/90’s that I was getting, this year the new PCP
wants to put me on a 3rd BP med, without looking at my home log. it is exhausting trying to work with a new doctor, as I’ve had 5 PCPs in 3 years who have each to had their opinions..:such
as ,” you know, you’re in my office so of course your BP is going to be higher” after being rushed back & getting the 3 BP in 5 minutes average technique. I’m trying to advocate & save my kidneys as a nurse patient. If I have a migraine “, BP will be high. Thank you for this! I find it so difficult to advocate for myself without feeling labeled as troublesome…we don’t want to be that as 68 year olds who need a doc to prescribe our 3 medications! Otherwise I swear I’d just skip the whole pcp bag all together in this day & age!
Really common problems here! I recall a few studies showing that BP's were highest in doctors' offices, as we are all under the microscope in that moment, techniques are often rushed or less than optimal for logistical reasons, and many people are never taught how to properly check a BP. I'm glad you monitor at home and I would certainly give those numbers more credence than what we get in the office (assuming we've checked your BP monitor against our own "expertise" and validated equipment). I am fortunate to work with a medical assistant who does things properly. Hate to admit this, but it is hard to find a good home base these days...
omg!
the bruise, right?!
Hey, it's called a vital sign for a reason. So, it is 'vitally important' to do it correctly. My PA friend tells me he had many Px rushed to ER due to faulty readings and they had normal BP. My own experience with a couple of MA lead me to message my doctor's office. I almost said something but didn't want to disturb the peace. One even took it over my long sleeve t-shirt that I graciously offered to bare. I was told it didn't matter that then didn't even placed the arm in the right position. (OK, rant over)
I had good luck with phlebotomists but a few could have been better.
Did I ever mentioned I had to do blood draw on Callinectes sapidus? (Atlantic Blue Crab). Remind me to tell you about Horseshoe Crabs, very worrisome.
Hi KB - more reasons to partner with people in managing and following their blood pressures... the more readings the merrier, preferably done well, sampled during different times of the day, but with a consistently good technique. And I definitely need to hear that Callinectus sapidus blood draw story?!
If the Horseshoe Crab story is about how they are going extinct, then we are really in trouble, as they have survived hundreds of millions of years before Homo sapiens showed up, right?
Let's say for extracting from a blue crab requires careful delicate work but Horseshoe Crab (not really a crab but more like a scorpion.) That's a sad story. https://www.npr.org/2023/06/10/1180761446/coastal-biomedical-labs-are-bleeding-more-horseshoe-crabs-with-little-accountabi
This is timely as I head to my PCP in 2 days.
Good luck! It's hard to hit all the boxes, especially during rapid visits, but wishing you well. Gently "steer" the medical assistant if needed... and the doctor :)
Yeah, technique really matters if you, like I, rely predominantly on well-done home BP readings for treatment decision.
I've found many patients sent to me with "refractory" hypertension have white-coat hypertension or have not been properly education on technique. One of my first questions is to have them show me how they hold their arm when checking BP. If it. is hanging down I know we can drop their BP 5-8 points without any med changes. If they don't wait 5 minutes while sitting quietly before making a recording, we can drop it another 5-9 mm Hg by waiting.
On the other hand I have had patients who sit and wait until they get a "good" BP, sometimes as long as an hour. That technique underestimates BP.
I've experimented with the clothing on arm and find little to no significant effect on BP with thinnish long sleeve shirts or sweaters. The 10-50 mm Hg alteration in the table you presented seems exaggerated, unless you are taking BP with a parka on.
I thought the recommendation to have legs uncrossed was BS until I looked into it (https://theskepticalcardiologist.com/2018/05/04/optimal-home-blood-pressure-monitoring-must-the-legs-be-uncrossed-and-the-feet-flat/)
I found that it does make a difference but it made me ponder more profound things:"
"A recent review identified 7 studies which support the influence of leg crossing on BP.
If leg crossing raises the systolic blood pressure 8 to 10 mm Hg why aren’t we doctors recommending patients sit with leg uncrossed the majority of the time. Personally, I had never heard there were any health complications to sitting with my legs crossed.
Apparently the myriad health information sources on the internet are near unanimous in their condemnation of leg crossing but the hypertensive effect of this maneuver is usually not cited.
My favorite title condemning the practice was “The surprising and inconvenient truth of crossing your legs.”
I must admit since doing this bit of research I have substantially reduced the amount of time I sit with my legs crossed. And I’ve pondered extensively whether sitting with legs crossed makes me feel any different and why I suddenly and seemingly randomly decide to cross my legs.
I’ve also started asking friends and colleagues and medical residents how much of the day they spend with legs crossed.
On teaching rounds one morning recently we tested a volunteer resident’s blood pressure with legs crossed and uncrossed. Sure enough, the systolic BP was 10 mm Hg higher with legs crossed."
Dr. P
Hi Dr. P! Fascinating stories from the trenches, and practices backed by good evidence. I agree the whole bare arm versus measured through a sleeve does not seem to make a big difference, like you said as long as the fabric is thin and the pulse easy to hear.
Such an important and overlooked additional consideration with the legs crossed. I will have to go back and add this, but glad to have it here in the comments, as well as the link to your previous post about it. Over decades this unconscious behavior could add up! I tend to think of this in the context of venous insufficiency/peripheral edema/varicose veins and uncrossing legs in these situations helps take some of the pressure off venous/lymphatic return, right? A good trick when you are standing (i.e. in the OR, which I haven't in a long time) or other situation and start to feel a little lightheaded, crossing one's legs while standing can help prevent presyncopal feelings. But if really feeling that way best to hit the deck and get horizontal! Surgeon taught me this. Maybe I looked green in the OR one day ;)
Great commentary, thanks for stopping by.
Always a pleasure to stop by! You are doing great work on Examined, which has become the best source of general medical information available for patients.
I remember that OR trick from med student days.
In my updated home BP summary (https://theskepticalcardiologist.com/2019/07/13/why-i-encourage-self-monitoring-of-blood-pressure-in-my-patients-with-high-blood-pressure/) I included a comment from a patient which I think likely reflects the practice in most offices and an attitude most patients should consider adopting.
"I had a high blood pressure event several years ago. Since then I have monitored my BP at home, sitting with both feet flat on the floor, not eating or drinking, not speaking or moving around, on a chair with a back, and without clothes on the arm being used for the measure. My BP remains normal.
I have never had my BP taken correctly in a doctor’s office. They will do it while I am speaking with the doctor, sitting on an exam table with my legs swinging, with the monitor band over my heavy winter sweater, right after I have sat down. They do not ensure that my arm is supported or at the right height. If I recommend that I take off my sweater, or move to a chair with a back, they tell me that is not needed. I have decided to refuse such measurements. How can they possibly be monitoring my health this way?"
I'm going to restack this quote. Although we don't want people to lose trust or confidence in our office measurements, we also don't want to be dogmatic like we are the only source of reliable data. To the contrary!
And many thanks for the highly generous compliment! As my slogan goes: "If I only had more time..." I could live up to "the best source of general medical information available for patients." But in terms of some of the other sites "ahead of us" on Substack, I think you and I are doing alright by readers!
Always feel free to correct or disagree with me by the way, especially in your field of expertise or when I get off the evidence-based track.
No worries. I always speak my mind but for worthwhile sources like yours I try to respect the author's platform and minimize my own pontification.
I really like the comments feature on Substack both from my readers and ones that I am able to leave on other authors.
The comments do go live immediately and only recently have I felt the need to silence/delete a commenter
A little late reading this but this all makes sense. I always say, “it’s normal at home and runs high here” (at the doctor’s office). Great information.
Exactly. Clinical situations are anxiety provoking for most people, myself included!