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Comment by sklargh | Hacker News Reader

I have a personal example of this. My father died largely because of his annual physical. He hated doctors, became nervous around them and thus expressed hypertension in-office. He did not have material hypertension but did defer to his physician. Over the long term, despite my best efforts, this killed him.

His blood pressure medication regime was poorly managed and severely impacted his quality of life. He eventually suffered a syncopal episode while climbing stairs and died.

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I was listening to Peter Attia on some podcast and he says to essentially throw out any BP reading that didn't occur after sitting down for five minutes. In his practice they have patients measure many times a day for multiple weeks just to get a baseline point to work from.

More and more i find that, at least in America, if you're talking to a GP you're just talking to a human interface of insurance approved treatment algorithms.

That’s a great way to articulate the problem.

Imho, a brilliant solution is direct primary care. For $80/mo, I have access to a dr that works for me, and not my insurance company. Absolute game changer in that he has a bias toward understanding and optimizing rather than gaming insurance metrics to be rated as a double-plus preferred provider or whatever.

Also gets my lab work done at a fraction of what my insurance deductible would be.

Combine it with a high deductible insurance plan to hedge against the truly catastrophic/expensive possibilities.

There are direct primary care providers all over. Google it. I can’t recommend direct primary care highly enough.

Is this the same thing as concierge medicine? I’m interested but it seems quite expensive. 80$ a month seems much lower than normal.

I honestly don’t know if ‘concierge medicine’ is a different thing, but from what it sounds like and my own experience with direct primary care they sound equivalent. Possibly different by cost or target demographic.

A rose by any other name, and all that.

We have DPC, and it's amazing. We pay $250/month for a family of 4. Some places charge less, but then also charge you for each time you see the doctor. Ours is all inclusive except for any in office incidentals - like lab work.

It's truly amazing. Our doctor knows us all well, can get responses to email or text within just a few minutes, generally same day appointments, or next day if she's really busy. Most things we don't even need to go in for - I did a recent international trip, and she just ordered me all of the needed travel medications without having to stop in.

Thanks. I might try this out for a year. Can’t be worse than my current experience of only seeing a NP for 5 minutes.

I think you’ll be very pleasantly surprised.

Consider talking to a couple local dpc providers and see which you feel you’d work best with.

At this point, I just reschedule if it looks like im seeing an NP or PA-C and the time is only going to be 10 minutes or less.

DPC is just concierge-lite; the difference basically comes down to the head count that the provider wants for their practice.

A lot of docs do DPC for a while to build up a client base, then exit to concierge, keeping a third of their previous roster at three times the cost.

I don't know how to get around this problem but wife and I paid $1,500 for a year's worth of concierge care only to have the physician close up shop after 4 months. I suppose if we paid month-by-month that would have helped.

Dr. Attia also shared his personal experience similar to @sklargh's grandfather where he suffered a head injury after fainting while standing up from bed. High blood pressure can kill you over years, but excessive low blood pressure can kill you tomorrow.

In America we also (mis)use blood pressure machines. I'd better quality or used correctly, they're usually ok. However, I've had nurses just crank the thing up to 200. No shit it's going to be high - it cut off my circulation for 90 seconds while it climbs all the way up and then all the way down. I can feel my pulse increase in force trying to get blood to my numb arm. Let's be lazy and let the machine do everything for us.

"More and more i find that, at least in America, if you're talking to a GP you're just talking to a human interface of insurance approved treatment algorithms."

I largely agree, although from a slightly different angle. Many newer doctors just read from their Epic WebMd equivalent and record your answers. I assume it's so they don't get sued.

Yah, I purchased one of the automatic monitoring machines at home after having a couple slightly elevated readings at dentist/etc offices.

And what I learned is that I can swing my blood pressure from slightly low to slightly elevated simply by how I sit, how relaxed I am, and untold other variables that result in being able to consciously swing it 20+ mmHg, and other times it can swing that much (or more) just between multiple consecutive readings where I don't move/etc between them.

I've also had Nurses swap the Cuff size and drop that much, or just do two in a row in the Dr's office and get massively different results.

So, for me, I don't know how to determine an actual bp if the noise is greater than the signal. Taking the average over multiple times a day, for a few weeks is probably reasonable. But then, I'm pretty sure the amount of exercise and what I eat day to day could swing it one way or the other depending on the time of the year (aka I sweat a lot more during the summer and drop weight, etc).

I was laid off in November, coincidentally on the same day I had a doctors exam. I didn't want to reschedule it so I went. My BP was suddenly 150-160. They were somewhat concerned (I'm young and almost an underweight BMI) until I explained I just got laid off about 4 hours ago. Fun stuff. Weird memory.

I did this for the doctor, and my pressure readings were much better at home, which should be no surprise. They asked me to bring in the machine to check it against their own measurements. It takes three readings a minute apart, and then does its calculations to produce the numbers. After the first cycle, the assistant wanted nothing to do with it, and started fiddling with the machine in annoyance to get it to do whatever she wanted. There was not even a discussion about it. There must have been many other sides of beef in the office that she had to hurry to poke and prod as fast as possible. And what do you know, I think that visit produced the highest blood pressure they had seen in me yet. I think that was the same visit I had to point out that their fridge with blood samples in it wasn't closed fully. The doctor made it a point to stop and ask me if something was bothering me that visit because my frustration at how bad US general practice had become was obvious.

> I was listening to Peter Attia on some podcast and he says to essentially throw out any BP reading that didn't occur after sitting down for five minutes.

Or just assume that your systolic will be about 3 points higher if you weren't sitting for five minutes, or whatever the normal correction is for you. You shouldn't accept a diagnosis of high blood pressure from your doctor if (as is most likely) they aren't measuring it correctly, but the deviation from the "correct" measurement also isn't random.

This is commonly known as "white coat syndrome". Some patients get nervous in medical offices, and some healthcare providers don't follow the recommended measurement protocol of allowing the patient to sit quietly for 5 minutes first. So this leads to some false positive hypertension diagnoses and iatrogenic harm.

Hypertension is common, dangerous, and generally under diagnosed. So primary care doctors have been trained to look for it and treat it aggressively. Overall the healthcare system is probably doing too little about hypertension rather than too much.

that's it right there, iatrogenic harm. Good term to know about.

On the better handled side of this, my doctor pointed out that issue at my physical and instead of putting me on blood pressure meds he told me to get a blood pressure cuff and gave me a paper to fill out with daily readings before jumping to any conclusions.

My doctor calls this doctor’s office hypertension. If the reading is high, he always makes a point to circle around and do it again at the end of the appointment. For me, there’s usually a 10-20 (units, I forget which ones) difference. I do not have hypertension

AKA "White coat syndrome."

I listen to my doctors advice, but I don't follow my doctors orders.

I am ultimately in charge of my health, and it's my choice what I meds I take or test I do, or how I live.

> my choice what I meds I take

Well, as long as you want to take a subset of whatever the doctor du jour wants to give you.

It seems very many people have this problem - skim through the hundreds of comments on this page [0].

I remember when I first panicked about having my BP taken: I had an irrational thought that the cuff would completely cut off my circulation and kill me. (I since discovered I have OCD.) So of course my BP shot up. And a second time, I was running like crazy to get to the appointment, and very stressed from a new job I'd just started and had just finished for the day, so again the BP was crazy high.

Since then, I always panic about taking my BP, even at home, though it's worse in the office. To my previous worries, I've added fears about heart attack/stroke from high BP, irony of ironies but a common one.

My solution is to buy a machine with a memory, take several readings per day over a period of at least a week (2-3 weeks is better), and cover up the screen on the monitor with a piece of card when taking the readings. At the end of the 2 weeks, remove the card, discard the first two days' readings, and take the average of the remaining readings. When I do this, my BP is almost normal (low 120s over low 80s).

I don't waste my time trying to relax, since it tends to make things worse, although I do make sure I've been still for a couple of mins. I have a supportive doctor who understands statistics, which helps.

(Standard disclaimer: this isn't medical advice. IANAD. Real hypertension is dangerous.)

[0] https://www.innerhealthstudio.com/phobia-taking-blood-pressu...

The first part of this story is the plot of the beginning of the movie Amelie.

I'm sorry about the second part. I wish he'd done blood pressure monitoring at home.

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