Hypertension Homework - Annals of Internal Medicine: Fresh Look Blog


Tuesday, July 3, 2018

Hypertension Homework

In the less than 2 years since I have been practicing primary care, I have had to explain to patients over time that they have high blood pressure, then do not, then do again. “So, you were wrong?” they ask. 

I’m early enough in my career to comfortably admit my errors, but there’s a difference between being wrong and acting appropriately on wrong information. Errors occur when what should have been done was not done. In the case of hypertension, I made recommendations based on what experts had recommended. Then those recommendations changed. And changed again.

This is why doctors still have regular homework to do. I explain it to my patients sometimes—and my trainees often—when they ask me questions I can’t answer. Practice groups like mine often have journal clubs to discuss the latest recommendation or studies in medical literature. However, the amount of medical information continues to grow, and the rate of growth makes staying up to date seem laughable.

Recently, I was asked to lead one of these sessions in my primary care clinic, and I chose to review the new American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines. Knowing my fellow primary care physicians weren’t likely to read an almost 500-page document, I e-mailed everyone a link to a much more manageable summary in Annals: “Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline” (1). We discussed the controversy of the original trials, whether guidelines can be applied to our older patients or those with diabetes or kidney disease. The conversation mirrored many of the concerns that were voiced by authors of the Annals editorial (2) accompanying the summary article. It was nice to dip back into academic discourse after so many tasks as a primary care physician have started to make me feel like a box-checker. However, the issue of checking those boxes nonetheless snuck back into our journal club conversation, driven not only by what goals to target for our patients, but also what targets we would be measured on administratively.

This was because with homework comes tests and grades. In this analogy, each patient is like a question on a test, and the overall grade is based on the number of “correct answers” (correct management decisions across the population of patients we are assigned to care for), scored against evidence-based or expert-supported recommendations, such as those contained in the ACC/AHA hypertension guidelines.

Like all tests, the goal is to measure performance and identify insufficiencies needing remediation. But perhaps unlike most other tests, which measure individual performance as an end in and of itself, such tests of physician performance aspire to 2 ends: patients receive the most appropriate care, and we do our best in delivering that care.

To achieve both ends, the medical community must address a number of questions: What is the best way to measure “change over time” when physicians are graded every month on an absolute number?  How can we promote “patient-centered care” when dynamics are complicated by the fact that grades determine things like physicians’ personal bonuses? How should we accommodate other factors that influence behavior (e.g., limitations on time spent in clinical visits)? Looks like we still have some homework to do.

  1. Carey RM, Whelton PK; 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline. Ann Intern Med. 2018;168:351-8. [PMID: 29357392] doi:10.7326/M17-3203
  2. Cohen JB, Townsend RR. The ACC/AHA 2017 hypertension guidelines: both too much and not enough of a good thing? Ann Intern Med. 2018;168:287-8. [PMID: 29204627] doi:10.7326/M17-3103


  1. I believe the administrative oversight of physicians' work, and the obsession with constant testing and grading is overkill and way excessive. It contributes to professional burnout for sure. Even the boards should be voluntary, not mandatory. Physicians spend a lot of time studying in medical school, residency, and throughout their careers, trying to stay abreast constantly. In addition, they are asked to accumulate CME credits on an annual basis. Isn't all that enough? I think it is more than enough. For the most part, physicians are responsible people. And they will never be perfect. Who is? And to try to justify this excessive and increasing burden of more and more regulations, and more and more testing saying that the pubic demands it is at best disingenuous. Patients love or dislike their doctors for different reasons, not lack of MOC or lack of CME course attendance. If there is a factor that directly correlates with the quality of medical care provided is not more testing or symposia on physician burnout, but limiting the number of patients we see in a day, and using scribes to help out with EHR. Practicing physicians, not clueless administrators and/or bureaucrats should be in control and in charge of our medical practices,

    1. Dr. Gonz, thank you for reading! I agree that the measurement is certainly one of the sources of physician dissatisfaction with the workplace. As a VA physician, I see this kind of box-checking entering my clinical conversations frequently, as I described in this piece. I do think it's important to be able to establish and hold ourselves to high clinical standards. I'm not sure I have an answer to balancing these goals, but I'm optimistic that in light of the recent CMS proposed rules about billing, we may be in an era where the regulatory bodies are listening to our plight. Keep advocating! (And keep reading! Thanks!)


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