Health

How Poor Procedures for Measuring Blood Pressure Often Indicate False High Blood Pressure

Are you certain that your doctor’s office is measuring blood pressure correctly? Because if it’s not, then the doctor could be using inaccurate results to advise you on your health, often leading to you taking unnecessary drugs for high (or low) blood pressure that you don’t have. Some might think that of course they measure your blood pressure correctly. After all, it’s done at the doctor’s office. That’s what I thought—until I learned the truth that inaccurate measuring of blood pressure is very common, not only at the doctor’s office, but also when the patient measures their own blood pressure at home. Here’s what happened to me—and how I learned to accurately measure my own blood pressure and to know when medical workers are doing it incorrectly.

Table of Contents

Please Read Medical Disclaimer

How it All Began: A Medical Worker First Tells Me I Have High Blood Pressure

In 2023, I went to see a new doctor for an ailment that was not urgent or critical. When I arrived at the appointed time, I went through a process that’s common in every doctor’s’ office I’ve been to. I first took care of paperwork, then waited in the reception area. Next, I was taken to a room and waited in a chair. Shortly afterwords, an assistant came in and took my weight and height.

Then the assistant measured my blood pressure. I was sitting in an armchair—a simple metal chair with cushioned seat and back, like an inexpensive dining room chair. The doctor’s assistant put the blood-pressure cuff on my right arm and told me to sit up with my back supported and put my feet flat on the floor, which I did. I was wearing a short-sleeved shirt with a T-shirt under it. I started to pull my sleeves up so she could put it on my bare skin when she said she could put it over the clothing. She then turned on the device and took a reading.

Then she said, “Your blood pressure is high.”

Little did I know the medical roller coaster I was about to go on. This is the same “general” procedure for measuring blood pressure (BP)—with some small differences—used in every doctor’s office I’ve been to in the previous 20-plus years. I’ve gone through this at least 10 times during this period. Each time, the attendant told me my blood pressure. In all these cases, the attendant who took my BP also told me what the reading numbers were, but I never paid attention to it before and never knew what the numbers meant. Why? Because a doctor never mentioned the words “blood pressure” to me in my 75 years (or more specifically, since I became an adult), so I ignored it. But in this instance, for the first time in my life, the assistant said to me, “Your blood pressure is high.” She also told me the numbers, but I knew nothing about the meaning of the numbers.

I’ve been extremely healthy my whole life and spent very little time with doctors. I’ve never had a regular doctor, and I’ve taken care of my health since I was in college in my 20s, plus my parents kept me healthy. And I am in great health now—minus this current minor ailment that drove me to see a doctor.

The doctor came in shortly after the assistant left the room. I talked about my health history and lifestyle. We discussed the reason I was there, and a little about the medical group that he was associated with, EZX Health (a fictitious company I made up). It was our first meeting, and we did not discuss my blood pressure, possibly because of a time constraint. We set another appointment for one week later.

I went home concerned my blood pressure was high. But I did not remember the numbers. The next morning, I opened an email summary of my appointment, which I read through a patient portal. The BP numbers were in the summary. My BP was at 153/96. Since I didn’t know anything about BP numbers, I looked it up online and yes, those numbers were quite high. I was greatly concerned and a bit worried. In fact, I couldn’t stop thinking about it. It kept me up at night for the coming week.

Little did I know—with my limited knowledge of how blood pressure was measured—the journey I was about to go on that would completely alter my view of doctors and the procedures used in many of their offices to check patients’ blood pressure.

Measuring Blood Pressure at Home

I started thinking about how to get another BP reading before my second appointment one week after the first. Since I had been healthy my whole life and lived a healthy lifestyle, I was a bit worried. Two days before the second appointment, I came up with the idea of getting a home blood pressure monitor. I knew absolutely nothing about them. I researched the internet and found out I could buy an Omron, a respected name in home monitors, within minutes from home. I bought one that day.

When I got home about 5:30, I opened the box and went to the “Quick Start Guide,” which led me to calling Omron. An attendant on the phone walked me through my first reading, telling me how to put the cuff on and tighten it, allowing two fingers (no more and no fewer) to fit comfortably in between the cuff and the arm. She also told me how to connect my cellphone to the monitor through the Omron app. At this point, I knew nothing about how to take a BP reading. This was my first lesson. My first reading (over the phone) showed my BP at 153/104—very close to the doctor’s office reading. Now I was even more concerned. After the phone call with Omron, I took two more readings that afternoon: 130/99 and 134/96. That was better by a lot, but I didn’t know why.

In fact, I was still a real novice to this whole blood pressure business. And I wondered why the readings are so different from each other, even when one is taken right after another. I took more readings: the next morning after coffee; then the next afternoon around 5pm; and another the following morning. I took two readings each time and all were in the 130s, 140s, even one at 151. And the diastolic readings (the second number) were all in the 80s, 90s and higher. From my elementary knowledge of BP numbers, I knew these were all high, but I still had no idea why each reading was different.

I later learned that I knew basically nothing about blood pressure when I walked into the second appointment. I always thought that taking your blood pressure was easy. I always had it done in a medical office by an assistant and trusted the results. That’s all I knew.

My Second Appointment — One Week After the First

At my second appointment, the procedure was the same: After measuring my weight, the assistant took my blood pressure using the same procedure as before. She put the cuff on over my two shirts while I was sitting down, told me to sit up and put my feet flat on the floor and turned it on. She again said my blood pressure was high at 157/103. She then asked me if I wanted her to take my BP after I met with the doctor. I said yes.

When the doctor came in, we discussed the original health problem I came to him for, and what tests we would do next. Mainly, we discussed my high blood pressure as I was anxious to do so.

I showed him the results from my home monitor that were recorded on my cellphone app, telling him that I just bought the monitor two days before. My readings were still high, and he wrote some of them down. By the end of the meeting, he had me totally convinced that I had high blood pressure.

Immediately after the meeting, the assistant came in and took my blood pressure using the same procedure, and again, it was high at 148/96. At this second reading, she put it on my left arm. The other readings were on my right arm. I had no idea if that mattered.

We set another appointment for five weeks later. I went home again, concerned about my blood pressure being high. I took two more readings at home at about 5pm. They were high. Little did I know how much I still had to learn. At the second appointment, while I was waiting for the doctor to come in, I noticed on the inside side of the closed door, a poster on how to properly measure blood pressure. The poster is for home BP measuring since the text instructs the reader to measure in the morning “before medications.” The image and its text also show the cusp should be over bare skin. I mentioned this to the doctor. The assistant who took my blood pressure must have never read the poster, since she put it over my clothing each time. Or maybe in the doctor’s office it doesn’t matter. After all, they should know. Right? But after seeing the poster, I first began to wonder about the procedures used for measuring my blood pressure.

Why Worry About My Blood Pressure?

Why was I so concerned about my blood pressure? Being healthy has been one of my main goals since I was young. I had a healthy upbringing. Plus, we had free healthcare because my father was a military officer. When I was in college in the 1960s, there was a food revolution going on, and I’ve tried to eat healthy ever since. And I’ve always exercised. I’m a hiker, swimmer, cyclist, sailor and more. That’s why, at 75, I’m doing great. And I’ve never taken any prescribed medication. But seeing a doctor regularly was not part of that regimen over the years. I saw a doctor only when I needed one, which was rare. I am not overweight, have great energy and feel great. I meditate every morning and most afternoons. Every day I stretch, do various other exercises, and then have a light workout with weights. So, when I was told I had high blood pressure, I was shocked and worried.

Over the years, I’ve learned some causes of high blood pressure, and there are, in general, only two solutions: Medication and/or change lifestyle. I’m very educated about what a healthy lifestyle is, and I knew that if I had to change my lifestyle, there is nothing I would change to improve it to be healthier. Consequently, I had to figure out what was going on. I had to investigate the readings. They were all over the place, especially at the doctor’s office, where they were consistently high. I wanted to know why. And why do they change every time I took a reading?

I always thought that when a medical person took my blood pressure, that it was some complex system that checks it, that it can be taken at any time on either arm, was easy to do and very accurate. The more I learned, the more I realized how little I knew.

I Learn More and More About Measuring Blood Pressure Properly

The day after my second appointment, I took readings in the morning, and they were high. I decided it was time I read the monitor’s instruction manual since I was still using the Quick Start Guide. I learned some very amazing facts in the manual, facts that are so simple that they changed everything. First, when I took my BP reading over the phone with Omron, I was sitting in a cushioned chair that had a table on my right, so I attached the cuff to my right arm, which I rested on the table (it was barely below the armrest). Plus, at the medical office at the first appointment, the assistant took my first BP reading with the cuff on my right arm. At the second appointment, the first reading was on my right arm and the second one was on my left arm.

The instruction manual said to put the cuff in a different position if using it on the right arm. From then on in, I moved it to the left arm, and positioned it according to the instructions. (How to measure for the right or left arm were the instructions for my monitor. They might be different for other makes or models.) As I read the instruction manual, I also started researching BP-measuring procedures online through articles, studies, YouTube videos and blood pressure forums.

Another revelation was that I never knew that you are supposed to rest for at least five minutes before taking a reading. As I look back on that, I find that truly amazing. As it turns out, that is one of the most important procedures for getting a reliable reading of your “true” blood pressure. Why did I not know this? Because in all the times I had my blood pressure taken in a medical office, including at the EZX Health office, no one ever told me to rest before a reading—and rest for at least five minutes. Why did no one ever tell me that? Don’t they know? They’re medical workers. They’re supposed to know.

I also learned that your arm should be raised so that the middle of the cuff is approximately equal to the level of your heart. In the past, I know that some attendants did raise my arm, but in some of those cases, I even had to hold it up. With others, they had a table to rest my arm on. Others used the armrest of a chair, which I learned is generally not high enough for the average adult. There was no standard that I ever saw. At the EZX Health office, I was never told my arm should be raised to the correct level. It was just resting on the arm rest, or barely raised at all. At the first visit, I was sitting in an armchair with arm rests. In the second visit, I was sitting in a chair with no arm rests and both tests were done without raising my arm any more than necessary so the assistant could put the cuff on from her standing position. There was no consistency in the arm position.

Another important practice is that the cuff should always go over bare skin. I’ve had some medical workers tell me that, but I didn’t pay much attention. But in the EZX Health office, the assistant put it over the two shirts I had on for all three readings that were taken over two appointments, one at the first visit and two at the second (with about 30 minutes between readings which was when I was talking to the doctor).

Another thing I learned that I have never seen done in a doctor’s office, including EZX Health, is that you should always take at least two readings and average the two. Some recommend three readings, then discard the first and average the next two. And they should be taken consecutively with at least a 1-minute rest between readings. No source I found online says one reading is enough, but one is all I’ve ever experienced.

You should also never talk while resting or while the reading is being taken. I began to notice the differences in the readings at home as I changed the procedure; they got lower. But they still were not consistent, going up and down on every reading—and I didn’t know why. I was still taking readings in the morning and at 5pm—until I learned that the best time, when you are the most rested, is in the early morning, 30-60 minutes after you get out of bed—before coffee, eating, or exercise. The next best time is late evening—at least an hour or so after eating (including no deserts) and no exercise beforehand. The worst time was in the middle of the day. From that point on, I only took readings in the morning.

Over the next few days, I experimented with being comfortable in an upright chair where I can sit up with my feet flat on the floor and rest. I used a light table I had and chose a throw cushion so I could rest my arm on it, palm up, at the height I needed, allowing the tube from the cuff to run along my forearm to the monitor. Then I learned to place the monitor so I can easily press the start button and take a reading. Another essential procedure is to make sure you do not have to pee, as it can really raise your reading if you do. I’ve never been asked that at a doctor’s office: “Do you need to pee, as it will affect your BP reading if you do?” All and all, if you are taking your blood pressure yourself, the final instruction is to take it at the same time each day for several days and you will get a good “baseline.”

There is No Such Thing as Your “True” Blood Pressure

In summary, what I learned with all of the above details on the proper procedure for measuring your blood pressure was that there is no “magical” blood pressure that you have. It’s not like, “Your blood pressure is 110/80.” If that was the results of a reading, it’s the reading for that moment under the conditions that it was measured in using the device (the monitor) you used. If someone tells you that such and such is your blood pressure, then they don’t understand what it means, or they are saying something they shouldn’t be saying. If a doctor says that, then keep an eye on them and don’t trust them completely. But a doctor, as well as a nurse, should know this (or at least I am sure they knew it at one time), but an assistant probably doesn’t (although five minutes of instruction should be enough to inform them to never say, “That is your blood pressure”).

All medical workers should really say—if they want to give you an honest and informed answer—”We measured your blood pressure as…” Then they should tell you what that measurement means and how it is not necessarily your “true” blood pressure.  It’s what they measured today, at this time in this place and in these conditions at this location. We are alive and constantly in a state of change, even when asleep. It will be extremely rare that you will get the same exact blood pressure read even just two times in a row. What they don’t tell you—probably because they don’t want to take the time to tell you—and because they often think you should just listen to them without question and do as they say—is that there is no exact measurement that is your blood pressure.

Your BP changes constantly all day as you walk, eat, talk, work, sleep, etc., etc., etc. What you need to do is find a “baseline” that will give an indication of what your blood pressure is. A blood pressure “baseline” is similar to finding your “true” weight. As you eat and move around all day, your weight goes up and down. Two eight-ounce cups of coffee (or almost any liquid) is one pound. But that doesn’t mean that you just increased your weight by one pound. If you pee one cup five minutes later, you just lost a half pound. It’s the same for exercise. You can lose a half pound with just exercise. In other words, all day long your weight goes up and down. So how do you find your “true” weight? You take it at the same time every day when you have the least amount of changes. It’s not perfect, but it’s the best-known way to measure your true weight. So, you weigh yourself, naked, first thing in the morning right after you pee. That is your “baseline” and the truest weight you can measure over time. But it’s never perfect, it’s just the best we can do. It’s a baseline.

What is a Blood Pressure Baseline and How Do You Get It?

A baseline for blood pressure is what you are seeking. But it’s less exact than finding your “true weight,” because it’s more complex to put a cuff on your arm and measure the heart pumping. The medical world has established that the best way to find a good baseline is to put yourself in a “rested state” when your body has had enough time to slow down, and to be in a physical position which is somewhat close to your truest resting state, without outside and personal interferences that can be changed easily. And your mental state can cause your blood pressure to go up and down, so it needs to be calm and relaxed. It’s when your body is not digesting lots of food, including stimulants like coffee, alcohol, cigarettes, sugar, drugs, etc. And since your blood pressure includes movement of blood throughout your body, you need be in a physical, sitting position that minimizes hindering or stimulating blood flow, like sitting comfortably with feet flat on the floor and in an upright position with a relatively straight back. And you should take the reading over several days, like five to seven days and average the readings each day and then average the daily averages.

The medical community has determined that the best way to get a baseline is to first take the reading in the early morning 30-60 minutes after you get up (after you get up, NOT after you wake up), in a sitting position (sitting up in a comfortable straight-back chair), with your feet flat on the floor. The monitor cuff should be above your inside elbow crease (1/2 inch above on my monitor instructions), and not too tight or too loose (based on monitor instructions, fit two or three fingers comfortably between the cusp and bare skin). You should not have to take a pee (that can raise your BP considerably if you do), and you should not talk while the reading is being taken. You also should not have eaten, exercised, smoked, or drank coffee, etc., at least 30 minutes before. And you should rest, with the cuff on, for at least 5 minutes before the reading—without any outside distractions and in a restful environment. All these conditions are generalizations to try and get you in a rested, baseline state—and to get the best reading, you should do everything possible to get into that state.

Another very important factor is the device being used, and it is recommended using a device where the cuff is on your upper arm only, not one on your wrist. You also must follow the manufacturer’s instructions. For example, the height of your arm the cuff is on. This too is a guide—not an exact position. The center of the cusp should be approximately the same height as your heart. That point is approximately the same point used to put pressure on the heart in CPR. It is found by finding the bottom of the sternum and measuring up two fingers width. The area above that point is where you put your palm to press on the heart for CPR. That area should approximately align with the  center of the cuff.  Some say it is the same point as the nipples, which is correct for an average adult, although this can vary considerably with people depending on age, weight and sex. A small high or low difference is insignificant, but way too low, like letting your arm hang straight down from your shoulder, can give a higher reading, and way to high can give a lower reading. For an average-size adult sitting in a chair, like a dining room or desk chair, your arm resting on the table or desktop, works well. But your doctor should be able to tell you the most exact height. But don’t always listen to the medical worker, who might be an assistant who is not well-trained in taking blood pressure.

Once you get the proper procedures down, then you need to measure you blood pressure at the same time every day for several days, maybe a week. Then, taking all the averages, and discarding any extreme readings, you can achieve a good baseline that will give you a good indication of what your blood pressure is. It will end up to be a final figure, but with your new knowledge of how you got to that point, you can now see that one reading, or just a few, is not even close to being enough information to judge what your blood pressure is. Relying on one measurement is just stupid. And if the procedures are poor on top of that, it’s downright ridiculous.

Why doctors don’t explain all this in their first meeting with you when the topic of blood pressure is discussed is beyond me. No one ever told me. But, actually, I think they don’t want to take the time to do it. And sometimes, they don’t want to pay for all the extra time of having you rest, getting comfortable, and taking more than one reading—all under the direction of a medical worker, who is rarely a doctor. To get a good baseline requires more time, and more time in the doctor’s office, especially if it’s done by a doctor, can be expensive. That’s why blood pressure measuring is almost always done by a lower-cost medical worker. After all, medicine is a business. And, unfortunately, business is often a top priority. Sometimes, it’s the main priority. Today, many doctors don’t run their own practice, but are part of a larger, profit-making enterprise that controls costs that are not always in the patient’s best interests. 

I Finally Get “Consistent” Results Measuring Blood Pressure at Home

Over the next few days after I learned the above information, I refined my procedure using not only the monitor instruction manual, but also from extensive online research. I decided that on the evening before I was going to take a reading, I would set up my chair, and the table and cushion my arm rested on. I then placed the monitor in the correct position for taking a reading. This way, in the morning, I would not be spending energy to get all this together. I did everything I could to maximize the chances of getting the best reading in a rested state 30-60 minutes after getting up.

In the morning, I sat in the chair and put the cuff on my left arm according to the guidelines and instructions. It only took a few minutes since everything was in place. Then, with the cuff on, I rested for 5 minutes (many recommend doing this—rest with cuff on, even in the medical office), using the stopwatch on my phone (with a gentle sound when the time is up), After the first reading, I took two more, resting one minute between them.

I was pleasantly surprised that my first readings under my “controlled” conditions were lower than my previous readings and far lower than those at the doctor’s office. I took three readings. The first was 117/85, the second was 126/86, and the third was 121/85. Over my first two appointments in the EZX Health office, the three readings taken were: 153/96; 157/103; 148/96. That’s a huge difference. That’s enough of a difference to change everything in my case. I felt exonerated—no longer with the worry that I might have high blood pressure. (I am not going to discuss here what the exact numbers should be, since your doctor should be advising you on that.)

For the next five days, I took three readings every morning with the same procedure. I made notes on each reading. After six days, I took the average of all three every day and then averaged all those averages. The final average was 121/86. That’s a far cry from the three readings at the medical office which were: 153/96; 157/103; 148/96. In other words, I established a baseline. It was an average established over six days using procedures recommended by the medical community.

As I look back to the second appointment when the doctor and I compared my home readings being remarkably like the readings taken in his offices, I realized that my first home readings that I showed him were done using the same bad procedures as used by his assistant. So, of course there’s going to be poor results. With what little I knew about procedures at the time, counting on my home readings was just as bad as counting on the office readings.

Can You Trust a Blood Pressure Reading Taken in a Doctor’s Office?

I was pleased that all my research on procedure showed me exactly what I had read in many articles and videos online: You cannot trust readings that are not properly taken, which happens in medical offices all the time—and it also happens at home. Yet what have I learned? Be very careful about the readings you get in a medical office, as well as at home. You probably can’t trust them unless you know the proper procedures. And what I have seen over the years—and currently learned online—is that this is common practice throughout the medical community in a doctor’s office.

Out of 10-plus BP readings I have had in a doctor’s office in the last 20 years, not one followed the proper and recommended procedures. In fact, not one was even close. I started asking myself. How can that be? How can it be that you can’t necessarily trust the blood pressure readings taken in a doctor’s office? That’s where you should be able to totally trust them. Decisions on whether or not you need to be on blood pressure medication are partially based on these readings. They are at the least an essential and prominent determining factor that your doctor will use in deciding on whether or not you need to be on medication, or to change your lifestyle, or both.

The doctor, in his daily summary of our second meeting (I accessed the summaries through an online portal), suggested that he would, at the next visit, “consider initiating antihypertensive therapy if readings remain consistently elevated.” One thing was for certain in his mind: I have high blood pressure. He’s basing that belief based on faulty BP measurements in his office and at my home. But I began to wonder: How many people in the U.S. are on blood pressure medication who don’t need it because of poor procedures used in reading BP, not only in medical offices, but also in home readings? After all, the doctor didn’t question me on my procedures. In his mind, my readings confirmed his office’s readings. How can he miss such an obvious problem?

The Procedures Recommended by the Medical Community for Measuring Blood Pressure 

After many hours and days of research on the internet, below is what I have found is the recommended procedure that should be used in a medical office. These guidelines are basically for everyone, but cuff size, chair, and table height to rest your arm on could vary considerably, depending on the individuals size, age and weight. Below is a result of reading the AMA guidelines, as well as other guidelines and practices I found that are recommended by doctors and other medical professionals. There are so many studies and resources out there that it’s impossible to count them—which makes me wonder why poor procedures are so common. The reader should keep in mind that I am a layman. I do not claim that the below procedures are correct. This is just what my research has found. You should really confirm them yourself. I am only trying to spread the word that you should not trust blood pressure readings unless you know the proper procedures both at a medical office and at home. Don’t trust what the doctor says blindly.

How Your Blood Pressure Should be Read at the Doctor’s Office

The best resource I found for proper procedures is at the American Medical Association (AMA) blood-pressure site, www.targetbp.org . In the top menu, click on the first link “BP Improvement” then click on “Measure Accurately.” The exact link: https://targetbp.org/blood-pressure-improvement-program/control-bp/measure-accurately/

Here is what I have learned. I am not a doctor, nor do I have any medical training, but I learned a lot because of a bad experience I had, which prompted me to research the subject. Verify everything for yourself. I have included links at the end of this article to many websites for more information.

The bottom procedure could change depending on the patient’s condition. A doctor will know what is correct, but it’s best to double-check them, since they aren’t all at the top of their game.

1. First ask the patient if they have to pee, telling them it’s best for a good BP reading.
2. Put the patient in a comfortable chair with armrests—because armrests are comfortable.
3. Have a table next to the chair that will allow the patient to easily and comfortably rest their arm on the table with their palm up, so that the middle of the cusp is level with the heart. Be able to adjust the arm height as needed in some way to get it close to ideal.
4. If this is the patient’s first visit, measure the BP on each arm and use the arm with the highest reading then and in the future.
5. Ask the patient if they ate recently and what (some foods take longer to digest). Also ask if they smoked, drank coffee or alcohol, or if they exercised before the appointment—and how much and when. All these comments should be written down every time the BP is measured on a checklist. Then the doctor can take the conditions into account—and tell the patient that.
6. The cusp should be attached in the correct position (height above elbow crease depending on monitor instructions) to the correct arm over bare skin. According to recommendations by most groups, the correct-size cusp should be placed over the arm so that two fingers can easily be inserted between the cusp and the arm (some cusps might state three fingers, depending on manufacturer’s instructions). It is essential that the cusp be the right size for the arm. It is recommended that every medical office have an assortment of cusp sizes easily available. (Wrong cusp size is the number one cause for incorrect measurements, according to the AMA.)
7. After the cusp is on, the patient is informed that they should sit up with back straight and rest their feet flat on the floor, legs not crossed. Then the attendant should tell them that they need rest for five minutes, with no talking, to get an accurate meeting. It is best if they rest with the cuff on. The patient should also be told they will take two (or three, which is best) measurements and they will rest at least 1 minute between readings, and they will discard the first reading and take the average of the next two or average the two, if only two are taken. Then the attendant leaves the room and turns the lights off, or better still, leaves them in a low light environment.
8. When the attendant returns, the patient should be told not to talk during the measurement. Do not engage them in conversation. Then the monitor is turned on and the measurement taken.
9. One or two more measurements are taken, resting between them. If any two are drastically different, then take another reading and discard one. Generally, taking three and discarding the first, and then averaging the next two, is the best result.

Procedures Used When My Blood Pressure was Measured at the EZX Health Medical Office

I had three measurements taken at EZX Health: One at the first visit and two at the second (these two were separated by about 30 minutes). All three procedures were the same with a few insignificant differences:

1. The assistant took me to a room where I sat in a chair with arm rests (At my second appointment, the chair had no armrests).
2. I was not asked if I have to pee.
3. The assistant put the cuff on my arm over my two shirts (at both appointments, three readings total). Based on what I later learned, the assistant took little care in placing the arm height correctly. There was no table for my arm. And she did not place the cuff in a certain position above the crease in the elbow. My monitor says ½ inch. And no care was taken for the tightness of the cuff.
4. She told me to sit up and put my feet flat on the floor.
5. We talked off and on during the procedure, but she never mentioned no talking.
6. She only took one reading each time.
7. I was never told to rest at any point at both appointments.

Although the reading at the first appointment was taken on the right arm, the two on the second appointment were taken on the left arm. There was no consistency.

Everyone Does it That Way

But the real problem, as mentioned above is: How can this be—that you can’t trust the blood pressure measurements taken at the doctor’s office—the one place that you should be able to trust?

Are they responsible? Or are they just normal? 

Or: “Everyone does it that way.”

Since every procedure I’ve experienced in every medical office I’ve been to also has poor procedures—then I would have to blame the medical community in general. They all share this responsibility. What could be more important than correctly measuring your blood pressure? And what does it lead to if the measuring process falsely indicates high blood pressure that requires “Antihypertensive Therapy”—which generally includes medication?

“Initiating Antihypertensive Therapy”

In the summary, the doctor had written up on my second visit, it stated (emphasis mine), referring to my blood pressure:

Patient’s self-monitoring of blood pressure at home has consistently shown elevated readings—most in 130s up to high of 150s SBP. Will reassess blood pressure at the next visit and consider initiating antihypertensive therapy if readings remain consistently elevated. Please continue monitoring your blood pressure at home using your Omron device and follow proper procedures for accurate readings.

In the above comments, it states that he “would consider initiating antihypertensive therapy if readings remain consistently elevated.” With my new knowledge since that last meeting, that means he would be considering medication as one of the main aspects of “antihypertensive therapy”—partly based on the BP readings taken at his office, which were done incorrectly. They would also be based on readings I took at home—when I didn’t have a clue how to properly take a reading. In other words, the procedures I used to measure BP at home were just as unreliable as the procedures used in the doctor’s office.

The doctor mentions in the above visit summary to make sure I “follow proper procedures for accurate readings” when I take the readings, yet he didn’t ask me one question about my procedure, so how could the doctor know? I told the doctor I bought the monitor less than two days before. I certainly did not become an expert in less than two days. During my first reading I was talking on the phone with Omron. Believe me, “talking on phone” during a reading is not an acceptable part of the proper procedure when checking your blood pressure.

Maybe the doctor didn’t know what the “proper procedures” were, since all the readings taken in their office weren’t even close to “proper.” I am certain though, that he knew at one time (from his original training—see the comments from the “27 Sources…” article in the next section below). I started to wonder: How many millions of people are on blood pressure medication who don’t need to be because the readings are poorly taken? I’d read many comments on discussion forums that discuss blood pressure and there is an entire world of people out there who don’t know anything about proper procedures, are scared to get their BP measured at a doctor’s office, are very worried about their BP being too high and are confused. Many take their BP and don’t know how to do so correctly. According to a 2017 analysis, 61.9 million adults in the United States were taking antihypertensive medication. Really?

How Prevalent are Poor Procedures for Measuring Blood Pressure in the Medical Community?

In my research, I found a large number of studies and opinions on the state of BP reading procedures. Below are two examples that help illustrate what is happening. Every health care worker should read these—or at least the excerpts below to perhaps gain a little humility—besides learning the truth about the state of measuring blood pressure in medical offices (and hospitals – see below).

A Study Involving 172 Health Care Workers

This is a 1995 study at a major city hospital. The full article should be read. It involved 172 health care workers, GPs, specialists, nurses.

“Evaluation of the Technique Used by Health-Care Workers for Taking Blood Pressure”

Excerpt:

Practical Test

All of the groups were notably inaccurate in the practical test. Only 3% of the general practitioners and 2% of the nurses obtained reliable results (P=NS in any group) (Fig 1). Arm and cuff positions were inadequate in 73%. Only 3% used the stethoscope bell.

Blood Pressure

Sixty-three percent of examinees were out of range in their readings of systolic BP (46% incorrect positive, 54% incorrect negative) and 53% in diastolic BP (40% incorrect positive, 60% incorrect negative). The nurses had the highest out-of-range values in both BP readings (P<.03 versus surgical specialists).

The above is a 1995 study, but what it shows is how long this problem has been going on and probably added to how the term “white coat syndrome” got started. To read the entire study, go to: https://www.ahajournals.org/doi/full/10.1161/01.HYP.26.6.1204  

“27 Sources of Error in Blood Pressure Readings”

Below is a 2023 article from the American Medical Assoc., and a good summation of the problem that shows how it is still happening.

“Are you sure you’re accurately measuring BP? Here’s how to know”

Excerpt (italic emphasis and text color is mine):

Twenty-seven. That’s how many potential sources of error can falsely raise or lower a patient’s blood pressure reading. Eight of these potential errors involve patient-related factors such as caffeine use or bladder distension. But the 19 others can be managed by the care team—including use of the properly sized cuff, sufficient rest prior to measurement, proper positioning, and using a validated, calibrated device. That’s a lot for anyone to account for without proper or recent training. And there’s the rub: Care team members are not often supported with the tools and training to measure BP accurately. Many health professionals were trained only once, like during medical or nursing school, but never again. It’s not as easy as you think “Many of us start to get the feeling that blood-pressure measurement is bread and butter—we can do it in our sleep—but it’s actually a very complex skill. And because it’s a complex skill, training is really important,” Kate Kirley, MD, a family physician and director of chronic disease prevention at the AMA, said during an AMA webinar. “All health care professionals need to be trained in how to take an accurate blood pressure measurement, and we should all be receiving retraining every six months to one year, according to the clinical guidelines,” Dr. Kirley said. “This is because our skills in blood pressure measurement decay over time.”

To read the full article, go to: https://www.ama-assn.org/delivering-care/hypertension/are-you-sure-you-re-accurately-measuring-bp-here-s-how-know For a long list of articles, written for doctors on how to properly measure blood pressure in their offices, go to: https://www.ama-assn.org/search?search=measuring+bp . This page is full of articles about how doctors in medical offices can improve their procedures and make them work in a medical setting, as well as how to teach patients proper procedures at home.

The White Coat Syndrome — How Did it Really Get Started?

At my second visit, the assistant who took my BP asked me if I had “White coat syndrome?” I asked her what that was. She said it was patients who get nervous and had a high reading when they have their BP measured because it’s being measured by a medical worker in a white coat. I obviously didn’t have it because I never had anyone ever tell me I had high blood pressure, so how could I be afraid of it being measured?

Previously, I naively looked at measuring blood pressure the same way I looked at measuring my height. After learning how blood pressure is supposed to be measured, I started to wonder how this term came to be. I had learned that measuring BP in a medical office could be unreliable because of poor procedures that lead to false readings. Perhaps, that’s the reason people get high readings around people in “white coats.” I’ve seen nothing but poor BP measuring procedures, so what came first? The poor procedures or the high readings?

Doctors generally believe they always know what’s best for a patient, and patients don’t. That might be generally true, but in my mind, it’s likely that medical staff invented the term, blaming it on the patient and not on the BP measuring procedures they use. The above study from 1995 shows how this problem goes back at least three decades. It’s become a self-fulfilling prophecy: Patients believe the doctors when they tell them they have high blood pressure. Every time a patient goes to the doctor, the poor procedures show they have high blood pressure, so it makes them nervous—and they have high blood pressure.

I am sure there are people who have white coat syndrome as it’s been known traditionally. But now, with my new knowledge of what is good procedures, I wonder how many people have high blood pressure in a doctor’s office because of poor procedures in those offices. So, what came first? The high readings or the poor procedures? One thing I learned from forums is that many people don’t know the proper procedures for reading their blood pressure at home. I am sure many just copy the procedures at the doctor’s office, thinking they must be doing it right. After all, they would know the correct procedure. Or would they? But I also wonder if the procedures at home are better than in a doctor’s office, then they should get lower results. Then their BP gets poorly measured in a doctor’s office and the medical staff says they have “white coat syndrome.”

If the medical community starts using correct procedures, then patients will start imitating them at home. And if the medical community also starts training people to properly take readings at home, then they can be assured that the home readings are reliable. Just telling patients to follow good procedures is the same as no training. But the training needs to be excellent and regularly updated. After all, I am sure that office assistants and doctors were once instructed on good procedures (although I wonder about the quality of instruction assistants receive). How well has that worked out?

When are the Best Times for Measuring Blood Pressure? 

The majority of the medical community agrees that the best time to take your blood pressure is in the morning, but there’s a lot of variables, so verify everything with your own research. It’s not that the doctors don’t know, it’s that they often don’t enforce what is going on in their offices because they assume they are correct, or that the medical worker should know because they were trained (hopefully). Just don’t assume that practices for measuring are always correct. After all, how often has your doctor taken your blood pressure? They might have forgotten their training. For the best information, go to the American Medical Association web page that discusses it. An informed doctor who is on top of things might tell you to take your BP at home at different times. Each case can be different. (Also read the links below to  learn more about taking your blood pressure.)

And remember: The worst time of the day to measure blood pressure is during the day when you are out and about working, playing, exercising—and seeing your lawyer, or your accountant or… your doctor. Your readings can be very high in these conditions, and if theirs lots of anxiety when you measure your blood pressure, it could be higher even still. Remember that the purpose of a good blood pressure reading is to get a good basepoint to use to judge your health. So take care and do it correctly.

So, What Do I Do Next?

The differences between my BP measurements at home were so great from the readings I received at the medical office, that I was very relieved that I didn’t have high blood pressure. But I was also a little irritated. Irritated that a doctor’s office, which I trusted, had put me through an unpleasant experience that they created from poor and misleading procedures. (What also annoyed me was that I paid the doctor and the company that employed him for these sloppy procedures and putting me through the aggravation I experienced. A refund would have been nice, but I’d be dreaming to get that.)

Heart disease is the leading cause of death in the U.S. Everyone should be extremely careful in measuring it. When you go to the doctor, you should be able to count on them to measure it with every care. I had completely lost my trust. I next started asking myself, “What do I do next?” I knew I had to first show my doctor what BP levels I found in my home readings. And I needed to explain how I got there, that I heavily studied how blood pressure is measured, and then put what I learned into practice. Consequently, I learned that it wasn’t being done in their offices correctly—and not only were they not correct, but they were also extremely poor. They were worse than a waste of time, causing more harm than help.

So, with all this new-found knowledge I now have, what am I going to do about it? Should I tell my doctor? Or should I just sit and do nothing and let him go on believing that I have high blood pressure? I knew I had to do something. I had to at least tell him my story that I don’t have high blood pressure. Knowing that the doctor would take it all as criticism, I was nervous and planned out what I was going to say. But I wanted to make it so that he would wake up to the problem. If my words were going to be taken as criticism, then so be it. That at least would get his attention and that’s what I needed.

I also knew our doctor/patient relationship would be different from that moment on—maybe even come to an end. But I had to speak the truth and let the chips fall where they fall. I was concerned that the reaction to my “criticisms” was going to be negative, so I planned to tell the doctor to not take any notes (and no recording of the meeting, which was done, with my permission, at the first two appointments), so there would be no record of me criticizing what he was partially responsible for. I wanted to inform him of the sloppy procedures being used without anyone else knowing I was complaining. I figured the doctor would awaken to the problem and proceed to fix it himself if he was the one getting the credit. I knew the meeting would be difficult.

I couldn’t have cared less that someone knew I was complaining, but I knew that if the doctor initiated changes, it’s more likely that they would happen than if the doctor told others in the office that he was making changes because a patient criticized their procedures and why. That would make him look bad and it wouldn’t end well.

I Tell My Doctor What I’ve Learned

When I went to my next appointment, which was for an annual physical, I told the doctor’s assistant in the beginning not to take my blood pressure, but that I wanted to talk to the doctor first. The assistant left the room, and the doctor came in a little later. I proceeded to tell the doctor my experience. Even though I planned out everything I was going to say, the meeting didn’t go as planned, and it was a bit of a confrontation. But so be it.

I left the doctor’s office and never returned. And I knew that I would never want to see him again or deal with his medical group again (although there were other reasons I didn’t like the company), not only because they had sloppy blood-pressure-measuring procedures, but because too much had passed between us to have a viable relationship. This all happened in 2023. Time will tell if I hear of any changes to their procedures. But how would I know anyway? It’s not like it’s public knowledge, and I doubt they want this information public.

My next plan was to do what I can to let the public know what are good blood-pressure-measuring procedures, both at home and in a medical office. My research has shown that there is a trend in the national medical organizations, like the AMA (American Medical Association), to get doctor’s offices to improve their procedures. I wrote about this above and I will repeat it here. For a long list of articles, written for doctors on how to properly measure blood pressure in their offices, go to: https://www.ama-assn.org/search?search=measuring+bp

In Conclusion

Was I accusing my doctor and EZX Health of doing something wrong? To a certain extent, yes. But I am accusing them, along with much of the medical community, of what I see as a practice that is common across the country: Sloppy procedures for taking blood pressure readings in medical offices that could lead to prescribing unnecessary medication—besides misleading a lot of people who worry about their blood pressure.

My doctor and EZX Health are not unique in this. “Everybody does it.” It is, at the very least, quite common. And why do I think it’s common? Not just because of all my experiences in doctor’s offices, but also because I found that the internet was strewn with hundreds of articles, forum comments and YouTube videos—all saying the same thing. And that includes national medical organization websites. If anyone wants to learn more, then spend some time on a blood pressure forum, like the one on Reddit.

Forums taught me how misled and upset people are because of the mass confusion of how to measure blood pressure properly, and how many people think they have “white coat syndrome,” although it’s often because of poor measuring procedures both at home and in medical offices. Well, many don’t have that “syndrome,” and I blame the doctors’ offices for promoting this fantasy, which has resulted in them looking innocent and the patient guilty. 

When my doctor commented that he thought you get more reliable readings at him with good procedures, I thought: Most people trust that procedures in a doctor’s office must be good, because they are experts, so they go home and copy those procedures, thinking they are correct. They might get lower and better readings at home because they aren’t in a medical office, but if they copy the doctor’s procedures, they still aren’t going to get reliable measurements. This so obvious, it makes wonder who is thinking this through.

At one point, my doctor suggested I bring in my monitor to compare it to theirs to see how accurate it was. The one I purchased was new, and it was a validated monitor listed on the AMA’s monitor validation website (www.validatebp.org). But if I can’t trust the doctor’s office to use proper procedures, it makes me suspicious that their equipment might not be up to date too. Bad procedures generate distrust on other issues.

To expose the problem, my goals were quite simple: 1) To clear the air on what my blood pressure was; and 2) To make my doctor aware that the BP reading procedures being used in that office are extremely poor. I’m not sure how much he was aware of this, but if he wasn’t, then why wasn’t he? Plus, I know that he was relatively new to EZX Health (a large company financed by venture capital) and maybe he didn’t know how bad the procedures were. But he had told me that he had been practicing medicine for 19 years.  I thought of the AMA doctor who was quoted in the above article, “27 Sources of Error in Blood Pressure Readings,” who stated that doctors need regular retraining too. Of course, if he knew the procedures were that bad, that’s even worse. That’s where he stands now if he does nothing—IF he takes my criticisms seriously. But I believe the procedures are the norm in many offices. Consequently, I don’t entirely blame the doctor. I hold the entire American medical community, EZX Health, and doctors, including this doctor, responsible. They all share the guilt.

What amazes me most as I look back on all this is how casually the assistant at my doctor’s office measured my blood pressure. The last time she took it was when she had asked me if I wanted her to measure it after the doctor met with me. It was about a minute after the doctor left the room. She rolled in a wheeled stand that had the monitor on it, stood in front of me, put the cusp on my left arm which was hanging straight down from my chair (which didn’t even have armrests—which would not have been high enough anyway) and turned the machine on and read me the numbers. No care was taken in the tightness, nor in the position, of the cuff—nor in the height of the cuff in relation to my heart. As I later learned of the 27 ways measuring can get false readings, I wondered if her instruction had lasted five minutes, because it was worthless in my opinion—after I learned what is a good procedures.

How Did We Get Here?

How did the medical community get to the point where poor blood pressure measuring procedures at the doctor’s office have become common? Even the AMA has created a web page for fixing this issue. The doctor that I dealt with was convinced that “white coat syndrome” was the probable cause of high blood pressure readings in their office and that home readings were better indications of blood pressure levels. But he wrote on my appointment summary: “Please continue monitoring your blood pressure at home using your Omron device and follow proper procedures for accurate readings. He never asked about my procedures, so how he could he know? It’s this kind of attitude that is clueless and led to where we are at. I still cannot believe he made that statement.

Where do we go from here?

There are two issues:

1. What should the patient do if they run into poor procedures? First is to study the issue and be certain. And if you can’t do that or don’t have the time to do that, then question the doctor, but that’s not easy. You could send them a link to this article, or to other information sources. But you must not let them lead you into thinking you have high (or low) blood pressure if you really don’t. And you can also do what I did and buy a blood pressure monitor, and then study how to read your blood pressure (and read what I did in this article), and then tell your doctor.
2. What should the doctors do? They obviously need to clean up their procedures and make them excellent. And they should also train patients how to properly measure their own blood pressure. Maybe even sell monitors to patients at an affordable price, making sure they are approved devices and creating a connection between the doctor and the patient that can be reliable.
   1. To improve their procedures, doctors can go to the AMA web page designed for that purpose.
3. Improve training of the doctor and all medical personnel drastically—and keep the training updated 1-2 times a year. This was recommended in the article above (“27 Sources of Error in Blood Pressure Readings“.

How I Suggest They Improve the Medical Office Procedures Immediately

I created this section because I think doctors and companies they work for will complain that they need time and money to make the necessary changes. But I think the below changes could be done quickly at very low cost and gain a lot of value. Of course, a long-term plan will be necessary, but these suggestions will get things done now.

1. Retrain all medical office personnel ASAP and make sure blood pressure cusps of different sizes are easily available.
2. Create a setting where the arm with cuff on it can be put at the correct height easily. For example: a height-adjustable table, or a table with pillows to raise the heights for different people.
3. Make a checklist sheet of paper to be used every time a patient has their blood pressure tested
   1. Put the patient’s name on the checklist, with date and time and the person doing the reading.
   2. The checklist should include questions that the medical person need ask the patient (eg, “Do you need to take a pee, as it will effect your blood pressure reading?”)
4. Have the medical person sign and date the checklist and the doctor should review it shortly after the reading, and then the doctor should sign it
5. Notes to the person doing the reading should be on the sheet, that says:
   1. “Never say to that patient that their blood pressure is high, low, good or bad. Only tell the patient the numbers. (This is because one never knows a person’s blood pressure, but only the numbers that were measured at that time and in the patient’s current environment and situation.” The doctor can discuss the numbers with the patient.
6. Strive for perfection and make all personnel proud that they are using correct procedures.

Spreading the Word

Because of all this, I have decided to make it a mission of mine to make patients, doctors and medical workers more aware of proper blood pressure measuring. I know that doctors (and most medical workers who received good instruction) were instructed at one time on how to properly measure blood pressure, but as quoted in the above-referenced AMA article (“27 Sources of Error…”) regular retraining is required because, “skills in blood pressure measurement decay over time.”  

Overall, the good news is that I learned about all this and now know that poor measuring procedures at the doctor’s office can lead to false readings that could lead to unnecessary blood pressure medication. Because I’ve learned this, I have published this article on the internet. Plus, I will also go on forums to spread the word about proper procedures.

In this article, I have decided not to disclose any details, not even the state where I had the experience, besides not mentioning the date or any names involved.  Why? Because people often become the targets in bringing about change, and ignore the real problem, which in this case is the processes. It’s best to attack the process and not people. I don’t want to ruin anyone’s reputation if all they are is just ignorant of what’s going on in their offices, although their ignorance can also lead to some bad consequences. And I don’t want to spread rumors about anyone or any group. I want to right a wrong. *

I didn’t tell the doctor about the problems I had with their procedures so they would change how they measured my blood pressure. I told him so they would change them for everyone who came to his office. Plus, I wanted the doctor to understand the problem from the patient’s point of view, including mine. 

Links to Online Articles, YouTube Videos and Studies on Measuring Blood Pressure

Below are links that helped in my research to understanding how blood pressure is measured at home and at a medical office. You can get good measurements and bad measurements depending on the procedures used in both locations. A general online search with the text ” measuring blood pressure ”  will bring up thousands of links .  I always suggest being cautious with the “AI” (Artificial Intelligence) results in Google searches. It sometimes brings up false results. For a list of many YouTube Videos, just go to YouTube.com and search for Measuring Blood Pressure. There are hundreds (maybe thousands) of videos on the subject for both medical office and home measuring.

Below are links I found with short descriptions.

Keep in mind that no single source is 100% accurate. I spent hours researching. If you want to get the best quick advice, then watch the YouTube videos below in the order they are listed. All taken together, they will give you excellent information.

Measuring Blood Pressure at Home and in a Medical Office — YouTube videos

• This is one of the first videos I found: The Cooking Doc – The Right Way to Check Your Blood Pressure at Home – A Doctor Explains  . This is a great video that’s clear and easy to view. It was one of the first resources I found that opened my eyes to the truth about measuring blood pressure, both at home and in a medical office
• This is another video by a doctor who discusses 11 Mistakes in Measuring Your Own Blood Pressure .  In the video he discusses how to properly measure blood pressure and also gives you an idea of much a mistake can change the BP reading. And another excellent, easy to understand video.
• The Best Times to Measure Your Blood Pressure. The title says it all.
• Why You’re Not Getting Correct Blood Pressure Readings. A great video showing how mistakes can be made in a medical office and at home.
• AMA web page directed to doctor’s who want to implement correct procedures in their offices. The page description: “These tools and resources are designed to help your practice improve blood pressure control for all of your patients.”
• When to Measure your blood pressure
• American Heart Association: How to accurately measure blood pressure at home

Miscellaneous Blood Pressure Information

• First of the two links listed in the above article on studies done in the medical community on improving measuring procedures in medical facilities. This was a 1995 study in a hospital.
• Second of the two links in the above article. This is a short article by the American Medical Association, stating there are 27 ways a measuring can give false results.

Below are links that are not directly related to blood pressure measuring procedures, but are related to blood pressure in general

• High Blood – Pressure Why We Shouldn’t Worry About the Number . This is a video that’s related to blood pressure, but not so much about the measuring process. I post it here because I ran into this in searches and found it important.

Notes:

*And to this day, as this article gets published a few months after I complained to the doctor, I have never told one person about what happened.  This is because I don’t want to spread any rumors, which can lead to negative, unintended consequences. And I have no idea if changes were made at my doctor’s office or the organization that he worked for, since I no longer deal with the doctor or their company. But I bet changes are being made. Most doctors’ intentions are totally honorable and sincere, and in my case, I think I shocked the doctor enough with my criticism that I got his attention—which is what I was hoping for.