In primary care, the above sentence is all too familiar, and it is the classic tell that this patient’s hypertension will be more difficult to treat. Patients are motivated to treat their illnesses if such illness causes discomfort or impairment. While our patients willingly seek care when something hurts, it seems preposterous to most patients to seek care when all feels well.
We know hypertension to be the “silent killer.” Most patients with hypertension are completely asymptomatic, even at life-threateningly high blood pressure values. So why would it even occur to a patient to check their blood pressure if they are feeling just fine?
The average person does not routinely check their blood pressure outside of a doctor’s visit, so it can come as an unwelcome surprise when told that “your blood pressure is high” at a seemingly routine visit.
When I counsel my patients about their hypertension, I have to be prepared to guide to the path of acceptance much like going through the Kübler-Ross Stages of Grief (Kübler-Ross & Kessler, 2005):
- Denial – See Above. “My blood pressure can’t be high because I feel good” or “Of course it’s high, I’m angry that I had to wait 30 minutes for you!”
- Anger – “See, this is why I don’t come to the doctor. They just want to give you bad news.”
- Bargaining – “I won’t have to take pills if I just lose 10 pounds, right?”
- Depression – “Why should it even matter if I have high blood pressure? My whole family has it, so what is the point of treating it?”
- Acceptance – “You know doc, that medication isn’t so bad. It’s nice to see a better blood pressure number at your office, and my legs aren’t so swollen anymore!”
Going through these stages often takes several visits. Therefore, regular follow-up and reinforcement is key to keeping your patient on track. When the patient knows that you won’t give up, it signals that this issue is important. With enough guidance and support, most patients will get to the stage of acceptance where the corrective work can begin.
Sometimes, a patient will get stuck at a stage, and we never make it to the point of acceptance. In these cases, the patient simply stops following up, or the next time you see them is after their hospitalization from a stroke or heart failure exacerbation. It’s devastating when a patient must learn about the dire consequences of untreated hypertension the hard way. In my experience, this is the minority of patients, but the poor outcome still stings.
For the patient who is willing to walk the path toward acceptance with you, I have found several methods helpful for a more successful journey:
Prove me wrong. When the patient is in denial, I offer them the opportunity to “prove me wrong” when it is safe to do so (i.e. they are not in a hypertensive emergency). I’ll ask the patient to keep track of their blood pressure values and bring them back for review at the next visit. I find that when the patient has to take the blood pressure and record the value, it gives accountability and familiarity.
At one point, blood pressure was just some nebulous figure found only at the doctor’s office. Now, they are familiarizing themselves with this important value in a comfortable setting.
If the blood pressure is consistently running high, it proves to the patient that there is a problem, and they are more motivated to correct it. On the contrary, if the numbers are normal, then the patient helped you rule out “white coat” hypertension. Either way, it’s a win.
Make it visual. When I diagnose a patient with hypertension, I usually will share a metaphor to help explain the concept of blood pressure. Few patients truly understand what blood pressure is and how it affects their body.
I will tell them that blood pressure is the pressure that drives blood around our bodies. I explain that the organs in our bodies need blood much like a flowerbed needs water. When you water a flowerbed, you want to get a hose with just enough pressure to water the flowers, but not so much pressure that you damage the flowers.
I then say, imagine what happens if you take a pressure hose to a flower bed. The high pressure destroys the petals and leaves of the flowers. Yes, the flowers need water, but not at that pressure.
This is what happens to your organs when your blood pressure is too high. Your brain and your kidneys are being sprayed too hard, and they get damaged.
Take the “pressure” off taking medication. Of course, lifestyle intervention is the first line of treatment for hypertension. We discuss more exercise, less salt in the diet, weight loss and stress management.
However, some patients feel defeated if they implement lifestyle changes and their pressure is still high. These patients often see the need for pharmacotherapy as a failure.
In these cases, I share that some of the factors that regulate your blood pressure are within their control (modifiable risk factors) and some are not (non-modifiable risk factors). I describe their non-modifiable risk factors such as age over 65, Black race, male sex and family history (Unger, Borghi, & al, 2020). I assure them that their chances of maintaining a healthy lifestyle are always higher when they practice healthy habits, but they may still need the help of medication to cover those factors outside of their control – and that’s OK.
As clinicians, we are experts in the algorithms and medications used for hypertension management. However, the hardest part of managing hypertension usually starts before the first step of any treatment guideline – it is helping your patient understand and accept the diagnosis.
We must have the patience to partner with patients and navigate the path to acceptance. While the gratification is often delayed, it is a unique honor to celebrate finally getting your patient’s hypertension under control. When my patients come back with a controlled blood pressure, the visit is filled with big smiles and high-fives.
I just hope and pray that our next visit won’t start with, “So doc, I was feeling great, so I stopped my blood pressure medicine.” Oh boy!
Dr. Cooke is a board-certified family physician with Wellstar Medical Group who has a special interest in metabolic disease, women’s health and health equity. Originally from Boston, she is a graduate of Spelman College and Morehouse School of Medicine. She completed her residency training in Family Medicine at Wellstar Atlanta Medical Center.