Wrong Diagnosis

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 All the best evidence protocols are worthless in the face of the wrong diagnosis. With the efforts to standardize medical treatment, reduce costs and enhance patient safety, planners pay little attention to missed or wrong diagnosis. Disease in my formal medical training was defined as a maladaptation to the environment, and at some level, indeed it is. Medical science and the physician’s art define the causes of that maladaptation as a diagnosis or syndrome. Unfortunately many diseases have common signs and symptoms. The body has a limited number of ways to respond to disease and there are so many diseases and syndromes – more than we can remember.  The identification of a diagnosis, therefore, may be uncertain at best.[1]  

Two thousand four hundred and fifty years ago Hippocrates confronted the challenge of diagnosis with terms meticulously describing the manifestations of disease. His precise descriptions and inductive reasoning lead to the abandonment from mythology in diagnosis and from the concept of disease as a punishment by the gods. His diagnosis was correct in that it was a precise description of its effect.

Today, however, with far greater knowledge of pathophysiology we struggle with identifying the cause of our patients’ problems. We try to identify the diagnosis in order to relate a treatment plan that is safe and yields a prognosis favorable to the patient.  What is the problem? With what little research there is on wrong diagnosis and missed diagnosis, we find up to a 20% error rate. Autopsy findings prove error rates much higher. In some cases, such as pulmonary embolism or aortic aneurism, the error rate runs as high as 60%[2] Outpatient ENT errors run high as well and most hospital admissions for pneumonia are signed out as community acquired pneumonia unidentified.

Many causes lead us to submit an erroneous diagnosis. Perhaps the greatest problem is the number of layers of cause and effect that we deal with. Is it a gross diagnosis or a tissue diagnosis or tomorrow a bio-molecular diagnosis – even genomic?  Is it left lower quadrant pain, a left ovarian mass, a corpus lutein cyst, a seromucinous cyst adenocarcinoma and if the later, what proteinomic predisposition?

Autopsy has gone out of style. Two hundred years ago Marie Francois Bichat wrote over his autopsy room in Paris, “Death comes to the Aid of the Living.” The abandonment of autopsy must be economic. Maybe insurance companies refused to pay for it. Patient’s families have always objected. The hospital does not want the responsibility. The pathologist finds it a low marginal return activity. For whatever reason, autopsy -- except for forensics -- seems a lost art. We find clinical pathological conference and morbidity and mortality conference replaced by the x-ray conference. With the abandonment of autopsy we have lost the gold standard for definitive diagnosis.

The CAT scan has replaced the autopsy in an intellectual sense, and that is all wrong. The CAT scan is expensive, far more so than an autopsy and is by no means definitive at the tissue, cellular and molecular level. Although X-ray conferences are contemporary, and bring together multiple specialties and the diagnostic suggestions of the group, they still may still fail to yield the right answer. CAT scans done extensively in place of careful differential diagnosis and basic cognitive disciplines cost the patient and the health care system enormously. With an initial wrong presumption the addition of added unnecessary tests and procedures lead to decreased patient satisfaction, safety and poorer outcomes. --- “First, do no harm!”

Patients are different. There molecular biology may be as varied as their noses. Statistically derived presumptions, may fail to account for geography, ethnicity or individual circumstances. Additionally, the physician may decline to write a diagnosis that may cause the patient to be ineligible for insurance, induction into the military or some other sensitive job such as hospital privileges for a doctor or class I medical for an airline pilot. These are usually minor omissions, but together they deny any meaningful analysis of a database based on the diagnosis.

Our very regulations seeking standardized care may cause a more insidious error rate based on the diagnostic requirement for laboratory or other diagnostic studies. The same may apply to treatment plans – a treatment looking for a diagnosis. A similar diagnostic distortion occurs, when the diagnosis is altered or selected for reimbursement purposes. Hopefully these alterations are harmless to the patient, but in some context can lead to a wrong presumption in a future event that misses a lifesaving solution.

Overconfidence, assumption, snap diagnosis and omission of essential parts of the history and physical contribute to errors as well.[3] We do not keep statistics on wrong diagnosis, but the trial lawyers do, and they can tell us something.  Graber et al chronicle the size of the missed diagnosis problem which results in between 40,000 and 80,000 deaths a year in the US. The problem may actually be greater.[4]

Cognitive scenarios as presented by primary care specialty boards, the review of systems together with listening to the patient, a complete history and physical at least for the organ system involved will go far. But the association of findings with the vast number of possibilities suggested by these findings presents a challenge to the clinician. It is a challenge that medical schools can meet with appropriate lists, current terminology and criteria for diagnosis  -- most of all a vigorous CME program. Johns Hopkins will hold a conference on wrong diagnosis this month.[5]

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[1] Delaney; Munro: Diagnostic difficulty and error in primary care; Family Practice 2008; 25 (6) 400-413

 

[2] Berner, Graber; Overconfidence as a cause of diagnostic error in medicine; Am J Med 2008;121: S2-S23

 

[3] Bringing Diagnosis Into the Quality and Safety Equations; Graber ML; Wachter RM, Cassel CK. JAMA. 2012; 308(12): 1211-1212.

 

[4] http://newsatjama.jama.com/2012/09/25/author-insights-diagnosis-error-is-ignored-as-a-quality-and-safety-measure/

 

[5] http://www.hopkinscme.edu/CourseDetail.aspx/80028747

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Misdiagnosis

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A review of the literature published in the Green Journal[1] Table1 lists diagnostic errors by clinical condition from various studies. Striking among them, ruptured abdominal aortic aneurysm was missed 61% and dissecting thoracic aneurysm 35% of the time. The radiologist missed breast cancer on the mammogram 21% of the time. The initial diagnosis of bipolar disorder was wrong 69% of the time. Among patients with fatal pulmonary embolism, the diagnosis was unsuspected 55% of the time. Psoriatic arthritis was missed or wrong 39% of the time. Amazingly, the machine EKG missed atrial fibrillation in 35% of the tracings and the reviewing clinician failed to pick it up in 24% of those.

In my own observation, misdiagnosis is rampant among less threatening clinical conditions especially those offered from outside of the relevant specialty among specialists, as well as the more unusual conditions encountered by primary care physicians. It is not uncommon to misdiagnose various forms of sinus disorder, otitis and respiratory disease. Pneumonia too, while recognized as such often lacks a credible etiology -- due in part to less scrupulous sputum collection and identification by microbiology. With a multitude of causes, pneumonia may be diagnosed by circumstance such as community-acquired pneumonia and treated with a high percentage antibiotic for the so-called community acquired condition.

Trial lawyers claim that the first physician misdiagnoses cancer 45% of the time -- probably not an overstatement.

Medicine is both an art and a science. Some physicians lean so to the side of art that they lay claim to the diagnosis itself. When they “make a diagnosis,” that diagnosis is laid in stone. The treatment, whether appropriate or not, is credited with the success whilst the body cures itself with or in spite of the treatment. So much is the body’s responsiveness to caring, faith and encouragement that the placebo effect is real. Thus, the patient’s response reinforces the physician’s self-confidence and further obscures misdiagnosis.

Then too, there is the right treatment for the wrong diagnosis, often developed over time based on experience, the outcome may be quite effective – or just an accident. Was this how a drug for Parkinson’s came to be effective for influenza, how an anti tuberculosis drug became effective for depression, or how a depression medication came to be effective for pain.

Diagnosis too is like an amoeba; it changes with passing specialties, fashion and even science. Current medical terminology changes as if with the weather, placing a slightly or even a profoundly different slant on the basic concept of pathophysiology and today a new understanding of the basics of disease through advances in molecular biology.

I’ve made the point now so often that is a cliché to add the distortion in diagnostic records produced by insurance clerks. Seeking to submit only the diagnosis that claims processors will accept for reimbursement, the insurance database bears little relationship to the actual doctor’s notes. Furthermore, the ICDMA consistently leagues behind current terminology. Whereas ICDA makes room for acute, sub acute and chronic, it makes little provision for differential diagnosis, presumptive, working or established diagnosis. One can write 3 or 4 digit codes and state the diagnosis simply as chest pain without specific cause or abdominal pain the same way, but in the wisdom of the reimbursement system, a 4 digit code does not garner reimbursement or authorization for further testing. Expediency thus codifies the wrong diagnosis in the accumulated database of medicare, medicaid and other third party claims processing agencies.

A further distortion results from the physician’s reluctance to saddle the patient with a diagnosis, which might cause the patient to lose insurance coverage. The same applies to a prior condition. Sometimes the physician may downplay a frightening diagnosis pending further counseling with the patient. In another case, the physician may avoid the true diagnosis to protect the patient’s confidentiality when a family member or others view or co-pay the insurance claim.
Unfortunately health care planers and even public health base medical policy on this vast corrupted pool of diagnostic data.

Diagnostic errors in hospitals account for 17% of adverse events and 10.5% of adverse events resulted from misdiagnosis.[2] Given that 15% of the time the clinician lists the wrong initial diagnosis, clinical decision support (CDS) – elsewhere called computer decision support system (CDSS) -- makes a lot of sense. While CDS finds its way into most commercial vender based electronic health records (EHR) and internally programed institutional EHRs, very few include diagnostic decision support beyond facilitating the problem list. Wright, Sittig and Ash et al, in the Journal of Informatics (AMIA) list taxonomy of 53 CDS front-end applications taken from a survey of seven selected vendors and four institutions. Only three provide any diagnostic support. Most CDS applications focus on medications, orders, incompatibilities and treatment protocols based on “best evidence.” Obviously, the best treatment protocol applied to a wrong diagnosis does more harm than good. If the clinician lists all of the possibilities as in a differential diagnosis, the list will likely contain the right diagnosis. It then becomes a process of selection and elimination. The final answer may still be in dispute at autopsy but there will be fewer misstatements along the way and a far more credible database. CDS can provide a differential diagnosis along with statical probabilities based on the patient data available. If the CDS contains the criteria for diagnosis and the patient meats that criteria, then the clinician will likely be on the right track. The human mind under the best of circumstances struggles with both memory and statistics. In no way can a computer replace the judgment, the intuition, and the wisdom of a well-educated and experienced physician, but well written database applications can remember it all unerringly, and apply statistical interpretation. Furthermore, to an even higher level of accuracy, the relational database can internally improve its statistical interpretation based on later proven diagnosis and or outcome. Ongoing analysis of internal data amounts to a simple artificial intelligence, but not of the human variety. Therefore, CDS acts as a complement to clinical thinking, not a replacement and an ongoing source of continuing medical education. (CME)

Diagnosis is like an onion, it has many layers. Changing patterns of cause and effect, a long and complex history and the patient’s adaptations both emotionally and physically yield hidden layers. The problem list helps as in problem oriented charting. Still not universally used, it at least provides a list of the elements. Sir Wm. Osler, professor of medicine at the U of Pennsylvania, 1884, Johns Hopkins, 1888, Oxford 1905[3] and the acknowledged father of modern internal medicine, suggested that the physician, in dealing with multiple problems not subscribe multiple diagnoses but rather look for an underlying cause. He also suggested that the physician’s primary role was convincing patients to take fewer medicines; hardly in keeping with today’s `Medicine Wagon` cornucopia of expensive drugs.

Most planners and non-clinicians miss the degree to which diagnosis, treatment and medical knowledge change over time, like an amoeba moving this way and that sometimes rapidly and other times slowly. The changes come with new knowledge, with current fashion and with genomic reinterpretation of the pathophysiology itself.  Furthermore, patients vary greatly as individuals. Geographical regions, even small ones, experience significantly different epidemiological and environmental problems.

Aggregating all of the known diagnoses and syndromes in the World into one database with criteria presents a formidable task. It would have not have been attempted just a few years ago due to limitations in storage capacity. That limitation no longer exists. Accumulating such an open source universal database for diagnostic CDS may go a long way in improving diagnostic accuracy. However, health care institutions and vendors may avoid incorporating a resource sensitive volume of material into their database system.

There are many reasons for the problem of diagnostic inaccuracy.  As mentioned one is the changing criteria and understanding of the etiology of disease with advances in genomics proteinomics and micro-molecular biology. Other problems result from the insurance clerk’s attempt to list a diagnosis compatible with the requirements for testing and or reimbursement. Another results from the snap diagnosis associated with high throughput, efficiencies insisted upon by profit-motivated management. There must be some significant reasons for the dismal ranking of US medicine compared with the rest of the world. Not to beat a dead horse, but a ranking of 36^th in infant mortality implies something more than mal distribution of providers and over-treatment. I submit that diagnostic CDS will go a long way towards closing the gap.
Table 1Diagnostic Error Rates from the literature[4]

Tuberculosis / Autopsy                                       50%

Pulmonary Embolism                                           55%
Aortic Aneurism                                                   61%       
Sub Arachnoid Hemorrhage                              30%
Breast Cancer / Mammogram                            21%
Bipolar Disorder                                                   69%
Appendicitis                                                          18%
Cancer Path                  2-9% GYN;   5-12% non-GYN     
Endometriosis                                                       18%
Psoriatic Arthritis / Standard Patient                39%
Atrial Fibrillation / EKG Machine                       35%
Infant Botulism                                                     50%
Diabetes Mellitus                                                 18%
Chest XR by / ER                                                   18%

                               

 

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[1] The American Journal of Medicine, vol 121 (5A), May 2008

 

[3] http://www.brainyquote.com/quotes/authors/w/william_osler.html

1 Over Confidence as a Cause of Diagnostic Error in Medicine, E.S. Berner & Mark L Graber, m.d. American Journal of Medicine, 2008, Vol 121 S2—S23

Thomas Sydenham 1624-1689

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I give a 1.5 hour lecture next week on the history of medicine. I am not a historian. I got into this while in medical school at the University of Michigan when I was elected to the Victor Vaughan Society, a medical history group that met once a month and in turn presented papers on some person or subject of historic interest. It was truly an elegant gathering; the experiance stuck with me.

I think my most interesting character for next week, outside of Hippocrates himself -- 2,000 years earlier, will be Thomas Sydenham. His father was a gentleman of property, Thomas was born in Dorset, educated at Oxford, A Saxon, Sydenham fought for the Parliament during England’s. Civil War as a cavalry officer. He taught the Hippocratic method: inductive reasoning, virtue, credible signs and symptoms, and differential diagnosis with meticulus attention to the patient.

Sydenham had the gout. Famously, he proclaimed, “gout attacked the rich more often than the poor, and it rarely attacked fools." ---“Those who may choose, may accept the present writer.” -- “If you drink wine, you have the gout…If you do not, the gout has you.”

Sydenham defined many disease entities with their signs and symptoms: Sydenham’s chorea for example. He described the association of scarlatina and erysipelas with chorea and may well have made the association of rheumatism and valvular heart disease.

 

The Future of Medical Diagnosis

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Medicine, the profession struggles with its identity. Will we be physicians in the likes of the great scientist philosophers and humanists since Hippocrates? Or, will we succumb to the trend of commodifying the profession?

Health and Human Services (HHS), National Institution of Health (NIH), Centers for Medicaid and Medicare Services (CMS), Insurance companies, regional Health Information Exchanges (HIE) will mandate certain quality metrics in the Electronic Health Record (HER) and the uniform claims submission process for reimbursement. Programers will likely build these metrics into the software developed by various venders of the EHR. Doctors are familiar with Best Evidence and some of those treatment standards are already appearing in EHRs. A new feature will be Clinical Decision Support (CDS). Best Evidence largely deals with treatment protocols. CDC will deal mostly with diagnosis. What follows is a discussion about how the later, CDS, deals with differential diagnosis, diagnosis and the problem list.

The review of systems (ROS) and the differential diagnosis lie at the heart of the matter and how electronic medical records interface with these two intellectual processes. Each item in the ROS, signs and symptoms related by the patient, becomes critical data in the process to follow. The negative response is as significant as the positive -- maybe more. Each positive response, when confirmed by further questioning, evokes a list. The list is critical as well and might as well be indelibly imprinted behind each data point or on the mind of the physician.

When completing the ROS, one then has a number of responses, each with its list of etiological possibilities. One or more diagnostic possibilities appearing on separate lists tend to point to the underlying problem and contribute to the establishment of a differential diagnosis.

Here is where statistics comes into play. The more often a diagnosis appears on multiple lists and the more completely the signs and symptoms on the ROS fulfill the attributes of a diagnosis, the more likely you are on the right track. However, all overlapping signs and symptoms are not equal and many illnesses have similar symptoms. Furthermore, individual patients seem to have a limited range of symptoms to account for a wide range of possible illnesses. Ongoing and realtime statistical analysis of the differential diagnosis with apparent outcomes and the coupling together of patient data with the vast store of medical information greatly assists in the interpretation. Database mining can provide statistics that the mind cannot grasp. The human mind, however, does far better at final interpretation.

The mindful and highly experienced physician sees the above analysis and assembles a differential diagnosis with a scanning logic. Other physicians have another sort of mind that rather than scanning has a concrete way of thinking. The later demands clear cut answers. Both approaches work but with the same human limitations. Most physicians navigate a differential diagnosis quite well but the process demands a high degree of commitment to the art -- and still is subject to error. There are in fact many missed and wrong diagnoses. Misses are almost inevitably due to omitting the ROS or ignoring one or two of the responses when they do not fit the assumption. Larry Weed[1], the inventor of the problem oriented record (POMR), insists that any positive, not accounted for by the diagnosis, belongs on the active problem list.

Our mind thinks and makes individualized judgments that the computer cannot. The computer on the other hand remembers and does statistics. We do not remember so well and we do not manage statistics well on a large database. We do need to take into account the computer’s future capabilities, however. So far the computer does not think, but IBM's Watkins comes close.

Statistics are limited to the relevant population. Do you depend on statistics developed on a national scale, an international scale or limited to a local population that might be more relative to the patient at hand? I say might be because each patient is a one of a kind individual. The only statistics that matter might very well be the patient's own genomics. The individual genome, despite the nail biting, is falling in price and will soon be ubiquitous. We need to be sure the tests are not sold like snake oil by bathers, naturopaths, charlatans and opportunists.

Arguably, we should do the thinking and follow a strategy in which the computer remembers the data, the lists and analyses statistically on a realtime basis, genomics included. Let the computer couple your precise clinical data with the vast store of medical terminology, nosology, and the salient features of each. The value here is in not missing something and not getting stuck in a wrong assumption. The analysis should present to the physician a credible preliminary differential. With or without assisted memory and coupling to the vast store of medical knowledge, the ROS and of course subsequently accumulated data are the key to patient safety and care. The ROS would of course be only the beginning. The rest of the history and physical examination-- hopefully you did a physical -- would yield further support to one or another of the hypothetical problems suggested by the ROS and your own pattern recognition. From this point on the human brain takes over the thinking with the advantage of the computer's perfect memory and superior statistical skill. The patient remains an individual, however, and will often defy the best of statistics. The physician's thinking combined with an intimate connection with the patient remains essential.

Some would advocate a process in which the computer and pre defined procedures defined by best evidence as written by so called experts take the prime role and relegate the physician to insuring the validity of the data points. The rationale to this approach lies in the frequency of diagnostic error and the never ending expansion of diagnostic and treatment procedures that do more harm than good costing more and more.

Others would say, we need to go back to the physician as the humanist and scientist of old with vast experience and ongoing medical education in a professionally structured society, dedicated to excellence. Today we are at a cross roads. The road to subordination, however, may have already been taken. Whichever path we follow, patient safety, access and consistent in depth handling of the data are primary. The differential diagnosis is critical to achieving anything like the health metrics of the rest of the industrial world.

Summary and Conclusion

 
Physicians and Medical Schools struggle with a conflict between physicians in the classic role of science, art, diagnosis and a newly proposed role in which the physician practices in a role subordinate to the computer, algorithms, protocols, check lists and the authors of Best Evidence.
At the heart of the conflict lies the complex process of diagnosis and the choice of individual treatment. To meaningfully apply the dictate of Best Evidence, one needs the right diagnosis. We suggest that the best application of computers, statistics will be achieved when the computer applies its faultless memory and capacity for data with dynamic real-time statistical analysis not on mass populations but on the internal data at hand. This strategy provides data more relevant to the individual patient. The strategy also leaves the physician and the patient with the choices, the judgment and the mindfulness of that data. The physician thinks, the patient participates, the computer remembers.

Arguably, the critical focal point for achieving the right diagnosis or at least having the right diagnosis in the differential rests with the review of systems, ROS and subsequent physical and laboratory findings. If this data is not complete, including negatives, the diagnostic process is compromised.

When the differential diagnosis depends on the physician’s memory, missed diagnosis often results from initial assumptions. Omission of the ROS, ignoring positive or negative responses and findings when they do not fit the assumption often leads to a wrong diagnosis. An inability to mindfully apply valid associations to literally thousands of diagnostic possibilities lessens the accuracy as well. When the best evidence, derives from mass-population statistical analysis, that analysis may be all wrong for the individual patient.

The direction medical schools point new physicians over the next generation or two will greatly affect the health of our Nation and the outcome for our individual patients. Reducing physicians to mindless gatherers of data and surgical robots leaves the judgment in the hands of a few of necessarily national experts. It stifles scientific advancement. Once you fix procedures and protocols and define best evidence, you have a one shoe fits all situation that may not apply to the individual. You have a static routine devoid of the variety and experimentation that defines the core of the scientific method. The unintended consequences of computer directed diagnosis, best evidence and a unified standard may turn out to be ulterior motives of political, religious, or economic entities driven by greed. Government, the courts, drug companies, insurance companies or the association of hospitals in which we work may inject subtle deviations for their own benefit.

Our further plea is for a continuation of classical medical education with bedside teaching and advancement to even higher levels of medical training. The honor should be limited to those worthy of the privilege in the tradition of the great physicians and surgeons of the past. Further advancement might require all to graduate as PhDs with core competence in genomics and database management. The genomics seems obvious. Medical schools must renew their covenant with patients and local providers serving both in exchange for teaching material, autopsies and CME. There are too many providers and peripheral merchants feeding at the healthcare trough. More physicians relative to population will not help. We have far too many specialists. Less well trained providers will not improve outcomes or meet the needs of our future.

Will we unionize and become nine to five Feldshers who follow algorithms and protocols? Will those dictums of best evidence be out of date or self serving? Will professional behavior be dictated and enforced by political and economic interests? Or, will a renewed pursuit of excellence and medical education put the patient first with the physician directing the tools of health information technology, translational medicine, biomolecular advances, research, science and genomics? The future is ours to grasp.

 

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[1] Medicine in Denial, Lawrence L. Weed and Lincoln Weed April 2011, Amazon

Type Two Diabetes (T2D)

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Cell 150, 1223-1234, 2012
Domenico Accili at Columbia studying the mouse Foxo1 gene discovered that pancreatic Islet β cells do not die in type-two diabetes (T2D) but revert back to endocrine progenitor cells that are unable to make insulin. This opens the possibility of treating T2D by turning these dormant cells back to normal. Once more an exciting contribution from genomics.

BRCA

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According to retrospective studies of three nationwide cohorts in Europe, young women with BRCA1 and BRCA2 are at greater risk from diagnostic radiation. Any exposure before the age of 30, increased breast cancer risk 90%. In another study reported in BMJ, any mammography before the age of 30 raised the risk by 43% (question of statistical significance?) The American Cancer Society recommends MRI screening for BRCA mutation carriers. No mention was made of physician breast examination.

Mammography suffers in silence from a lack of sensitivity. Women are given to believe that mammography will protect them whereas it occasionally misses the diagnosis of a palpable lesion. In my practice, it angered me to find four patients with negative mammograms who came to me with palpable lesions much further advanced than they might have been but for a simple breast examination. Admittedly, four in my practice was probably a skewed series. The women involved, however, would not think so.

Sadly, today women are reluctant to remove their clothing for examination and providers are all to happy  to forgo the challenge out of expediency and for the sake of time. It comes to a sad state of affairs when providers and patients look to a machine for a diagnosis --- to say nothing of the widespread abusive application of CT scans.

Flora E. van Leeuwen, PhD, Netherlands Cancer Institute and reviewed by Dori F. Zaleznik, M.D.; Assoc. Clin. Professor of Medicine, Harvard Med Sch.

CDC: 35 Million Americans Have Uncontrolled Hypertension « CardioBrief

CDC: 35 Million Americans Have Uncontrolled Hypertension « CardioBrief

30.4% of US adults (about 66.9 million people) have hypertension.

53.5% have uncontrolled hypertension (about 35.8 million people).

39.4% with uncontrolled hypertension (about 14.1 million) are unaware that they have hypertension.

89.4% with uncontrolled hypertension have a “usual source of health care and insurance, representing a missed opportunity for hypertension control.”

The so called team approach accounts for the missed diagnosis of HT on a consistent basis. Taking a BP in most institutions is relegated to the lowest level assistant’s assistant or to an automated BP cuff that consistently records low readings. This "team approach" fails to give reliable readings.

When administrators make cost saving medical decisions, cutting corners that real doctors would never knowingly cut, a surprising level of negligence can grow unnoticed to a National scale.

I speak in part from personal experience. I’m a teaching clinical physician but old enough to have a number of problems that take me to the doctor’s office, ER or major clinic. Including Cleveland Clinic, I have yet to have my BP properly taken and never by the attending physician.

Assistants consistently ignore which arm to use, take the pressure through clothing, and utterly disregard arm position. I submit that the physician will never know who has HT unless he or she takes the BP themselves, nor will he or she know who is under control and who is not.
The Ophthalmologist can tell you but the assistant cannot. Relegating the BP to apothecaries, bathers and other so called providers will not help either and for the same reason — never mind an adequate HT work-up..