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Join Alan Lindemann, an obstetrics-gynecology physician, as we explore the fascinating interplay between evidence-based medicine and the invaluable insights gained from individual patient stories. Alan shares his insights on navigating rigid medical guidelines, the art of personalized patient care, and how his expertise has shaped treatment decisions beyond textbooks.

Alan Lindemann is an obstetrics-gynecology physician and can be reached at LindemannMD.com, doctales, and Pregnancy Your Way. Follow him on YouTube, Twitter @RuralDocAlan, Facebook, Pinterest, Instagram @ruraldocalan, and Substack.

He discusses the KevinMD article, “Personalized hypertension care in pregnancy: Beyond evidence-based thresholds.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Alan Lindemann. He’s an obstetrics-gynecology physician. Today’s KevinMD article is titled “Personalized hypertension care in pregnancy: Beyond evidence-based thresholds.” Alan, welcome back to the show.

Alan Lindemann: Thank you, Kevin. Nice to be back.

Kevin Pho: So Alan’s been on several times. Go to KevinMD.com/podcast, go to the search icon in the upper right-hand corner and search for Alan’s name to hear his story in prior episodes. But today we’re going to talk about a case, so let’s jump right into it. Alan, tell us how this story and article came together.

Alan Lindemann: Well, I was reading Contemporary OB/GYN, and there was an editorial by Dr. Spong, who was talking about how nice it is now to have new evidence-based guidelines for blood pressure management, that is, chronic blood pressure management in pregnancy. She was happy to have the new 140 over 90, and she was very happy that the 160 over 110 was gone. The problem is that I don’t think ACOG ever really told us we should wait until somebody gets to 160 over 110 before we treat them. They have said that if we have somebody near labor, or near term, with a blood pressure of 160 over 110, they need to be delivered within half an hour, and that makes sense. The only problem with that recommendation is that it’s not sensitive. In other words, there are many women who would get into trouble way before 160 over 110.

So I thought, “OK, fine. I’m happy we’ve decided to have a new threshold of 140 over 90, but still, what does that mean?” If you want to wait until your patient is 140 over 90, or they come in at 140 over 90 for the first visit, and that is what you require to treat them, then what do you do with somebody who’s 138 over 88? In theory, they wouldn’t be treated under that protocol, but on the other hand, they would have a lot in common with the 140 over 90s. So I’m thinking, “Why do you need a protocol for this? Why do you need somebody else to tell you what to do? Can’t you figure out how to manage this blood pressure yourself?”

My wife was helping me with this, and I wanted to just end it there, but she said, “No, you should put these other patients in there.” So, OK, here we go. This one is from many years ago, in 1981, my first practice, when I was a young, naive doctor. This lady came in with a blood pressure very close to 140 over 90, and I was thinking, “OK, what are we going to do with this? How much trouble are we going to have? Should we treat her?” In those days, we didn’t know for sure whether treating her would help the baby or hurt the baby, or whether what helped the mother would hurt the mother. But I thought, “This blood pressure is too high,” and I was worried about the outcome. In those days we used Aldomet; of course, we don’t use that anymore. But my patient didn’t die. In any event, we kept her pressure right around the 120s over the high 70s or low 80s. She went on to term, and she delivered a nine-pound, three-ounce baby vaginally with good Apgars. So a high blood pressure doesn’t need to end in disaster. You don’t need to have eclampsia or preeclampsia. As a matter of fact, her blood pressure stayed quite stable throughout her pregnancy. So the treatment didn’t hurt her, and it didn’t hurt the baby; as a matter of fact, we have evidence that it probably did them some good. As far as I’m concerned, that’s just using my head.

We have another example, which is the extreme opposite. That’s a lady I was called in on. She had seen a family practice doctor, and her pressure was a little elevated, like 130 over 90. But she was 17 years old, and when I looked through the chart, I could see that her pressure starting out was 90 over 50. She was actually one of the most challenging and sickest people I’ve seen in my entire pregnancy career, and it’s been about 6,000 babies now, with no maternal mortality and no seizures either, no eclampsia. So it’s possible; I know it’s possible. Anyway, I talked to her and said, “We’re not going to get this baby out vaginally. Your cervix is not favorable. We’re not going to do this with an epidural, because it’s just going to take too long, and I’m worried about your blood pressure becoming unstable. So we’re going to do this under general.” We did, and everything turned out fine. The baby was fine, with good Apgars, and Mom did fine. I did give her some blood pressure treatment in the hospital, though. We kept her for an extra day, and I saw her many times as an outpatient, but she did fine. She eventually returned to a blood pressure of 90 over 50, and she was so happy. So these are the extremes of blood pressure management.

Kevin Pho: So before going on, just give us a little context, for those of us who aren’t obstetricians. How common is it for women to come in pregnant with elevated blood pressure? How common is that scenario?

Alan Lindemann: I would say it’s quite common. One of the things we do right in obstetrics today is what we call the preeclampsia model. That means we check blood pressure, we check urine, we check reflexes and of course we check babies’ heart rates, and we talk to moms and listen to moms. Many moms will have some blood pressure elevation, and I think probably as many as 10 percent will have a little bit of preeclampsia, something that we should just pay attention to. In other words: Stop working if you have an extra job outside the home. Stay home. Don’t go to bed, but stay calm, because I think our anxiety sometimes does raise our blood pressure. So I think that if you find these people early enough in pregnancy, and treat them early enough and well enough, you can really manage preeclampsia without having it progress to eclampsia. Like I said, I’ve never seen any eclampsia in the 6,000 patients I’ve delivered.

Kevin Pho: And you mentioned that the American College of Obstetricians and Gynecologists has new guidelines saying that blood pressures above 140 over 90 should be addressed. Let me ask you to clarify, and maybe expand on, those new guidelines.

Alan Lindemann: Well, this actually didn’t come from the American College. It came from a study that Dr. Spong quoted. What they did was treat these people with blood pressure medications, and they found that the outcomes were better in the treatment group than in the control group. But that’s something I knew already, and I think probably anybody with a little bit of common sense could also figure it out. So I’m thinking, “Why do we need a study to tell us these things that should be obvious to us?”

Kevin Pho: So there’s always that tension, right, between guidelines and the art of medicine, the individual patient. And it’s not just in cases of preeclampsia but in pretty much every area of medicine, right? That tension between standardization and the art of medicine. So talk more about that.

Alan Lindemann: Well, thank you for that opportunity. As an old doctor now, of course, they can’t fire me, because I’m retired, so that’s good, and it doesn’t matter whether they take my boards away or not. But I do think there is tension. We’re not supposed to think very much anymore. If we look at the way we’re trained in medical school, it’s more memorizing than it is learning. For example, they’ll teach us on Tuesday that A plus B equals C, and then they’ll ask us on Wednesday, “What does A plus B equal?” That’s not really learning; that’s memorizing.

I also know that we are really in love with evidence-based medicine, and to me, evidence-based medicine is a lot of times taking some iffy number, multiplying it by something to get a whole batch of other iffy numbers and making it have some kind of meaning. But I think the art of medicine is really like looking down through a batch of transparencies and finding the experience you’ve had that most nearly matches the present situation. That’s experience; that’s judgment; that’s discernment, and I think some intelligence. Of course, in the beginning, when you’re in your first year, you don’t have a very thick pile to look through, so you don’t have a lot of experience, but you can still have that. I know we’re not supposed to like the experience of one. I know that’s anecdotal; it’s not, supposedly, good medicine. But I think in the long run, when the rubber meets the road, that’s the way we practice on a daily basis. That’s how we make it through the day. That’s how we take care of our patients.

Kevin Pho: So in your eyes, in your opinion, what is the ideal role of evidence-based medicine?

Alan Lindemann: Well, it should give us at least some guidelines. And yes, I understand this study now says we should treat at 140 over 90. Great, I’m all in favor of that. But the problem I have with it is that 140 over 90 will only fit a certain group of patients, and there will be patients who fall outside that group who need to be treated. For example, the young lady with the 90 over 50: When she got to be 130 over 90, she was in trouble.

Kevin Pho: Do you feel the pendulum has swung too far today toward evidence-based medicine, to the detriment of those individual patients?

Alan Lindemann: I think so. If we look at the way things are happening now, I just read an article yesterday about how we now have sepsis committees. Well, for goodness’ sake, I’ve never had a patient die from sepsis. You have to look at your patient. You have to know your patient. You have to go see them every day, you have to listen to them and you have to take action, the right action at the right time. I sit back and wonder: What’s happening to us, that we need to have our judgment replaced by a crew of so-called experts with somebody in charge? What happened to personal responsibility? When patients came to see me, I felt personally responsible for their outcomes. If they got sick after surgery, or sick after delivery, I was there. I didn’t wait for the neurologist to come in, or the surgeon or anybody. I was the first one there, and if I needed to call in other doctors, I would do that. But we really need a doctor to be responsible for a patient, and we’re missing that. Yes, we have these so-called committees trying to take the place of that, but still, why aren’t the patients’ doctors in there on the front lines, taking care of sepsis?

Kevin Pho: If a physician pushes back against the evidence, against guidelines, in today’s world, what can happen to that physician?

Alan Lindemann: Well, every time you turn around, you’re threatened with some kind of discipline for something or other. So yes, you’re probably going to at least get a visit from some friendly person telling you that you have to behave yourself. Unfortunately, thinking is going out of style today, and in some cases I think it’s even considered bad practice. As somebody who’s always been a little bit outside the box, I’ve had my share of lectures about how I ought to behave. But in the long run, like I said, look at my patients: There are no deaths associated with my patients, and I haven’t even had any serious illness. In other words, I have had no moms with a liver rupture, a liver capsule rupture; no 25-year-old ladies, or even, for that matter, 45-year-old ladies, permanently in a nursing home because of strokes; and no permanent kidney disease. Everybody’s recovered. And I think a lot of that has to do with the fact that I liked my patients and felt responsible for every single one of them. That’s what we need today.

Kevin Pho: What do you say to the proponents of evidence-based medicine who say that these guidelines protect patients from practitioners who practice so individually that their decisions actually harm patients? Because that’s one of the arguments in favor of evidence-based medicine: We want to protect patients from physicians who may practice so far outside the standard of care that they may actually harm patients.

Alan Lindemann: Well, yes, I know that’s the excuse we give for our evidence-based medicine stuff. But in the long run, good results do count for something, and they are, in a way, a defense. Even in a court of law, if you get sued, there has to be a bad outcome; that’s one of the four things you need. So a good outcome is a good defense. Although, certainly, I think one of the things evidence-based medicine is trying to do is make up for doctors who don’t feel responsible for the outcomes of their patients.

There’s a story, and this comes from NPR, about a 33-year-old ICU nurse who died from a stroke at the time of her delivery. There were numerous, numerous times when people were talking about her blood pressure being too high. As a matter of fact, the nurses got so tired of it that they took the monitor off. They said, “We know it’s high anyway, so why do we monitor it?” Well, she had a bad headache, so they were waiting for the neurologist to come in. The neurologist needed to have some medication, and it couldn’t get there for another 12 hours, and in the meantime the patient stroked out and died. Nobody was in charge of her care. So I can understand that you’ve got evidence-based medicine, and groups of people looking at that and saying, “Oh, gee, if we had just had a team take care of this, it would have been better.” The problem with a team is that if everybody is responsible, then nobody’s responsible, and we’re getting back to responsibility again.

Kevin Pho: Alan, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Alan Lindemann: Well, I would say to patients, and, again, we’ve got an audience that’s bigger than patients: If you’re a patient, find a doctor who will listen to you. And if you’re a doctor, listen to your patients. Take everything they say very seriously, whether or not you think it’s foolishness. Take it seriously and listen to them, because, like an old friend of mine said, if you listen to them, they’ll tell you.

Kevin Pho: Alan, thanks again for coming on the show and sharing your story and perspective.

Alan Lindemann: Thank you very much, Kevin. Always nice to be back.