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RUNNING HEAD: THE WHITE COAT HYPERTENSION PHENOMENON
White Coat Hypertension: Doctor-Patient
Communication and Physiological Outcome
Kathleen Deegan
Bloomsburg University of Pennsylvania
Undergraduate Student Paper
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RUNNING HEAD: THE WHITE COAT HYPERTENSION PHENOMENON
Abstract
This literature analysis will examine the modern evidence of White Coat Hypertensio (WCH),
which is defined as a significant increase in blood pressure that a patient experiences in the
presence of a medical professional (Chung & Lip, 2003). It will cover the varying definitions that
have been attributed to this phenomenon, and will examine the health risks associated with this
phenomenon’s prevalence in hospital visits; including: the development of chronic hypertension,
increased likelihood of experiencing cardiovascular complications and disease, and
hypertension-targeted organ damage over time (Standberg & Stalomaa 2000). The analysis will
also examine the many unanswered questions about the phenomenon; as well as highlight the links
amongst blood pressure, stress, Cortisol levels in the body. Using this information, this paper will
also propose an alternative form of research regarding the associations between patient-doctor
communications and WCH. Assuming the associations that high blood pressure and cortisol levels
have with the amount of stress felt throughout the patient-doctor interaction, the proposal would
support the argument that there is a positive correlation between poor communication skills
performed by the medical doctor, and the likelihood of experiencing WCH.
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White Coat Hypertension: Doctor-Patient
Communication and Physiological Outcome
Virtually anyone who has worked in a health care facility has heard of the White Coat
Phenomenon, also known as White Coat Hypertension (WCH). This has been researched and
defined in a variety of ways by both medical professionals and scholars (Lipman, 2013). In fact,
contradictory results have been suggested about the phenomenon that has left it up for speculation.
For example, some studies suggest that the implications of WCH are not as severe as permanent
hypertension, making it an area of lesser concern (Ardeleanu, 2011). Yet, various other studies
have suggested a link between those who experience WCH and cardiovascular complications,
including the development of permanent hypertension (Parati, 2000; Tsai, 2002). Therefore the
phenomenon itself has been largely overlooked and misinterpreted, and led to false-diagnosis by
medical professionals (Tsai, 2002). Specifically, this paper will examine the possible risks of
WCH that are continually experienced by patients in a clinical setting. Likewise, it will propose a
potential cause of WCH should be more prominently studied.
Defining WCH
Though there are various ways that White Coat Hypertension has been defined, throughout
decades of research, WHC can be generally defined as a significant increase in blood pressure that
a patient experiences in the presence of a medical professional (specifically a medical doctor), in a
clinical setting (Chung & Lip, 2003). The phenomenon is considered to be effective on both those
who have been treated for hypertension, as well as those who are considered to be “normotensive”
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RUNNING HEAD: THE WHITE COAT HYPERTENSION PHENOMENON
(Tsai,2002; Bang, Høegholm, Holm, Kristensen, & Nielsen, 1994) . A normotensive individual’s
blood pressure would register within the "normal" or "healthy" range, outside of a clinical setting.
In other words, a normotensive individual’s systolic pressure would ordinarily register at less than
or equal to 130 mm Hg, and their diastolic pressure at less than or equal to 80 mm Hg (130/80)
(Tsai, 2002). However, when consulting with a medical doctor, these normotensive individuals
would show a similar reading to a person suffering from hypertension, which is considered to be
anything equal to or above 140/90 mm Hg (Cheung, Lam, Lau, Man, & Ong, 2004).
Risk Factors
Various studies examine the effects of WCH. Some medical professional and scholars have
considered the phenomenon to be "benign", or even consider it to be a "Cinderella syndrome"
(Chung & Lip, 2003). However, empirical studies provide evidence of the prevalence of this
phenomenon and have suggested the link to cardiovascular implications (Tsai, 2002). For
example, research has concluded that the long term effects of those who experience WCH can lead
to many health complications. In other words, WCH may be a direct risk factor for the
development of persistent hypertension, an increased likelihood of experiencing cardiovascular
complications and/or disease, and long-term hypertension-targeted organ damage; such as,
damage to the kidneys (Tsai, 2002; Standberg and Stalomaa 2000). In fact, a twenty year
follow-up study demonstrated that 68% of those who experienced white coat hypertension, while
experiencing normotensive non-clinical measurements, later became hypertensive (Ohkubo,
Kikuya, & Metoki, 2011).
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Similarly, other experimental studies have demonstrated that WCH may be a direct cause
of Left Ventricular Hypertrophy (LVH) (Glen & Elliott, 1999). LVH can be associated with a large
volume increase in the left ventricular mass of the heart. This will cause left ventricular portion of
the heart to do an overload of work, to compensate for the volume increase, and possible lead to
serious health problems; for example: a myocardial infarction, or heart attack (Gardin & Lauer,
2004). Considering LVH, along with all the previously listed complications with the
cardiovascular system, and organ damage that are associated with this phenomenon, makes it
imperative that WCH remain a topic of discussion.
Other Altercations
Although research suggests that White Coat Hypertension is expressed in as many as 10% to 30%
of patient hospital visits, there are still many questions that remain unanswered (Donahue, 2011).
For example, little research has been done in regards to how many people are falsely-diagnosed as
hypertensive, due to their experience of WCH. Yet, it is clear that there is an over-diagnosis of
hypertension associated with the phenomenon (Clemow, Ogedegbe, Mostofsky, Pickering,
Schwartz, & Spruill, 2007). This also leads to unnecessary prescriptions being filed for
anti-hypertension medication, which in turn may contribute to unnecessary medical costs. In fact,
in an individual study of 255 patients that were diagnosed with persistent hypertension, 21% were
found to have only been experiencing WCH, and did not need to be prescribed anti-hypertension
medication (Ernst, 2003). Therefore, an estimate of $110,000 in medical bills would be saved in a
six year period (Ernst, 2003). There is also little research on the effects of repeated exposure to
doctor-patient clinical exposure on WCH, and what effective strategies can be used to minimize
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the exposure to WCH.
Relationship: Blood Pressure, Stress, and Cortisol
As previously stated, a hypertensive blood pressure reading of 140/90, or higher, is
associated with a variety of health complication; such as: chronic hypertension, cardiovascular
complications, and various others (Parati, Ulian, Santucciu, Omboni, & Mancia, 2000; Tsai,
2002). However, acute hypertension may also be associated with the body’s response to
challenging or threatening stimuli, such as stress (Floyd, 2008). Previous research has created
association between stress levels in the patient-doctor interactions, and the WCH that is expressed
in a clinical setting; commonly suggesting that the authoritative role that is attributed to a doctor’s
presence, and the potential for the baring of bad news can be associated with the clinical stress
levels that cause the sudden increase in blood pressure (Field, Mccabe, Schneiderman, and Skyler,
1991). Other studies have suggested that the period of time that the patient is talking about a
stressful health topic, to their physician, is the point of highest increase in blood pressure during
the clinical visit (Pailleur, & Vacheron, 1996). These examples, in turn, demonstrate a link
between stress and clinical blood pressure levels.
Similarly, stress is associated a release of the adrenal hormone, Cortisol, and is associated
with the body being forced out of its homeostatic balance. (Katan, 2010). When the body is
exposed to stressful stimuli, Cortisol is expected to be released in the body and blood pressure is
increase (Floyd, 2008). Therefore, in times of stress, blood pressure increase is expected to have a
positive correlation with an increase in Cortisol levels that are excreted (Floyd, 2008).
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Furthermore, studies have also shown that the peak in Cortisol levels is at the earliest point in the
day, as well as twenty minutes after a stressful stimuli, such as a hospital visit (Ockenfel, Porter,
Smyth, Kirschbaum, Hellhammer, & Stone, 1995; Floyd, 2008) Given the correlations between
stressful and hospital experiences, the following section proposes a research study that would
enhance the understanding of the White Coat Hypertension phenomenon and possible implications
of the subjects.
Proposed Study
The proposed study will test the correlation between doctor-patient communication skill,
and the salivary Cortisol level and blood pressure of patients in a clinical setting. This study is
based on the assumption that medical doctors with poor communication skills would be a
contributing factor to the experience of White Coat Hypertension. This would mean that the
hypertension that the patient is experiencing is in some way correlated to the effective or
ineffective skills that a doctor displays when relaying information about anxiety-filled, stressful
topics relating to the patient’s health. This study is aimed to determine whether patient-doctor
communication could be, in any way, altered to be more beneficial to a patient’s health.
Sample
The participants in the study are between the ages of 18-75, and responsible for their own
health-finances. Participants will be eligible to participate if they have not previously been
diagnosed with chronic hypertension, and have had at least one previous experience with WCH.
The study will not have a preference to sex or race, due to a random selection process. Finally,
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participants that are eligible for this study will be having an extensive consultation with their
doctor about a severe medical concern, which could potentially result in their admission into the
hospital.
Method. A sample of 500 patients would be throughout a 12 month span in a previously selected
clinical hospital. The patients would be informed that their participation is required to gain further
knowledge about blood pressure and Cortisol elevation, while consulting with a doctor.
Participants will be asked to stay after their consultation and fill out a questionnaire but will not be
informed of its context.
Patients will be asked to not eat or drink an hour before their appointment, and arrive
twenty minutes prior to their appointment in order to provide a sample of whole saliva. All
appointments will have previously been scheduled in the mid-afternoon, in order to avoid any
experimental errors relating to their diurnal rhythm of Cortisol, which has been proven to be at its
daily peak at the beginning of the day (Ockenfel, Porter, Smyth, Kirschbaum, Hellhammer, &
Stone, 1995). Each patient would also be required to have their blood pressure monitor within 15
minute intervals, throughout their entire consultation. About twenty minutes after their
consultation, each patient would be asked to provide another whole saliva sample for a salivary
cortical test, post stressful stimuli. Finally, each patient will be asked to fill out a questionnaire, on
a likert-scale, of how they felt their doctor’s communication skills were. For example, each patient
would be asked on a likert-scale of 1 being “completely agree, and 5 being “completely agree”,
that: “I felt that my doctor was empathetic to my situational needs”. Based on the results, these
patients would then be separated into groups, categorized by their general emotional opinion of
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RUNNING HEAD: THE WHITE COAT HYPERTENSION PHENOMENON
their doctor’s communication skills. The groups would then be analyzed and compared to one
another; looking for distinct difference between doctor-patient communication skills, and their
effect on their patient’s average blood pressure and Cortisol level results.
Results
Expected results would be a positive correlation between those who generally reported that
their doctor had poor communication skills, and those who had the most significant increase in
blood pressure, and Cortisol levels after their consultation. Therefore, it would be expected that the
patients who thought poorly of their doctor’s communication skills, would have a blood pressure
that registered as hypertensive (>140/90) throughout the consultation. Likewise, these patients
would have also had the strongest color results on their salivary Cortisol test. These results would
be expected due to the idea that when involving a health concern, poor doctor-patient
communication skills would result in a heightened feeling of stress and anxiety, by the patient;
resulting in the increased hormonal release of Cortisol, and an increase in state blood pressure.
Similarly, those who felt positively about their doctor’s patient communication would feel more
relaxed and comforted about their medical situation, and therefore have a less dramatic increase in
blood pressure, and Cortisol secretion.
Conclusion.
This study could induce further research on the impact of doctor-patient communication.
These findings might suggest that doctors be required to build their cognitive complexity in
situation of stressful health matters. This may, in turn, increase doctor-patient relations, decrease
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effects of WCH, and ultimately increase the patient’s overall health, care, and satisfaction, which
is a primary goal of any healthcare facility.
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