How to say no

With the rise of direct-to-consumer advertising and the easy availability of medical information on the Internet, it's more common than ever for patients to come to a doctor's appointment with specific requests for treatment or tests, and expect to receive them. But what if “Dr. Google” has pointed a patient in the wrong direction, or an aggressive TV ad campaign has piqued a patient's interest in a drug that's not quite right for his or her condition? It can be difficult to say “No” to patients, even when you believe doing so is in their best interest. In our cover story, Charlotte Huff looks at how doctors can consider testing and treatment requests and refuse those that are inappropriate without harming the doctor-patient relationship.

Once a relative new kid on the block, the metabolic syndrome is now more widely recognized, but it's still the source of some clinical controversy. Some experts believe metabolic syndrome is a vital diagnosis that allows clinicians to hone in on effective treatment, while others maintain that managing its individual criteria, such as hypertension and increased waist circumference, is more important than what you call them. Paula S. Katz sorts through the available evidence, including the role metabolic syndrome plays in new guidelines on secondary stroke prevention from the American Heart Association, and offers advice on how to achieve treatment success no matter which approach you choose.

This issue also includes two articles on dealing with hypertension, both in the office and out of it. Research has shown that measuring blood pressure at home rather than at one point in time in the office leads to better adherence to and less intensive use of antihypertensive medications. Stacey Butterfield's report from the American Society of Nephrology's annual meeting offers advice on what type of blood pressure monitor to use, how often to use it, and how to interpret results. For details on a group visit approach to managing uncontrolled hypertension, read our Success Story, which focuses on the Michael E. DeBakey Veterans Affairs Medical Center in Houston.

How do you handle patients with uncontrolled hypertension in your practice? We'd like to hear from you. E-mail us.

Jennifer Kearney-Strouse