[pachyderm]

This primary care physician asks his young patients about their lives. Is this a good idea? Are there cautions to be observed?

http://opinionator.blogs.nytimes.com...op-span-region

[jelly-bean]

I think the doctor is trying to practice outside his field of expertise. He needs to go back to school and change his field if he wants to do that. I would not want to answer any questions that didn't pertain to the reason I went to him in the first place.

[geis]

If you look for stuff enough (i.e., drug use/abuse), you're going to find it. But I think it's irresponsible to assume that patients are drug users just because they fit into a certain age group. I'm 28 years old, and I've never used marijuana. I can count on one hand the number of times I've consumed alcohol. Yet because I have a mental illness, doctors all too often assume I abuse substances, which I find offensive. Not only that, it often delays getting a diagnosis and treatment for real physical issues that are not caused by substance abuse.

Every time I see my primary care doctor for any issue, his office staff gives me a ten-question depression screening test. It doesn't tell you it's a depression screening test, but I've been around the block enough times to know what it is. I've taken my doctor to task about this because the particular questionnaire he uses is biased against people with chronic physical diseases. Loss of appetite and/or weight loss? Well, yes, I have an autoimmune disease that attacks my GI system, so those are typical symptoms. Lack of energy and fatigue? Yeah, my immune system's so busy attacking my own body that there's not a lot of energy left over for running marathons and such. The steroids, immunosuppressants, and chemo drugs I have to take don't help with that, either. Poor sleep quality? Yes, but that's because my symptoms are worse at night, so I'm constantly having to jump up out of bed to run to the bathroom, and the pain (which they refuse to adequately treat because OMG ADDICTION!) doesn't help with sleep either. Low mood? Hopelessness? Yeah, I'm sick all the time from an incurable disease that has left me crippled, housebound, impoverished, and isolated.

I do have depression, but even if I didn't, I'd test positive for depression simply because of my chronic physical illness. I don't trust my primary care doctor and his ten-question form to adequately diagnose or treat me for a mental illness. And when I go in because I need a refill on my asthma inhalers or because I sprained my ankle, they don't need to be screening me for depression anyway. I find it intrusive, and it can hamper adequate medical care.

[All Is Full of Love]

I absolutely agree with geis. I went to a new primary care doctor a couple months ago and after 15 minutes of talking with her and going over my history, she diagnosed me with bipolar disorder. My mom and I told family and friends I had it, then I went to the Cleveland Clinic and had a huge evaluation with doctors there to find out that I had something completely different and they couldn't believe she told me that. Stay out of an area that is not your expertise. I never went back to her and she is doing damage to families and her own reputation.

[All Is Full of Love]

Kimberly Garren-Hudson, DO - Family Medicine, Cleveland Clinic

This is the evil one, in case anyone's interested

[AncientMelody]

A primary care doctor seeks to know his patients and we ask if this is a good idea? Of course it is a good idea. I think it's a very clumsily written piece, hopefully his patient interactions are a little smoother. But the fact that he shows genuine interest in his patients' lives is at the heart of the primary care relationship. It would be dangerous and unethical yes to try to perform true analytical psychotherapy in this situation yes but I can assure you that a primary care physician is not only trained but indeed obligated to counsel patients on potential risks to both their mental and physical health.

Additionally two symptoms or health history items that may seem unrelated to each other to some may actually be the key to accurate diagnosis and treatment.

I hear so often how people want medical providers to treat them as whole people, not as a list of diagnoses. This doctor does just that.

[AncientMelody]

Originally Posted by All Is Full of Love

I absolutely agree with geis. I went to a new primary care doctor a couple months ago and after 15 minutes of talking with her and going over my history, she diagnosed me with bipolar disorder. My mom and I told family and friends I had it, then I went to the Cleveland Clinic and had a huge evaluation with doctors there to find out that I had something completely different and they couldn't believe she told me that. Stay out of an area that is not your expertise. I never went back to her and she is doing damage to families and her own reputation.

This is indeed unethical...one thing to take a thorough history, another to rush a diagnosis especially one with such serious implications. I'm sorry you went through this.

[Rose76]

It all sounds very appropriate to me. I don't think these kind of conversations should be the basis for slapping a major psych diagnosis on a patient. Most doctors would not even wish to do that. Normally, a general practitioner will send a patient for a psych consult, if there is the possibility of some heavy duty psych diagnosis, or even garden variety depression. That's what has happened to me over the years.

[geis]

Originally Posted by AncientMelody

A primary care doctor seeks to know his patients and we ask if this is a good idea? Of course it is a good idea. I think it's a very clumsily written piece, hopefully his patient interactions are a little smoother. But the fact that he shows genuine interest in his patients' lives is at the heart of the primary care relationship. It would be dangerous and unethical yes to try to perform true analytical psychotherapy in this situation yes but I can assure you that a primary care physician is not only trained but indeed obligated to counsel patients on potential risks to both their mental and physical health.

Additionally two symptoms or health history items that may seem unrelated to each other to some may actually be the key to accurate diagnosis and treatment.

I hear so often how people want medical providers to treat them as whole people, not as a list of diagnoses. This doctor does just that.

From the article linked, it doesn't sound like he's seeking to know his patients or seeing them as whole people--he's just looking for substance abuse everywhere. There's a logical fallacy known as confirmation bias--basically, if you go into a situation with an already-formed assumption, you're going to find evidence that it's true. If you assume every patient in a certain age group is abusing substances, you're going to find evidence that yes, some of them do use substances. But while you're busy finding evidence of that, you're going to miss the concerns of patients who aren't using, or patients who are using but for whom it's not problematic. (Consider that more and more states are passing medical marijuana laws, and there's a growing movement toward legalization of marijuana.)

Also, my experience (as well as the experience of many other people; the New York Times has even run several articles about it) has been that once you're slapped with the label of "substance abuse" or "mental illness," symptoms of genuine physical illness are often written off as all in your head. I nearly died of an autoimmune disease because the intern treating me in the ER was convinced I'd caused the symptoms myself by overdosing, even though my symptoms were totally inconsistent with symptoms of an overdose. But I was a psych patient with self-harm scars all over my body, so she assumed beyond all reason that I couldn't really have been physically ill. It wasn't until my blood pressure crashed to 50/40 and they had a crash cart next to my bed that she decided that maybe I wasn't just crazy.

Too often, doctors' first assumption is that symptoms are drug-induced or psychosomatic, when that should be the assumption of last resort, after all the other possible causes have been eliminated. It often discourages patients from seeking out further health care and contributes to the reason that the life expectancy for people with mental illness is twenty years less than people without mental illness.

[AncientMelody]

I can see your points regarding this doctor specifically who may see to have an almost excessive interest in the substance use side of things. My broader discussion was in response simply to whether a physician should be asking these deeper questions in general. In a primary care office (not ER) a flexibly minded medical practitioner need not choose "either or" between the thought processes of "physical vs mental vs substance abuse.they prepare a differential diagnosis considering MULTIPLE possibilities at once .

[pachyderm]

Originally Posted by All Is Full of Love

Kimberly Garren-Hudson, DO - Family Medicine, Cleveland Clinic

This is the evil one, in case anyone's interested

I don't understand. What "evil one" are you referring to?

[Mygrandjourney]

Originally Posted by AncientMelody

This is indeed unethical...one thing to take a thorough history, another to rush a diagnosis especially one with such serious implications. I'm sorry you went through this.

If the PCP suspects a MH issue, the appropriate response should be to offer a referral, rather than a specific diagnosis.
OTOH, PCPS are often the front line providers for the vast majority of patients who seek treatment for depression and anxiety (see other discussions about stigma) and a patient may not seek out specialist care outside of their PCP's office.

[Rose76]

Quote: Too often, doctors' first assumption is that symptoms are drug-induced or psychosomatic, when that should be the assumption of last resort, after all the other possible causes have been eliminated. [/QUOTE]

It can go either way. I knew of a situation where a man was judged to have a sudden onset of psychotic depression. He was getting psychotherapy everyday and getting worse. It turned out that he had toxicity of the brain from the antibiotics he was taking. When those were stopped, his mind went right back to normal . . . and high-functioning normal at that. It was astonishing.

They kept thinking he had a psych problem, and the psychiatrist confirmed that he did. At last, an infection disease specialist guessed that the whole thing was due to the antibiotics. He was right.

I would agree that psychosomatic should be a diagnosis of last resort. Anything else is disrespectful to the patient. But the rule of thumb has always been that a complete physical assessment should be done prior to delving into serious psych issues. Actually, as a poster wisely said above, the physician should keep an open mind to any possibility, while gathering info to rule in or out whatever.

[AncientMelody]

Originally Posted by Mygrandjourney

If the PCP suspects a MH issue, the appropriate response should be to offer a referral, rather than a specific diagnosis.
OTOH, PCPS are often the front line providers for the vast majority of patients who seek treatment for depression and anxiety (see other discussions about stigma) and a patient may not seek out specialist care outside of their PCP's office.

I certainly agree, I work in family practice and see patients with mental health concerns on a weekly basis, it is truly an epidemic .

[eskielover]

When I was in the medical with serious anorexia problems....my GP who was the one that admitted me put me through almost $70,000 in tests just to prove that it wasn't something physical.....but along the same lines, the hospital staff pdoc & psychologist didn't listen to me about the trauma that I was & had been going through which was the major trigger for the anorexia situation at that point in the first place.

MY GP was new to me that previous summer & really didn't take the time to get to know me even during the time that summer I was in the hospital with a horrible asthma attack from forest fire smoke that engulfed the valley where I was living while I was sleeping in my jeep on foal watch. While in the hospital that summer, it was only supposed to be for 3-5 days but I ended up loosing my voice.....I was smart enough to realize it was a reaction to the medication I had been given......& when he finally LISTENED to me (had to write it down because I couldn't talk).....he discontinued the medication & it took 3 days for the effect to go away.....it was definitely a side effect to the medication.......something that is a very normal problem for me.

I wish that GP's would get to know their patients better.....not just a drug screening process. I know many people who don't go to a T....who need to have their GP or a specialist to talk to & feel good that someone actually is willing to listen. I have a friend who is a Physician's assistant & she always talks to the patient. It's well known that physical & mental are tied together with the health & many people don't go to T's like we do & don't necessarily have mental health problems but really do need someone to talk to about things in a place where they know it's safe.

If a patient comes into a GP with a problem & there are family issues & huge stressors that they are going through...many times the anxiety can be tied to what the patient is experiencing unless it's flu or a cold or something that is obvious....but when a patient come is with a "something's bothering me" without it being a specific illness, it's important to know what's going on in their life because it can seriously help point to what the problem is.......just like stressful situations in my life if they are long term normally trigger my anorexia. Also I have noticed that when a patient does have a psychologist/T, the MD is less likely go get into even wondering about that area of their life even though there still can be ties between the mental & physical problems that are going on.

The whole person needs to be treated & unless there is a serious determined problem, the MD doesn't even consult with the pdoc/T.

I love my pain specialist group has their own psychologist group they use in helping the people who have chronic pain......as they understand that there is definitely a connection that is necessary

[lizardlady]

I am w-a-y outside the age range this doc talks about in the article, but have been asked questions about drug/alcohol use at an initial appointment with a new PCP. It was part of taking my medical history. I did not find it intrusive. I thought they were taking a complete history and treating the whole me, not just a group of symptoms.

What flabbergasted me was the doc saying he spends 30 minutes with a patient! When is the last time a doc spent 30 minutes with you???? The most my last two PCPs spent with me was 5-10 minutes and one of them stood with his hand on the door!

[eskielover]

When is the last time a doc spent 30 minutes with you????

My new pain specialist spent about 1 hour 2 weeks in a row with me......the procedure is now being done by a wonderful physician's Assistant who also spends quite a bit of time talking with me.....we even chat about our horses & we talked about helmets because of my migraines......& shock of all.....they didn't have the time so they double booked me for the procedure....& told me if in lowering the dose of the medication that I had really bad pain that I could call & they would get me in IMMEDIATELY for another treatment.......amazing that the lidocane on long Q-tips in the back of my nose for about 40 minutes (2 20 minute treatments) has really helped me 1/2 the high dose of medication I was on that no one was willing to prescribe....but no other pain specialist was willing to come up with a treatment to help me lower the dose slowly.

He spent a lot of time listening & trying to understand exactly what was going on since no real cause was ever found for the migraines & the neck fusion didn't help......it's awesome having an MD who really cares....& they also care about the mental aspect because it does cause triggers for my migraines just as smells like "skunk" does & living in the country...there is a lot of skunk smells at night.

OK....lucky me, I got in with the founder MD of the pain clinic who is partially retired thanks to my pharmacist having the right contacts with him.....but he was still willing to spend time with me.

I just went to a GP to get a referral to a new pain specialist.....but the PA I saw there is a friend who knows me anyway.....small towns are so different than what it was like in Los Angeles.

[Altered Moment]

When I was a kid I had the same doctor from the time I was born until I left home at 19. My whole family had always had this same doctor until he retired. He knew us all very well and we trusted him very much. I think this was a very good thing.

There used to be something called "good bedside manner", meaning a doctor who had it was interested in you as a person, your overall mental and physical health, and built a relationship and trust with you. I believe there are studies that show that doctors with a "good bedside manner" have better patient outcomes.

Then I entered the world of HMO's and specialties and changing insurance. I had a PCP for a long time who whenever I went to him would listen to my complaints, then he would grunt three or four words, type some stuff in the computer, and then send me to have some lab work done. No interest in me whatsoever as a person. He was very good medically and scientifically, and very smart, but a lousy doctor in my opinion.

I do not see anything wrong with the doctor in the original post other than he should not just be interested in the problems of young people but all his patients. There was a time when a family doctor wore many hats and it was a good thing. Like he said it may be the only encounter a person has with a medical professional in a long time. Why not take a holistic approach and build trust.

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