do the pdocs really know what they are doing?

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Or is the med game just a crap-shot?
I am not sure my pdoc knows why some meds work and some don't. Seems like pdoc just tries the latest fad or the ones that worked on others like me, etc.
Like throwing darts waiting for the bullseye.

Unfortunately nobody knows what and how any particular med works. There are just too many variables aside from the obvious, male/female, age, weight, sensitivity to chemicals, allergies, developed tolerances, medical fads, stubborn patients, etc. I try to work in partnership with my PDoc when he prescribes meds. There is a lot of back and fort discussion and very careful self observation to decide if something works or not. Unfortunately this happens in a lot of medical cases, in cancer, sometimes chemo works, other times radiation. With a broken bone you might get a permanent cast or a removable one. In my case, if I have a headache I'll take ibuprofen, for skeletal pain from exercise I take Aleve, if I have arthritis pain, or pain in my joints in humid areas I take Tylenol Arthritis. You just have to listen to your body, your gut, and make the most educated decision.

It's not just p-docs that throw the dart and hope it lands in the correct place. It seems very hard for many people to accept, probably because the facts can be scary, but medicine in general is a crap-shoot. It really is. As someone said, "Medicine is an art, not a science".

As others have said no one really knows why they work in some people and not others. Everyone is so different. Everyone metabolizes things much differently and that in large part is what causes such a wide range of reaction.

The SSRI's and SNRI's for example - they have a pretty good understanding of what they do in the brain as far as reuptake of neurotransmitters in the presynaptic cleft and how they effect receptors on the neuron and dentrite on both sides of the cleft. Why one would work for you and not another or why one would work for me and not you.....who knows. It is a crap shoot. I believe it has a whole lot to do with how we metabolize them and what active metabolite our liver produces. There are now a couple of genetic tests available that will tell you how you will metabolize a set of drugs but most pdocs don't have access to them yet and they may not say anything about effectiveness and only tell you about side effects. So a pdoc really has no idea how you will metabolize it or how effective it will be.

I also work in partnership with my pdoc and it is often me who throws the dart. My guess is as good as his. It is a game of try it and see what happens. What side effects you get and will they go away. Can you tolerate the side effects for awhile or the whole time you are on it. Often it takes four to six weeks to find out if it is even working.

This is not unusual. It has always been this way for regular medicine as well. Trial and error and they learn little bits at a time. A drug may work very well for something but they have no idea why. Blood pressure meds were first discovered totally by accident. They may have a good understanding today how blood pressure meds work but it took many years of study. And you would think that would be pretty straight forward and easy to study. I read once that there are 200 factors that contribute to high blood pressure. If that is true then it is pretty complicated. Compared to the brain it is very easy to study.

The brain is extremely difficult to study. You heart they have learned a lot about. They can run cameras up your arteries. They can do live very hi res color ultra sound images and all kinds of things. Your brain they can't just cut open and see what is going on.

As Sister Rags said it is as much an art as it is a science. That's why they call it the medical arts.

I completely trust my pdoc. In addition to being an MD he's a PhD, and he's primarily a researcher, he sees clinical patients about 1/3 of his time, and he's really on top of all the meds. He's also a full prof at our med school and publishes regularly so he's on top of the research.

His latest thing with me, was not to prescribe more drugs but to prescribe mindfulness meditation, which he thinks will help me learn to regulate my limbic system. I really like that he's open to non-med alternatives.

But I've generally had good luck with pdocs.

splitimage

I tell my GP what meds I want because after 50 years I know more than him, an he knows it he is not a shrink. THE SHRINKS are worse they have attitude to go with it, they just take a shot in the dark without reading if your allergic to anything

Hey, I agree. Pdocs have lots of attitude, they are impersonal, unfriendly and downright cold. That has been my experience with the pdocs I have had. They want to call all the shots, and don't want any arguements.
I really hate having to deal with pdocs and wish my PCP could prescribe
my medications for me. When a medication doesn't work, the pdocs don't
want to hear it, and tell you that you are doing fine.

I really feel like it's a crap shoot. Sure, if you're psychotic you probably need an anti-psychotic, if you're bipolar then a mood stabilizer, if depressed an anti-depressant. But in terms of which one - - crap shoot all the way. That's why it's so frustrating. Not an exact science at all.

As a friend of mine who is lifelong a pharmacist explained it over 20 years ago:

"It is all a black box effect. We really don't know, can't really know how this stuff will work with any person. It's a black box. That's all it can be."

Black box - Wikipedia, the free encyclopedia

Love my pdoc and have found him to be extremely knowledgable about the nuances of my illness personally, how I react and respond to various meds, and how to put the whole puzzle together to best help me. He treats me as a whole person, focusing not just on meds, but everything from lifestyle, therapy, physical health, etc. does he have all the answers all of the time? No, and he's quite straight with me when he is unsure, but he always has a plan (actually usually a plan A and a plan B) and can explain his thinking to me. I respect that.

you must have good insurance

The ones that focus on the whole body like that? The good, common sense ones?

Don't take insurance :/

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That's not entirely true Some don't take every insurance. Finding one who gets the whole picture, is possible.

Maybe, it's the combination of patient and pdoc?

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No, he takes insurance. Quite a few different insurances actually. He's just very good at what he does. He's been my pdoc for almost 10 years now. He's very experienced and very well-respected in the medical community. Really a kind being.

I actually stumbled upon him the first time I was hospitalized and I was randomly assigned to him there. He took me on as his patient outpatient and I've been with him ever since. My husband sees a pdoc in his practice who is also excellent with a very similar approach and demeanor. They are out there, but I agree they are probably hard to find. It helps to be in a large city with many docs to choose from I guess. I dread the day he retires, but I definitely know what to look for now.

That was more tongue and cheek. I've seen/heard of docs like that leaving the system. There are some good reasons. You submit codes for everything you discuss. Those codes determine how much they get paid. Don't know if there is one for exercise for example. Then there is the issue of time. That is restricted by insurance too. So if they charge patients directly they are free to spend a >quality< hour with the patient and family.

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At one time, my husband did see a pdoc that did not accept any insurance. He was good, but we didn't find it translated into more time with my husband or particularly better care than he gets now with another very good pdoc who does take insurance and spends usually 45-60 minutes with him each visit (which insurance pays). We left the other pdoc because without insurance help, he was just not feasible. Good pdocs on insurance are out there.

We've found our insurance very helpful and it has paid for all services without any question: therapy, pdoc, hospitalization, ect, and all. Very fortunate that way.

I know you are right. I had one too but she has since opened her own practice without insurance. I had been looking at private insurance. The most popular insurance in my state since ACA is kaiser. It is substantially lower than everybody else. They are really good for preventative care and things like pregnancies. In my state the MH stinks, IMO. Even my T has never heard of a good experience from her clients. I know first hand because I had them for a brief period. Factoring this in all my MH would have gone out of network which means no reimbursement whatsoever. It still may have been cheaper than other plans as long as I didn't need extra care. There is one doc I have not been able to afford but now that I have some coverage I may seek him out. He will "prescribe" more than just rx's and do more of an evaluation. I like the office I work with but they have their specialty and he has his. I do like that freedom.

The doctor that didn't spend extra time or expertise is kind of a ripoff, IMO. I mean, why pay more for what you can get in network?

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I am currently in a small rural town. I go to community mental health and that is probably all that is available. I am lucky because they happen to be very good and thorough. My pdoc who is actually a PA to a pdoc is the best I have ever had. There are total of three psychiatrist in town and two are at the clinic i go to. Not much choice. I am just fortunate this clinic is so good. Community or County mental health in large cities I have never been to because I always had Kaiser in Northern CA, but I have heard that those are horror story. Way to many people and not enough staff. Kaiser in Northern CA was very good.

Staff isn't the problem in CO. Whole range of issues I can't go into right now. PAs tend to more focused on meds and often come from nursing background (and training?). Generally I find them to be better when it comes to meds. They aren't fully equipped for dx and evaluation. You probably don't need that so much anymore. That's been my exp and what I have heard from docs.

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My pdoc is similarly awesome and he listens to me---he realizes he doesn't know it all, and that I'm the best expert on me. Although he has studied me very thoroughly and understands me better than some of my friends and family! Sometimes he even goes along with my suggestions on meds and treatment; I think part of that is because I'm a nurse and he greatly respects nurses, but also because he respects me as a person. Not every doctor does that, so I really value this one and I actually follow his advice.

being a nurse puts you up on top priority , look after your own first is a rule what ever you do. You no meds to so he can talk easier with you than a normal punter. Your lucky HE WANTS YOU ON A WARD NOT IN ONE .

Not entirely clear what you are saying or if you are responding to me

A PA is a physician assistant. They have more training than a nurse. Less than a dr. A lot come with a nurse background or they did 10 years ago when the degree was new. I think that is why they are so much easier to work with. They are required to report to a doctor so they aren't able to have their own practice. If they could pdocs would probably be out of business.

I did have one terrible one though. I guess they can't all be perfect.

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