10 reasons to feel pessimistic about health care

1. Process vs. product. Computers are just machines.  I repeat, they are just tools.  Health information technology is a shell which houses knowledge and human ability.  It is nothing more .  Electronic medical records may either streamline our thought processes or make them more cluttered.  They will not, however, lead to better or more perfect care.  They haven’t yet, and they won’t in the future. And they are prone to be adulterated by commercial intentions.  Looking for an answer to our complex health care problems here is like waiting for Godot.  You can wait and wait, but no one is coming.

2. Role confusion. Physicians, nurses, and therapists are some of the most educated, expensive cogs in the health care machine.  Forcing them to become secretaries, scribes, and box checkers is both inefficient and redundant.  Furthermore, it doesn’t take a physician to make sure a patient has had a flu shot, colonoscopy, or pap smear.  These are roles for nonclinical, low payed employees.  Take them of the clinicians plate.  Let doctors be doctors, nurses be nurses, and physical (and occupational) therapists do what they are trained to do.

3. Call it courage. Until physicians have the courage to practice sound medicine and are willing to deny inappropriate antibiotics, narcotics and futile care, we are lost.  Until politicians are willing to forgo the electoral advantage, and vote for what is sound, we are handicapped.  Until patients are willing to own up to their own unsavory habits and practice will and self control, our medicines are impotent.

4. In data we trust. Data is being collected on the backs of physicians and nurses who have no reason to insure its fidelity, and have almost every reason to fudge their answers to move on to the herculean task of treating their patients.  Garbage in, garbage out.  The medical decisions of a generation will be based on crappy, nonsensical, inaccurate information.

5. Right or privilege. Either health care is a right or it is a privilege.  If it is the former, tax the American people more (like we do for roads and such) and implement a single payer system.  If it is latter, then let the market have at it, and accept that the have nots will have not.  This is how we do it in America.  Somebody has got to choose.

6. In government we trust. Can anyone out there say Healthcare.gov? Need I say more?

7. Anti-intellectualism. Few would call the care of the human body a simple matter.  Some would argue that it is remarkably harder than, oh let’s say, setting up a web site for a health care marketplace.  So why ever would we consider shortening medical school, truncating residency, or replacing MDs with less trained practitioners?  Anyone?  Anyone?

8. The sands of the hourglass. My belief is that the number one determinant of quality health care is the amount of time your clinician spends thinking about you.  In other words, most practitioners are relatively smart and caring.  Mistakes are made when the amount of time relegated to the task is insufficient.  Yet we add more and more trivial chores to each encounter without expanding the allotted time.  Something has got to give.

9. It’s futile. We offer dialysis to centenarians, physical therapy to end stage lung cancer patients, and a bevy of harmful and costly treatments inappropriately.  The main reason, of course, is that there is no such thing as futility in American medicine.  We are so busy charging up the hill, that we fail to see that the apex is a ledge that we are about to fall right back off.

10. The foxes are guarding the hen house. Do we really think that pharmacy run clinics are going to be the savior of our access problem?  Are we to trust expert opinions from specialists when their suggestions are both self serving and run counter to what our best data tells us?  Should politicians wield so much legislative power when they receive financial support from pharmaceutical companies, insurers, and the device industry?  Why do we have so much faith on those who have their hands in the cookie jar?

If we want to meaningfully reform our health care system we have to take a hard and difficult look at ourselves. I’m willing to own up to my professions role in this horrible debacle, are you?

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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  • JR

    “Until patients are willing to own up to their own unsavory habits and practice will and self control, our medicines are impotent.”

    Let’s spin this.

    “My stubborn patient does things that hurt their health.”

    To:

    “What happened to this patient that caused them to develop negative coping skills? What can be done to teach this patient positive coping skills to replace the negative ones and improve their health?”

    • SarahJ89

      I can offer one thing: the food supply in the US is heavily contaminated with processed foods. I work on a farm, buy or grow my food locally. I haven’t set foot in a supermarket in years.

      Recently I had occasion to be in one. If you haven’t been in a long time, it’s like visiting another planet. There was aisle after aisle of what I consider non-food. And, thanks to the efforts of savvy marketing professionals, it was incredibly tempting. The boxes made the stuff look delicious, the copy made it sound effortless.

      I was shocked to see how difficult it is nowadays to shop without bringing some of this fat-, sugar-, chemical-laden boxed non-food home with you. And I haven’t even mentioned the row after row of fast food places you pass on the way to and from there.

      It’s easy to say people are lazy or uncommitted to eating well and exercising enough when the press of society means you are swimming upstream against a very strong tide. I put a LOT of effort over several years to research local alternatives and change my lifestyle and buying habits. It’s paid off, but I had no idea when I started this process that it would. I cannot imagine doing it with small children and a low-paying but demanding job or in an urban area.

      We’d really be better served in assuming people are doing the best they can in a basically unhealthy society that has handed it’s children over to marketers. (Note: Why are we even discussing what kinds of advertising or vending machine snacks should be in our schools? There should be NO ads or vending machines at all. This is a recent and unnecessary phenomenon.)

      End of rant. Thank you one and all.

      • buzzkillerjsmith

        Question: What happens when people exercise right, don’t smoke, and keep their weight under control?

        Answer: They live a long time and outlive their brains and wind up in the nursing homes, costing society a fortune in medical care and social security.

        Every silver lining has a cloud.

        • Patient Kit

          Healthcare was definitely cheaper when people, with and without serious chronic conditions, didn’t live so long. Living long productive lives as cancer survivors, for example, is a good thing, of course. But it was cheaper when we just died.

        • SarahJ89

          “Every silver lining has a cloud.”
          Oh god, I love a good pessimist. Thank you for that.

        • DoubtfulGuest

          Well, there’s this take on it…Canadian version:

          http://www.youtube.com/watch?v=Qo6QNU8kHxI

          I think I’ll try those inline skates again today…

      • Patient Kit

        I agree with a lot of what you are saying. Big Food is at least as powerful as Big Pharma. A lot of junk food is actually engineered to be addictive. And there is a ton of money at stake to keep it that way. I consider myself a moderate and generally healthy eater and I exercise regularly. I’m at the Y 5x a week, where I swim a mile and do some weight room. I’m in NYC, not on a farm, so I’m sure I don’t eat quite as healthy as you. We walk a lot in the city though. I haven’t had a car for 30 years. Our legs are our wheels. Tonight we’re having spaghetti squash with meat sauce and mixed green salad for dinner. Yum! I can see why people have a hard time getting off — or just limiting — the junk food though. It’s addictive. It’s everywhere. And there is lot of money to be made from it, so it’s not going away. We had apple vending machines when I was in school.

        • SarahJ89

          It’s not only ubiquitous and addictive, it’s just so PRETTY. Seriously, they pay those marketing people money for a reason.

          Or, as I often say about living in the overly capitalistic society in the US, we’re all prey animals now.

          • DoubtfulGuest

            True…I’ve shot myself in the foot more times than I can count by eating too much sugar. Brightly colored, sparkling, sugary things. The older I get, the window of time between the fun of eating them and the moment I start to feel cruddy gets shorter. So, I’ve been trying to do something about it. Ever since, um…this morning. :/

            http://www.pbs.org/pov/foodinc/fastfoodnation_03.php

    • DoubtfulGuest

      I can see asking the second question but not the first. Health care professionals just don’t have the resources to address patients’ emotional traumas, beyond showing general compassion and making appropriate referrals. Unless their field is mental health. They all have emotional traumas of their own. They can’t think much about those and still get their work done.

      I understand from reading some of your other comments that much of what you’re asking for is a shift of mindset. To be more open and compassionate to the different ways stress manifests itself in patients. I sure agree with you there. For example, doctors need to understand that for some patients, bringing in a female chaperone will increase anxiety. Doctors have the right to protect themselves, but then they shouldn’t be surprised if the patient feels less protected.

      I’m concerned about expectations of doctors to address specifics of a patient’s traumatic experiences. Most simply do not have the time or training to do so. People have to deal with those things at their own pace, anyway. I’m not sure it would be helpful for many people to be asked in a medical setting what happened to them, and then not have the time to discuss it or process their emotions with a qualified professional. What I think is helpful, is for everyone to keep in mind that lots of people have lots of bad stuff happen to them. And give people a chance to do things right instead of rushing to negative judgment.

      • JR

        Do you think the doctor sits and makes fun of a patient and tells them their problems are all caused by their own actions?

        Oh, yeah they sometimes do that don’t they? Sucks to be chronically ill without a diagnosis.

        Now I have a diagnosis, my illness is in remission, and my life is AMAZING.

        But I can’t help but think: I have seen so many doctors in 30 years, and only one ever sat down and listened to me, coached me on healthy behaviors, and actually helped me live a healthier life. I couldn’t see her when I lost my health insurance (aged off parents plan, still in college) and then I eventually moved.

        She was a Nurse Practitioner.

        If Doctors should only deal with “real health problems” and not bother coaching people on health and wellness and behavioral changes, why are they so hesitant to allow Nurse Practitioners to take on that role?

        Luckily my current doctor has no problem doing those tasks, he takes all insurance, does same day appointments for critical issues, I could go on about how great he is. But I have one caveat – he’s not trained in trauma informed care and he re-traumatized me badly. I know from an intellectual standpoint he was simply abiding by his training and is a good person. But that didn’t stop my horrified reaction. PTSD is like that.

        That’s why I’ve become an advocate for “Tramua Informed Care.” It’s a shifting of the delivery of care services based on research into stress and trauma. Many negative behaviors are coping skills that someone learned in their life. Everything from exploding in anger, cowering in a corner, to stress eating, to addictions are coping skills to deal with stress.

        A lot of research into trauma has been done by the VA and NIH. Slowly the tide is turning, and the concept has been exploding in the past few years, but it still hasn’t reached a critical mass.

        This is a pretty good explanation of the model:
        http://www.thenationalcouncil.org/wp-content/uploads/2012/11/Is-Your-Organization-Trauma-Informed.pdf

        Part of it is helping patients who’ve experienced trauma, but part of it is also helping those with “secondary trauma” – ie – the care givers. I read somewhere that 85% of nurses do not feel safe on their job. 85%! That has to change.

        You’re right – most doctors haven’t had training in how to handle traumatized patients, and they re-traumatize those in their care without intending to. The training is available now. Doctors in their own practices can implement it and train their staff. Doctors at hospitals can bring it to the attention of the admin and make small changes.

        And it can be successfully implemented – it’s been successfully implements all over the country, all over the world – but only bit by bit, organization by organization, office by office.

        • PoliticallyIncorrectMD

          Do you really think someone needs to be “coached” to be physically active, eat healthy, avoid tobacco and get enough sleep?

          • JR

            Someone I know has gout and kidney stones. These need to be managed through dietary changes. Should the patient not get any help on how to do that? The foods that are good for one aren’t good for another.

            What about a diabetic? Should they get coaching on how to manage their disease through diet and exercise?

            How about someone with restless leg syndrome? Should they just get told to get more sleep?

            Primary care physicians are being directed to be responsible for helping these patients manage their disease without training on how to coach their patients to succeed. Take a patient who started using food as a coping skill to deal with negative emotions. They go to the doctor, get chastised for their weight, then they go home and eat even more.

            Chronic illness makes up 75 – 85% of our medical costs. Someone with training on how to engage patients with motivational behavioral changes needs to be involved in their care. And all those involved in their care need to avoid de-motivating their patients.

            My doctor is a partner in my health care who empowers me to make my own changes in my life and be healthier.

          • PoliticallyIncorrectMD

            Patients shouldn’t be chastised for engaging in unhealthy behaviors. Neither it is the physician’s responsibility to coach them into embracing healthy lifestyle. Physician’s function is to provide competent professional advice on life stile, pharmacologic and other interventions to prevent and treat disease (similarly to a priest advising one on moral virtues, an accountant – on one’s finances and an attorney – on legal matters). But it is no one else’s responsibility to assure you are healthy, virtuous, make financially sound decisions and follow the law. Unfortunately, this idea of personal responsibility is becoming less and less popular in our society, while assigning the blame to someone else or making them responsible for one’s problems is becoming the norm.

          • DoubtfulGuest

            Well, and there are health professionals who are specially trained in these areas, like dieticians and physical therapists. I’ve had very positive experiences with them. Are they in short supply? (I’m honestly not informed about this). It doesn’t make sense that a Primary Care doc should handle all the self-care stuff. I get why people might need help and encouragement, but I can’t understand why personal responsibility isn’t more popular. It gives us control over our own lives, and more options than we’d have otherwise.

          • PoliticallyIncorrectMD

            If there were more people sharing your beliefs, we would have much healthier nation and much happier physicians!

          • buzzkillerjsmith

            Dietician. That’s the ticket. They have an hour to go over the number of peas you should eat. I have 15 minutes to manage your heart failure. That’s more interesting than counting peas anyway.

            PTs are good too.

          • DoubtfulGuest

            LOL…but let’s give dieticians some credit? They can be great for food allergies, weight loss, weight gain, neurological diseases with trouble chewing/swallowing. They can also help address time, access, and motivational barriers to good nutrition. It should be straightforward and we should all learn this stuff in school, but some don’t, and need a bit more help. Of course patients need to hold up their end of responsibility.

          • buzzkillerjsmith

            Hey, I like dieticians. They are women who keep themselves up, if you know what I mean.

            Some of the PTs are pretty “interesting” as well.

          • DoubtfulGuest

            Priorities, Sir…

            But yes, “upkeep” is a good thing. Fitness and nutrition go a long way.

          • buzzkillersmith

            I know my priorities.

          • DoubtfulGuest

            As long as upkeep isn’t just the women’s job…that gets old fast.

          • buzzkillerjsmith

            Whether other men keep themselves up ain’t my problem. For my own self, I do what I can.

          • DoubtfulGuest

            Very well, then. Most doctors seem to have that carotenoid “glow”, and a decent level of fitness. Surely a good example for the rest of us.

          • JR

            Ok you lost me.

            How is creating a supportive environment that empowers individuals to take ownership of their health and making positive changes the same as “assigning the blame to someone else or making them responsible for one’s problems.”

            As far as physicians “not being responsible to coach on healthy lifestyles…” uh, well this is just one example of an article from the AAFP. They certainly think it’s something their physicians should be doing.

            https://login.aafp.org/siteminderagent/forms/fpm_login.fcc?TYPE=33554433&REALMOID=06-00096500-1414-11df-a59b-0a3f0a0a90bc&GUID=&SMAUTHREASON=0&METHOD=GET&SMAGENTNAME=-SM-LruSShOS4DLLVvn7F6gUnkTlLbhm%2b3kPEB1doWsqO3FDodIovnBt9umX%2fTJe80AM&TARGET=-SM-HTTP%3a%2f%2fwww%2eaafp%2eorg%2fcgi–bin%2ffpm_lg%2epl%3fredirect%3d%2ffpm%2f2014%2f0100%2fp32%2ehtml

            “Although it can be difficult to find time for lifestyle and healthy behavior counseling in the context of a busy office visit, two tools can help. The “5-2-1-0″ tool teaches patients how much fruits and vegetables, recreational screen time, physical activity, and sugar-sweetened beverages they should have each day. The “MyPlate” tool depicts how much of each meal should be devoted to the various food groups. The tools take only a few minutes to explain and are a good starting point for most patients seeking to change.”

          • DoubtfulGuest

            I hope PIMD will correct me if I’m wrong, but I don’t think docs are saying that they shouldn’t provide any assistance at all with this. I think they want to offer compassion, help with problem identification and appropriate referrals. It’s just 1) their job is to treat and help prevent disease, 2) the primary motivation has to come from the patient, 3) when emotional problems interfere with self-care, then mental/behavioral health professionals are often needed in addition to primary care, 4) where specific dietary issues exceed the capacity of these time-efficient tools you mention, a dietician’s expertise may be needed, 5) when exercise issues from pain or deconditioning arise, then PT may be needed, and so on. Also, patients need to make our own efforts in each of these areas. Some of us get a poor start in life and shouldn’t be judged for not knowing what to do. What doctors have a problem with is when folks don’t even want to try.

            They have 24 hours in a day like the rest of us. And they are being held responsible for way too much. I don’t know how much of it is an access problem, I’m sure that’s part of it. But I’m also aware of people who just expect to dump any and all problems in their doctors’ laps. They want their doctor to know them inside and out, be their spiritual advisor, solve their marital problems, career issues, everything. It can be a combination of emotional needs, and not wanting to pay the different professionals if folks believe their PCP can do it all. We should expect compassion but also show it in return, and think about what is a reasonable workload for the people who care for us.

          • JR

            “If patients only had self control they would be healthy”. When a physician says that here, you think they aren’t saying that to the people in the office? You think the person who says that doesn’t have a strongly held believe that fat people are lazy?

            Did you know that research shows that a doctor starts to discriminate against male patients when they reach 70lbs overweight… and females when they are 13lbs overweight? Only 13lbs!

            Did you know that researchers have started to conclude that part of the reason fat people don’t live as long is because of discrimination in health care? For instance, many cancer chemotherapy drugs are given at a set dose and not adjusted for weight, so overweight people are more likely to have cancer re-occurrences after chemotherapy than thinner people.

            When a person is fat, their conditions are blamed on them being fat and their diagnosis is missed.

            The first step is to change the way these people are viewed. If someone is fat – why? Is eating a coping skill to deal with stress? Is their illness causing their weight gain? What is the root cause? Is the illness causing the weight gain or the weight gain causing the illness – the truth is we don’t actually know.

            Obesity is just one example. Here’s another. When a person is a young women of child bearing age, her conditions are frequently missed and assumed to be exaggerations or mental illness.

            When someone who eats as a coping skill is told to “stop eating and exercise more! you just need self control!” they go home and eat. They haven’t been helped, they’ve been harmed.

            Now let’s look at a health condition that causes obesity. When the colon is full, a message is sent to the brain causing the person to feel satisfied. Now give someone chronic diarrhea. Their colon never gets full, and they are constantly feeling like they are starving, so they keep eating. Their body also is getting plenty of calories, but the bowel isn’t absorbing the nutrients needed so that also triggers the body to want more nutrients, so the person keeps eating. That’s why only 5% of people with celiac disease are underweight, and a whopping 40% are overweight.

            It’s not a “self control” issue at all – it’s biological functioning. So the “self control” nonsense gets old fast. And that’s not “telling people to blame others” but rather “recognizing the root cause of the problem so the problem can be solved”.

          • DoubtfulGuest

            You make some good points here, and I had a progressive neurological disease missed for many years partly because doctors thought I was a hysterical, malingering female. They misinterpreted my underweight-ness as an eating disorder, even though there was no indication of any body dysmorphia and I kept trying to gain weight. So, it happens on the low end, too. They need to focus on the diagnosis part. They need TIME to focus on the diagnosis part. Patients need to try to take care of themselves, and like I said, where legitimate mental health problems exist, people need access to mental health care. PCPs can’t cover all that and make an accurate diagnosis of disease.

          • JR

            Ok –

            Where do the mentally ill seek help first? PCPs
            What position prescribes the most mental health drugs? Family Physicians. http://www.reuters.com/article/2009/09/30/us-drugs-mental-idUSTRE58T0NE20090930

            PCPs are already dealing with mental illness in their office.

          • DoubtfulGuest

            Yes, with drug treatment, not talk therapy. But the PCP can make referrals for that, and for psychiatry, dietician, PT, etc. If there’s other physical stuff going on, they have to have time to make an accurate diagnosis. If all their time is taken up with diet/exercise/trauma discussion, that’s less diagnosis and treatment time. We can’t have it all from the PCP. They’re just people.

          • JR

            I’ve never said or suggested that doctors should give talk therapy.

          • DoubtfulGuest

            I know, it’s just that “What happened to you?” could require quite a bit of time to deal with. It could be unfair to the patient to bring all that up with a doctor who doesn’t have time to discuss it much. A mental health professional is better qualified to handle emotional trauma. Certainly the PCP can be aware of it and patients should be treated with compassion and respect. I agree with you in principle about a lot of this, it’s just a “tall order” for our already overburdened doctors. I’d better get some shut-eye now, but I enjoyed the insightful discussion. :) Will check back tomorrow.

          • buzzkillerjsmith

            Walkin’-around around depression, anxiety, panic, PTSD, social phobia, etc., etc., is brain-rot. If you’re not a doc, I could teach you in a day or two. A week at most. If you are a primary care doc, you know this.

            SSRI, psychology referral, SNRI or Wellbutrin if a couple SSRIs don’t work, etc., etc.

            But if you don’t have psychological backup, you’re dead in the water. I can’t do talk therapy in 15 minutes. In truth, I don’t want to do talk therapy as I am more interested in internal organ derangement than I am in psych. Harsh, but there it is. My fellow family docs feel the same way.

            In refer suspected bipolar for a drug consult and a firm diagnosis, but then I’m a wuss. I follow them on my own once things stabilize. See a shrink once a year, maybe not even that often. Of course I live in the boonies, but I’ve never had one of my pts commit suicide or homicide.

            I like psychiatrists. Some of my best friends are psychiatrists (not really). But there’s not a lot of there there. A few diagnoses, a few drugs. I can cover most of the field in my spare time.

            Time to get back to heart failure!

            Truth be told, the shrinks only need to get involved if the pts are taking up too much of my precious time. That happens rarely.

          • JR

            When someone who has depression, anxiety, panic, PTSD, or social phobia, becomes ill or injured, they should be able to get medical care.

            That doesn’t require therapy on the part of the medical care giver. But it does require the caregiver know how to work with those kinds of populations and help them feel safe so they can receive medical treatment.

          • DoubtfulGuest

            But can’t we just ask them to be nicer, and to explain better what they’re doing and what they need us to do? I looked up the bathroom thing, and apparently it’s because any rules saying “No” (as in “Staff Only, No Clients Allowed”) are “hurtful”. But they also say one bad effect of trauma is having boundaries between ourselves and others break down too much. Some of it comes across as an entitlement thing, seriously. If I’m trying to control where my doctor can pee, that’s a problem. Where’s the line? At what point are we excusing violent crimes because someone was “traumatized”? It creates a special class who get to “traumatize” others so as not to “re-traumatize” themselves.

          • JR

            It’s nothing like that at all.

            All people have coping skills for dealing with stress. Some of those coping skills are successful, some are not. Recognizing that certain behaviors are coping skills allows a care provider (of any kind) to better work with someone. And knowing how to recognize, and respond appropriately, to certain reactions can prevent escalations.

            I can’t say I’ve ever worked somewhere that had a separate bathroom for employees vs customers, so I’m not sure why that’s needed, but I really couldn’t care about bathrooms.

            You have to realize what kind of treatment this is trying to address. Current practice in most places is tie people up, strap them down, drug them up, to control the patient’s behavior.

            Here’s a nice example – this type of stuff happens in our ERs every day.

            http://cityroom.blogs.nytimes.com/2008/01/16/forced-rectal-exam-stirs-ethics-questions/

            This is the type of situation that can be completely avoided but only if there is education on how to recognize the reaction and what to do when it happens.

          • DoubtfulGuest

            According to TIC, how should the case in this article have been handled? I can see a lot of different aspects to it, but I note that they did explain what they needed to check and why. I would say to doctors that this case is an excellent example of why patients shouldn’t be in the dark about how things work. Maybe we should all have more biology and anatomy in school. I don’t blame the guy for being scared. But why can’t he work at all? Why is he suing the hospital? Just because something reminds us of assault doesn’t mean it IS assault. And he hit the doctor. Does he care about that at all? It doesn’t sound like they handled it in the best way. But they have to make decisions fast, and it looks like they were trying to make sure he didn’t die.

            A much milder example, when I went to the neurologist for the first time, I was kind of scared by the exam. The pinprick test, especially. It would have been better for me if the doctor had explained what he was doing. But he was trying to help. I’m not suing him…I just went home and looked up on the internet what the test was for, so I’d know why he did it. He doesn’t need special training. If he explained things more, he’d be just fine.

            Separate bathrooms: it’s their workplace, it’s stressful. Depending on different problems their patients have, they might feel safer with their own bathroom. And they might just need a break for a minute.

            This stuff you’re saying, a lot of it does make sense. As with any relationship, though, people have to make compromises and think about what one another need. I don’t think it’s okay to have everything center around the traumatized patients. We have enough problems as it is, without this kind of thing making a bad impression on the health care professionals.

          • JR

            Do you know what a traumatic reaction is? A traumatic reaction is when something happens to a person and they can’t stop thinking about (intruding thoughts) or they can’t sleep at night because of nightmares… they can’t just “let it go” because it’s out of their conscious control. It’s a completely subjective experience unique to the individual.

            Anyone who has had a reaction like that in the past is likely to have that reaction again, and they need special handling to avoid loosing 6 months of their life to fear, pain, and misery.

            A recent study of soldiers showed a clear correlation between those with high inflammation markers and those that developed ptsd later after combat exposure. They could almost predict who would get it, and who wouldn’t. We also know there is a strong correlation with auto-immune disorders though the connection isn’t understood. Another thing is that the brain function itself changing in a measurable way.

            When someone starts “over reacting” to an experience, that means they are experiencing it in a more intense way then one would expect.. that’s the warning sign of someone having a traumatic experience.

            One of the key things that study after study after study shows that these people need to feel they are in control. It’s the fact that someone takes away control and forces themself onto someone else – that’s something you’ll see over and over.

            So let’s look at this case. The test they wanted to perform has been studied scientifically and show to have no diagnostic value. It’s just a standard move that’s been handed down doctor to doctor as the “art” of medicine. It is in decline just about everywhere except teaching hospitals where students are required to do it just about every chance they get to learn the skill, so they can go out into the real world and stop doing it.

            Knowing that – and knowing that this person seems to be over reacting to having the test done…

            They could have skipped or delayed the test. It wasn’t an emergency, he refused the test, there are alternative tests that provide more accuracy, there was just no reason to do it.

            Instead, they pinned him down, and when he got loose they drugged him. He had to have a tube shoved down his throat (he had complications from the tube not mentioned in this article). And afterwards, he could not stop thinking about it. He thought about it every day, every night, every hour…. that’s an acute trauma reaction.

            Part of TIC is “stopping when the patient is distressed by the procedure”.

          • DoubtfulGuest

            Maybe you’re correct about the test — I’m uninformed about it, but he hit the doctor and now he’s suing them, too? If he can’t work, it’s become chronic now, right? Not acute? If I knew all the details, I might take the patient’s side, who knows? But I am troubled by some things that don’t add up.

            Yes, I know what it is, have had it myself. Not as badly as some other people, I’m sure. One of my pet peeves is people telling other folks to let stuff go, so I am not doing that here at all. But we can’t completely stop caring about the rights of others as well as our own. That’s my whole argument with the model of care you’re advocating.

          • JR

            But TIC is about equipping caregivers with the skills they need so that they don’t get punched, don’t burn out from compassion fatigue, don’t get sued…

            It is all about respecting the rights of everyone involved.

          • DoubtfulGuest

            As I said before 1) Some of it makes good sense, but could be better conveyed through respectful conversations, not “training”, 2) Some of it absolutely does not respect the rights of healthcare professionals or other patients. It allows the self-designated “traumatized” patient, usually genuine but occasionally not, to control small nuances of any environment in which they set foot. Not just their own bodies…but other people’s bathrooms, and whether or not anyone else is ever allowed to tell them “No”.

            Some folks might feel traumatized by the suggestion that they need training (does it cost money?) to learn “skills” so they don’t get punched. I can’t say for sure about this guy’s case because I wasn’t there, but at some point, it’s blaming the victim.

          • JR

            The victim was the patient that was was being held down who fought in self defense. No way you can spin that any other way.

            As for the rest – I have no idea where you got that information but it’s not correct. An organization taking surveys of the people they serve and finding out things they would like to see changed is an organization listening to the people they serve. That’s what service organizations should be doing.

            I mean, this organization chose to what, make gardens as a way of making people feel comfortable? That wasn’t some diva forcing them to do it, that was something they chose to do to help all patients in their care.

            I also don’t know why “training” is a word that triggers you so badly, but it seems to be you that has a problem with it, not anyone else. All doctors go through training.

          • DoubtfulGuest

            Sigh…I feel empathy for the patient. I don’t know all the details. In general, I’d agree with you on one’s rights to one’s own body. But I think you’d get much further with your advocacy if you’d recognize where health care professionals are coming from and make it a *conversation* so that everyone could understand one another better and come up with workable solutions.

            I honestly don’t know how consent works in emergency situations. The guy showed up to receive emergency medical care. This does not mean they can justify doing whatever they like to us. But if they weren’t assaulting him, then there are other questions to be asked. We put the responsibility on the ED to save us when our lives are actually in danger. It’s not always clear if they’re in danger or not. Sometimes, they have to do things we may not like in order to meet our expectation of not dying and they don’t always succeed.

            I’ve read about people who thought a doctor was assaulting them just for doing a fundoscopic exam (the eye scope thing where they get really close). Should doctors explain what they’re doing? Yes. Are they actually assaulting anyone and should they be sued for doing a fundoscopic exam? No.

            I looked at several sources, but bathrooms and “Do Not” signs are addressed on slide 12 here.

            http://www.cpe.vt.edu/ocs/sessions/csa-trauma.pdf

            The boundary thing is mentioned on slide 22. Boundaries are great. I can’t imagine demanding anyone share a bathroom with me, or even really noticing that staff use a different one. Gardens are nice. Who pays for them? How much does the training cost and how long does it take?

            One thing I do agree with is here:
            http://pathprogram.samhsa.gov/resource/10-tips-for-recovery-oriented-trauma-informed-agencies-33505.aspx

            Item #3, night checks in a homeless shelter, don’t just burst in with a flashlight or you’ll scare people. That’s alright.

            Things don’t “trigger” me. I might feel bad about them or have a bad memory. I’ve already explained my disagreement with TIC. All doctors go through training, yes. These days, all kinds of folks are wanting to put them through ever more training, which takes time away from their patients. Some even say they feel “oppressed” by it. Does that not matter?

            I agree with you on some things, but not the whole TIC package, sorry. If they really want to accomplish what they say they want to, they need to address constructive criticism and think about the health care professionals, too. Another thing you mentioned is how they can recognize trauma in one another so they can refer for help. There is actually no (or very poor) support system for physicians to get mental health care. That needs to change. How about listening to them about all the stuff going on on their end? Maybe then we could solve these problems.

          • JR

            PS – I also think the “training” bit is a tone argument. “Your points are invalid because you are angry/irritable/emotional/not presenting it in a way the recipient who is being criticized wants to hear”. Criticism isn’t a pleasant experience.

          • DoubtfulGuest

            Huh?

          • JR

            Google “tone argument”.

            When people bring up criticism, and someone says “well people might listen to you if you just said it in a better way.”

            I think it’s funny – I approach it this way to avoid the tone argument and you’re using the tone argument.

          • DoubtfulGuest

            I know what it is. Please address my specific concerns, which are not about tone.

          • JR

            ” It allows the self-designated “traumatized” patient, usually genuine but occasionally not, to control small nuances of any environment in which they set foot.”

            No it doesn’t.

            Patient A is being encouraged for a preventative screening colonoscopy. He has a family history of colon cancer. He reveals he was sexually assaulted and cannot bear the idea of getting a colonoscopy and being naked and drugged.

            The doctor agrees to allow the patient to wear colonscopy shorts (backwards briefs) so that the staff does not see him naked. The doctor also agrees to do the procedure without sedative, because they’ve honored this request for others. The patient makes it through the procedure and is very grateful.

            That’s trauma informed care: providing care in a way that is respectful of a patient’s previous trauma.

          • DoubtfulGuest

            When I have it done next, I will also ask for no sedative. Had it with sedative once and didn’t like it. So, that all sounds fine. Is training needed? Or just asking? Are colonoscopy shorts difficult to come by? That’s a nice option to provide. Some people are just very modest, with no traumatic history. Cultural differences and so on.

            Would you please address my specific concerns that TIC could interfere with the rights of others? The parts about patients who just don’t want to be told “No”? Also, would you please address my concerns about doctors’ time constraints and lack of mental health support for them? And about the costs and time needed for training? Please acknowledge that I am actually agreeing with many changes you suggest. I’m sure these social workers are really nice folks. But I think the TIC model is tunnel vision-y. It doesn’t take into account some of the bigger system problems that affect others besides the traumatized patients.

          • JR

            TIC doesn’t interfere with the rights of others.

            Doctors should have mental health support.

            Time constraints of course are an issue, but there is value in allowing doctors more time with patients – including less lawsuits.

            There is a lot of money flowing into trauma research from NIH, VA, other government agencies, non-profits, etc. There are non-profits providing training.

            The things that benefit traumatized patients benefit all patients, things like managing pain, protecting modesty, allowing a patient to be a partner in their care, empowering patients to take control of their health (as opposed to having health be something “done” to the patient), allowing more time between doctors and patients, etc etc. There are a lot of good ideas floating around out there.

            Just in case you have the idea that traumatic experiences are rare, take a look at the ACE study which only covers childhood:

            http://www.cdc.gov/ace/prevalence.htm#ACED

            Only 36% are not exposed to at least one traumatic event in their childhood. The majority of people are.

          • DoubtfulGuest

            Exactly, it’s not rare. Looks like a minority of patients are trying to hoard the majority of attention and resources. You are still not answering any of my specific questions. The parts about rules, signage, bathrooms. You think doctors don’t already want more time with their patients? You think most of them wouldn’t ask sensitive questions on their own initiative, given enough time? Let’s stop threatening to sue them, and ask them how these changes can be made feasible. Ask, and listen to what they have to say.

          • JR

            I feel your argument is going like this:

            I read this one presentation about trauma informed care, and there was one point about bathrooms I didn’t like, therefore…

            it’s kind like:

            I read this one feminist who said x, therefore I’m going to behave as if they are representative of all feminists everywhere and they all feel the same way.

            Seriously, just because there was one slide in one presentation that had an idea you like, doesn’t mean I’m the one who suggested it. I already addressed this before and I’m tired of rehashing it with you.

            I’ve never been to any medical practitioner who has had separate bathrooms, I have no clue if there are some out there who do or why they do. They were probably referencing a specific example and had a story to go along with it that isn’t contained in the slide.

            The majority of patients have tramatic exposure and would benefit. I’m not just talking about people with PTSD, but rather the full spectrum of trauma reactions. Some 80% of patients have acute trauma reactions after a hospitalization – that’s not a minority hogging resources. That’s the industry failing to care for patient’s in general.

            Study after study shows: Patients do not disclose a history of trauma. Doctors do not ask. The majority of patients wish they would ask. There is a LOT of research around it.

            I would like to see the “standard of care” thrown out as being silly nonsense, but just giving doctors full swing to do whatever whenever? eh. I’ve never sued a doctor, just paid to have a meeting to give them feedback and get their perspective because you can’t speak to them if you don’t pay them for a visit. I’m not sure how much more “listening” you can get then to have a conversation with them directly.

          • DoubtfulGuest

            I found the bathroom thing in several places. The presentation you linked, the one I linked for you, and several others. Some of them only say bathrooms should be well-lit and lock-able. That sounds good to me. But really, if you’re going to be an advocate for this thing you need to understand every aspect of it. If staff someplace would feel safer with their own bathroom, I can’t imagine changing that because of someone’s “story”. Bathroom privacy is good, right? Boundaries are good, right? The main problem I have with TIC is it’s apparently boundary-protecting for some people but boundary-intruding for others.

            I made a lot of really thoughtful points that you’ve chosen to ignore, which is disappointing. You have not answered most of my questions. You’ll be pleased to know that I’m running out of gas with this topic. If you did want to add anything about the perspective you heard from doctors you paid to see, I would be interested in that. It sounds like a good strategy to go and talk with them. It’s just, on this blog, I’ve seen you kind of talk AT them without taking into account what they say.

          • JR

            You’re the one who keeps harping on bathrooms. :)

          • DoubtfulGuest

            Because it’s kind of important? I’ve been trying to be polite, but frankly some patients with mental problems could make advances on staff if they shared bathrooms, and say weird things to them. I can’t blame staff for wanting a moment of sanctuary where that can’t happen. All health care jobs are hard and stressful.

            I have never once gotten personal with you, only criticized the care model. It would be nice if you could answer my questions. And give examples of the doctors’ responses when you listened to them, please? G’night…

          • JR

            As I said before: I’m not here to change anyone’s mind. I’m here to ask a few questions and provoke people to think. That’s it.

          • JR

            I think my other comment was eaten so:
            I can’t even respond to that, just, wow.

          • DoubtfulGuest

            None of our conversation is showing up in my Disqus. I’m having problems with it. But I get notifications of replies in my e-mail. Would you like to talk?

          • DoubtfulGuest

            JR, I apologize for coming across like I’m criticizing you personally. I don’t mean it that way at all. It’s just that some of the recommendations of TIC could seriously backfire on patients, especially outside a mental health care setting. Many doctors think patients with a history of abuse are going to be manipulative, entitled, even sociopaths. There’s a lot of medical literature essentially saying that, although the studies tend to have methodological problems. We need to consider how the way we come across might affect how other patients are perceived.

            Pretty much everyone on Kevin’s blog comes in with an agenda of sorts — or to spin it more positively, things that are important to them that they keep bringing up. But we also have to listen to others’ experiences and opinions. These are huge problems to be addressed in health care. And I’d be very supportive of what you’re trying to accomplish if you took that approach.

          • JR

            And here I think I have a moderate approach.

            When I tell people things that have happened to me, they are shocked and apalled. They don’t understand how anyone could do such things.

            Part of processing that is becoming more aware of physician’s perspectives and also understanding their training. The things that happened to me consist of two categories: 1. Things they were trained to do or 2. coping skills that were developed to deal with a difficult and stressful job.

            Now, I could take this approach: Doctors and Nurses are evil and sick and live to cause pain in others.

            I cant though, because I know that they believe they are trying to be helpful, even when they are doing things that are harmful to patients.

            Because certain beliefs are so ingrained into our medical system, it’s difficult to oppose them. I know just talking about them with someone won’t change their mind.

            But it will sometimes open the door a crack. It will make them reconsider. It will make them wonder “maybe I should think about x issue and the impact it has.”

            And over time, it might evoke some change. I talk about “training” because doctors and nurses are taught that certain behaviors and processes and procedures are “good” and “ethical” and “correct” and believe it through and through to be that way.

            I also say “training” because our current understanding of trauma goes against long ingrained cultural beliefs which are hard to see past. Someone won’t just one day wake up and understand it, they need exposure to the ideas to gradually come closer to understanding.

          • DoubtfulGuest

            Have you tried just talking about them with someone? I have not seen give and take between you and doctors here. Would you please address my specific concerns about TIC? You don’t seem open to anyone else’s perspective here.

          • JR

            Talking about what with who? I’ve actually had a lot of conversations both here, in person, and elsewhere on the web.

            And I talk over and over about respecting the trauma that other’s have been through – even physicians – and how it impacts and effects them too. I respect that perspective, not so sure why you have read past that.

          • DoubtfulGuest

            There is more to the picture than trauma. Would you please address the time constraints and resource limitations? Life does not center around trauma. It should not define who we are. It is one aspect of life to be dealt with. Our society needs to become more compassionate in general. Part of that is dialing back our own requests for attention or help and *asking* other people what they think, feel, and need.

          • buzzkillersmith

            Agreed.

          • DoubtfulGuest

            I’m mostly in agreement here, but this might be a good time to ask, when patients do have these problems, what’s the best way to approach it with the primary care doc so the doc will be the least bored and annoyed possible? (Perhaps a dancing gorilla?)

            Your reaction is understandable, and, yes, I think you all feel the same way. But I can see patients feeling pretty downhearted and burdensome just for broaching the topic. People should be able to tell you they have the problem, right? And it doesn’t mean they expect you to fix it yourself. But docs sometimes recoil at the mere mention of any psychosocial issues, no matter how reasonable the patient’s expectations may be.

          • buzzkillersmith

            Answer: You need at least a half-hour appt for this problem and no other problem. If you add in hypertension and diabetes and so on, you’re beating up on the doc. I really can’t blame you for it, but you’re beating up on the doc. Remember he has 25 more pts coming down the pick–and maybe a night shift.

            If you have half hour, the doc will listen. If you have 10 or 15 minutes, both you and the doc are unhappy.

            The problem here lies in the hamsterwheelification of primary care, itself driven, in private practice, by wicked and worsening overhead and administration. If you work for a hospital, your CorpMed taskmasters don’t care if you and pt are unhappy. If you get sued they start to pay attention but otherwise it’s all good.

            There is no answer. Check that–there is an answer for med students, if not for pts. Don’t go into general medicine.

            Of course you should not have to manage anxiety/depression on your own, especially since we can help.

            People in Africa could also benefit from physicians to treat malaria and such, but often those docs aren’t around. Same with the USA.

          • DoubtfulGuest

            “Hamsterwheelification” is the best neologism I’ve heard in a long time. Many patients don’t know if they can ask for a longer appointment. If insurance won’t cover it, can they ask to come in as a self-pay for that? Or is it better to request multiple shorter appointments? I would like doctors to recognize the difference between patients who try to dump multiple complex problems on them, versus patients who simply HAVE the problems, and aren’t sure how best to fit them in with the system constraints.

          • buzzkillerjsmith

            I’m not blaming the pts here really. Pts are sick and are just visitors in the jungle of medical care. They don’t understand the dynamics, and, frankly, most docs don’t want to discuss the dynamics because it is mostly pointless. Pts want care; they don’t want to give it. Rightly so.

            So what do docs do? They avoid primary care and those trapped in primary care (like yours truly) quit their jobs every few years or so and move out of town in the vain hope that things will be better elsewhere. Unless they’re trapped because of the wife and kids.

            CorpMed often puts docs on salary for a year or two and docs are livin’ the dream then. The marriage sours in 3 years max and then you start thumbing through the docs wanted ads in the AFP journal. And there are a heck of a lot of those ads.

            I’m sure you’ve seen quite a few docs come and go. If not, you’re atypical.

            Asking for a half-hour can be done. Definitely. You get more time and we get paid for the time. But as I said, pts are mostly scared visitors to the jungle. Multiple shorter appts is an option, too. Most pts hate that because they have to pay an extra co-pay.

            We surely recognize this and that and the other. Docs are pretty quick on the uptake. But recognizing that a beating is coming when you’re on your way to work doesn’t make the beating any less painful.

            There is no hope. Embrace the despair. I have. Oddly, it doesn’t bother me as much as it should. Maybe I’m still in the afterglow of the Hawks winning the Super Bowl. But I’m not betting on the farm on the Mariners.

          • DoubtfulGuest

            This sounds truly awful. I’m sorry. I’m a fan of hopelessness in small doses. I can at least laugh at the absurdity. Yes, I’ve seen the turnover of docs in my community. So that’s where they are, at some farther-away points on the hamster wheel of doom.

            It’s nice to know that longer appointments are an option. I bet quite a few people would ask, and some would be fine with the extra co-pay for multiple shorter visits, rather than beat you all up if they knew. I appreciate your time and the thorough, if disheartening, explanation. Have a nice weekend.

          • querywoman

            I like to use malaria as an example. I could get it in the US, and I’d want an African doctor.

          • buzzkillerjsmith

            I saw a case a couple years ago. Most impressive, but not in a good way. Treatment is easy as pie unless the pt has kidney or liver failure–oral meds. In a couple days he was looking healthier than I was.

          • Patient Kit

            NOTE TO SELF: if I ever happen to be severely depressed, paralyzed by anxiety or panic or feeling suicidal, do not mention it to a primary care doctor!

          • buzzkillerjsmith

            Now you’re gettin’ it!

          • Patient Kit

            I would never expect my primary care doc to be my therapist. I do expect a PCP to treat me as a whole person, not just as a disease, preferably a disease that you are interested in. I’m sorry that you are so bitter and hate being a doctor so much. We’re all grappling with major change in healthcare and in the world in general. I understand the issues of time and money. They effect me at least as much as they effect you. But I think I’d rather try to self-treat than end up in the so-called “care” of a doctor that hates being a doctor as much as you seem to. Trust me, you all don’t hide how you feel from patients as well as you think you do. It’s no wonder that so many patients have started treating PCPs like Rx vending machines and consulting Dr. Google. I get your deep sense of betrayal — that this isn’t what you signed up for and worked hard for. I get it because I feel betrayed too — by doctors who hate being doctors too much to care. My specialists all treat me with compassion. But, oh yeah, PCPs don’t get paid enough to care like specialists do. We get it. You’d care more if you got paid more.

          • Suzi Q 38

            “….It’s not a “self control” issue at all – it’s biological functioning. So the “self control” nonsense gets old fast. And that’s not “telling people to blame others” but rather “recognizing the root cause of the problem so the problem can be solved.”

            I don’t agree. I did loose the weight after being overweight for about 20+years.

            One day, in my doctor’s office, my doctor of over 20 years told me I was “Waaay too fat.”

            He was right.

            He told me he was truly worried about my developing diabetes and heart disease.

            I figured out the “root cause” of my weight gain.

            I liked food. My favorites were based in sugars, fats, and salt. Fried foods were even better.
            I loved going out to eat at restaurants.

            A truly strong and fizzy Coke was a fantastic “pick me up” in the afternoons. Dessert after dinner was divine.

            I wasn’t unhappy in my marriage, I had some childhood issues, but that was long ago.

            I just had fallen into a rut of eating whatever I wanted and in any quantity that I wanted.

            I hit an all- time high of 190 pounds on my large, 5’6″ frame. I wore a size 16.

            Biologically, I should not have had a problem with weight, as most people of my culture are fairly thin

            (Asian).

            It took time for me to be sick of being fat.

            Self control worked for me, but I will admit it doesn’t work for everyone.
            I used to hate the idea of the lap band surgery and such, but some people are so fat, they need it.

          • JR

            Let me tell you about chronic illness. When you are chronically ill, your body doesn’t work right. So the things that normal people can do, you can’t do.
            When it’s cold out, other people can move around and get warm. As a child, I’d move around and get colder. My nose was swollen shut with inflammation, so I was breathing the cold air in through my mouth and straight into my lungs, where my throat and lungs would freeze. Even at a mild 60 degree weather I could not run outside. It wasn’t until years later I even learned one could breathe through a nose. I didn’t know it was possible.

            Other people feel good when they exercise. I would feel ill.

            Every morning I was sick to my stomach until around 11 am. Then I’d finally be able to eat, but I could not tolerate to eat before then. Breakfast was out of the question.

            Eventually I got to the point where I couldn’t manage stairs because of my joint pain.

            A few days ago, I was working out and all the sudden I felt good. It was totally weird – I’ve never experienced that before. I’m guessing it was some kind of adrenaline rush. I guess other people spent their life feeling that way when they exercised. It makes sense why they’d not comprehend that someone else doesn’t feel that way – but not everyone can exercise like I can now. I feel very lucky.

          • DoubtfulGuest

            I also experienced that surprised feeling good with the exercise – it’s really something. Healthy people do have to push themselves to some extent, to stay on track with their workouts, but there should also be an element of fun in it.

            I have to agree with you that weight is not always a simple matter of willpower. I mean, we have to try everything we can to get better. But there can be underlying biological reasons that it’s a major struggle. Doctors: it sure does help to have the correct diagnosis and treatment for one’s disease. Funny how motivation can improve overnight…

          • Suzi Q 38

            I am happy that you finally can exercise and feel good when you work out.

            I was feeling back pain and aches all over. I decided to exercise anyway, and work through the pain, slowly and deliberately.

            I will admit that I feel better, and have more stamina.
            I hope to lose 10 pounds this year.

            Last year was rough because I couldn’t exercise.
            The reason was that I had to rest after my cervical spin surgery and my knee surgery.

            The neurologist finally told me last month that it was O.K. to exercise more.

            About 2 weeks ago, I started to exercise 45 minutes to 1 hour, 5 days a week.

            I feel so much better.

          • buzzkillerjsmith

            The AAFP is 100% morons. I should know. I’m a member.

            Teaching people about good habits does not require a doctorate degree and several years of postdoctoral training. It is a waste of our time in these shortage days. Maybe if there were more of us we could chat enjoyably with our patients whilst relaxing in our easy chairs –chat about cutting down on the Fritos, the unfiltered Camels, and the Pabst Blue Ribbon ( cut down a little, but not too much), but that’s never going to happen.

            Let the nurses do this job, or the MAs, or the people on the local news, or whomever.

            Our job is to patch people up once bad health habits or time or bad luck have messed them up. Our job is disease diagnosis and treatment, not health maintenance. In truth, that’s always been almost our entire job.

            Don’t listen to the AAFP. Listen to me instead.

          • JR

            Well, medicine is really good at identifying/treating the things that kill us suddenly, and not so good with the things that make us sick for a long time but don’t kill us.

            I’d much rather die suddenly but live healthy up until that point. Different priorities for different people.

          • DoubtfulGuest

            But what is the patient’s responsibility for that? And what about all these other health professionals who are qualified to help with maintenance/prevention? Why so much pressure on the primary care doctors?

          • JR

            My friend has good private company insurance, but they won’t pay for a dietitian unless she has a diagnosed illness. Obesity doesn’t count.

            Same with physical therapists, they are generally only covered for a short time if someone has an injury or serious illness. I know someone who did physical therapy, then paid out of pocket for a personal trainer after their PT was no longer covered for a back injury.

            There are some medical plans that cover weight counseling, but only at a PCP, and generally only if there is a specific illness where lifestyle changes are indicated as treatment.

          • DoubtfulGuest

            Okay, I didn’t know that. I was wondering about access being a problem and can’t say I’m surprised. But what I hear doctors saying is, why aren’t we taking this up with the insurance companies who refuse to cover treatment that makes sense? Why are we piling that expectation on the PCPs?

          • JR

            About 85% of health care is chronic illness. And most chronic illnesses can be helped with lifestyle changes. Most of what PCPs are doing is dealing with the chronically ill. Healthy young people rarely get even yearly wellness checks. It’s the chronically ill that visit their doctor every 3 months.

            My doctor asked me about exercise and I said I didn’t know where to start, I’d gotten so weak from my illness. So while he was documenting info into his EMR (another touchy subject here!) he had me watch a youtube video on how to do some modified core body exercises. I’d never heard of this “core body” thing. Now I have a whole routine of them. Certainly didn’t waste either of our time.

          • DoubtfulGuest

            That sounds great. But maybe he has a personal interest in those exercises and does them himself. It’s not that they can’t make occasional suggestions, but it’s not their area of expertise. Some people don’t do well with core training at all, and the doctor shouldn’t be penalized if that suggestion doesn’t work out. It seems just as okay or even better if he had referred you to a PT for a long-term exercise plan. And we should push our insurance companies to cover that kind of preventive care. That’s really between us and them, not us and our doctors.

          • Patient Kit

            In general, our healthcare system addresses acute illness and injury far better than chronic illness. Many insurance plans severely limit access to physical therapy, dietitians and treatment for mental health. They like those things to be handled lickedy split in as few sessions as possible. And access to those services is equally limited by many people’s inability to pay out of pocket for them. However, it’s unrealistic and unfair to expect primary care docs to take all that on, especially in the current healthcare economic environment. We’re pretty much on our own when it comes to some of those things. We can hire psychotherapists and personal trainers if we have the money. Me? I just go to my local Y 5x a week and workout without a personal trainer. It’s nice when I get a word of encouragement from my docs though when they see progress being made.

            That said, it’s ironic that we hear constantly about the obesity epidemic in the US and how it causes many of the chronic conditions that drive the overall cost of healthcare up. Yet insurance doesn’t seem to want to pay to treat obesity.

            I’m all for individual personal responsibility. But, clearly, a lot of people need help, in some form, with this. There is a huge weight loss industry with assorted good and bad answers. There is an industry for everything. Big Pharma. Big Food. Weight Loss. Healthcare.

          • buzzkillerjsmith

            Indeed. But if you think hat I and my ilk can keep you healthy, you have another think coming.

          • querywoman

            Morons make the world go round.

          • Suzi Q 38

            “…..Patients shouldn’t be chastised for engaging in unhealthy behaviors….”

            Why not?
            My PCP chastised me for being about 40 pounds overweight. this was because my A1c was about 7.1, an all-time high for me.
            He didn’t realize that yes, my weight and eating habits were bad, but I also was not exercising.
            After I changed my diet and added exercise, the weight and blood sugar values came down.

            I also had a hunch that my statin may be messing with my blood sugars. After I stopped those for 4 months, my blood sugars really came down.

            I still remember my doctor’s words:
            “You are waay too fat.”

          • querywoman

            Chastising me for being fat never worked. It doesn’t work for most people. However, I was well trained on how to use my insulin and gradually kept dropping my dose. Insulin can cause weight gain. And then I went on Victoza and dropped more pounds!
            It’s a pity my experience has nothing to do with anyone else. The only relevance is that it means doctors are getting new tools in their arsenals.

          • DoubtfulGuest

            A good point anyway, QW…cruelty is never the answer. People respond better to different approaches. I know someone whose cardiologist (a very gentle and tactful man) put it this way: “When I start to see more of you…I need to see LESS of you.”

          • querywoman

            My endo and I have a good relationship. I know he barely understands why the Victoza works so well for me. It literally cuts my carbohydrate cravings. I never understand why I couldn’t stop eating cake or cookies before.
            Sometimes I think I should write the manufactureer and tell them about our experience.
            Victoza is obviously treating my insuliin resistance, unlike insulin which treats deficiencies.

          • Suzi Q 38

            You are lucky.
            Most doctors do not have the time to be dietitians.

        • DoubtfulGuest

          Thanks for the information, JR. I’ve been trying to reply for some time but have had trouble with Disqus. You raise some really important issues and I think this would make a great topic for a guest post. I have some concerns about this training because I truly believe that most people in health care are naturally compassionate. But different parties are always wanting to “train” them without having meaningful two-way conversations about their experiences or the issues at hand.

          I’m not a fan of “consumer” language used anywhere in health care. I agree there are some deeply entrenched patterns of interaction that medical folks learn and subject their patients to that are unequivocally damaging, and not consistent with their mission to care. I can think of several examples of things they do that I would like to change, or at least have a discussion about why they do it. For example, why do medical people say: “You’re going to feel” a certain way, like with injections or personal examinations? I’m like, “Huh? I’ll decide what it feels like…now you’ve thrown my whole coping mechanism out of whack. I was fine til you said that.” Does anyone want to be told how they will feel? I think it comes across better to say: “Many people tell me this hurts, so I’m sorry. I’ll be careful”.

          But there are many items in that presentation that seem appropriate only for mental/behavioral health professionals. Others appear inconsiderate toward the professionals providing the care. For example, if I was seeing a psychiatrist and they maintained a separate bathroom in order to feel safe throughout the day, do their business and gather their thoughts in a few private minutes away from patients, I can’t argue against that.

          I wonder how this all plays out with your doctor now? Have you talked with him about your feelings? I don’t have a PTSD diagnosis, but I had a previous abuse and trauma experience that negatively affected my health care. So I’m not asking these questions as an outsider. I’m actually very supportive, with some caveats as I mentioned. This isn’t the right post to go much further into this topic, but I hope we’ll have the opportunity to discuss it more. I also think that you’d get a more positive response from doctors if this were not approached as “training”, but a constructive discussion about how to make the health care environment more respectful for everyone involved.

          • JR

            Unfortunately since it’s a slide from a presentation, they use a lot of abbreviations – but it’s quicker to read through. The same information fully written out would be a very long book. :)

            The thing with trauma is that our society is that we don’t recognize it. Three responses are fight, flight, or freeze.

            If you find this video disturbing, don’t watch and just listen to the way it’s described. It’s… a whale attacking it’s trainer (he lives). They describe him being totally cool and calm and rational and knowing what he’s doing. He’s obviously not scared.

            I watch this and see someone in full “freeze” trauma mode. Perhaps it’s because I’ve seen that in action before. But this isn’t seen as a traumatic reaction, it’s seen as heroic.

            http://www.youtube.com/watch?v=SgwJUNDBD18

            How can people learn to recognize this person is NOT ok and may need immediate counseling without training?

          • DoubtfulGuest

            I was okay to watch the video, thanks. The guy looks scared $hitless to me! I don’t have a problem with what you’re saying here. It’s just that some of what this care model is expecting of doctors and nurses presents a serious problem for their time constraints and their own stress management. In a way, it’s abuse of our health care professionals to keep piling on more stuff for them to do. Not this program specifically, but everything that’s expected of them these days. In particular, the “consumer” perspective bothers me. That’s why, instead of training, I think it could be more of a mutual conversation to accomplish the same things. I am completely in favor of greater sensitivity and compassion.

          • JR

            Well keep in mind that particular slide show isn’t about what an individual provider should do, but is about what an organization should do.

            For medical personnel, it’s really more about learning to recognize trauma reactions and knowing what to do when facing a patient that is having that reaction.

          • DoubtfulGuest

            In a system with such limited resources, though, some of the advice is impractical. Why the “integrated bathrooms”? Lots of businesses have separate bathrooms for staff…why are we even thinking about where they answer the call of nature? Some of the talking goes way beyond the time they’re allowed to spend with each patient. Mental health problems need general compassion and mental health care. I do agree doctors can get way better about explaining what they need to do and, more than anything else, just cut the patient some slack if they seem anxious.

          • JR

            You’d have to contact the authors to find out why they recommend it, I haven’t seen it recommended in the other literature I’ve read. They may have been addressing a specific situation in that slide.

            And remember TIC is about recognizing that ALL people engage in negative behaviors as coping skills for stress. ALL people. Learning to recognize that is important to providing care, no matter what kind of care you provide.

            These are recommendations for schools, hopsitals, social care facilities, and criminal justice systems.

            The thing is – mentally ill people should be given medical care too. They need to have blood tests, surgery, emergency treatment, etc. They can’t get that care if no one knows how to deliver it in a way that makes them feel safe.

          • DoubtfulGuest

            Agree. But even the mentally ill need to adapt to the health care system constraints that everyone else does. Should we work to improve the system at the same time? Of course. My main concern is that some of the changes suggested, can potentially step on the rights of other patients or the professionals providing the care. There’s unfortunately a lot of medical literature out there saying that people with a history of abuse are more likely to engage in inappropriate attention-seeking or even be faking their illness. Basically that they expect to special treatment. Some of the recommendations you advocate could actually reinforce those beliefs, which are not very scientific but have apparently widespread support. If we’re going to change this, we have to also look at the resource limitations that put so much pressure on doctors and push them to make these kinds of snap judgments.

    • querywoman

      Have doctors always blamed patient lifestyles for illnesses? Let’s see, if one works a lot of hours, one may not have time to cook the most nutritious foods or to exercise. If you work certain jobs, you get occupational health problems. Some people keep working at jobs that are destroying them just so they can keep their health insurance. How about the many bodies that are born with defective parts? How about infectious disease?

  • Dorothygreen

    Right or privilege (of health care) – How about just a reasonable interruption of the “general welfare” clause. Every modern, rich country has something like this. In Switzerland it is put simply that “the whole healthcare system is geared towards to the general goals of enhancing general public health and reducing costs while encouraging individual responsibility”.

    There is a mandate that everyone has health insurance. There is regulation and monitors so none of the players ie. hospitals, pharma, insurers, others rip off the government or citizens or each other. The government (federal and cantons) regulate and insurance administers. Basic insurance cost is same for all – want choice higher premium and it is affordable enough so that 70% of country chooses “choice”. There are other “perks” insurance can sell. This is a reasonable way to go for the US, is it not?. Those who want smaller gov – get the health care adm out of gov (but it will still be good to pay into old age care – this would be Medicare off fraud, waste and excess care) and those who want the single payer model will have it through pretty through government regulations. Some for single payer say Switzerland’s health care leaves too many people hurting. Well, we can work through that can’t we? Make it even better than? or does this all make too much sense for Congress and is too threatening to their owners – the “corporation people”

    What the author says if “a right” then single payer ie. government regulated and administered. If not than it’s all “free market”, no mandate and by the way under these circumstances the law that people have to be treated if they come to the ER, must be repealed. Yes, and it will be a “free for all”.

    • Lisa

      Switzerland’s Heatlh care insurance is really a version of Obama Care:

      1) Having nsurance is mandentory and is not employement based.
      2) Insurance for lower income people is subsidized. The month premium can’t exceed 8% of personal income. If it does, the governement subsidizes the cost.
      3) Insurers can’t turn down anyone or delay coverage due to age, medical history or health risks. They are also not allowed to profit on the basic package. They can make money seling supplemental coverage, for things like alternative medicine and private hosptial rooms.
      4) 99% of people are covered.

  • PedsDad

    And yet, when the door closes and we are face-to-face with a patient, learning about his life, guiding him to better choices, treating his illnesses, heck even curing him sometimes, it’s the best job in the world. (And the pay’s not bad either.) I feel so sorry for people who seem so pessimistic about being doctors. When we let computers and algorithms and Press Ganey scores and politicians become what defines healthcare for us, then, yes, everything points to pessimism. But when I shut out all that noise and focus on me, a patient and a problem…I love my job.

  • DoubtfulGuest

    So, I guess it’s a matter of nuance and how much time it takes. I can’t argue with your flu shot example. I just think, in most cases, the detailed background of trauma is not something they are qualified to deal with. Do we want them to even try? They’re very fallible people with biases and their own personal problems. At least mental health professionals are trained to put those aside…never 100% successful, I expect. I’m not even sure it’s a good idea for primary care to prescribe psych drugs, because I think it creates confusion among the public about what problems they can and can’t address.

    They should respond compassionately, e.g. patient has a domestic violence situation, refer to appropriate services and follow up with the patient. But they are being held *solely responsible* for way too much. And some of them might feel like they’d be signing up to ask “What ha–” even if the patient lunges at them and physically attacks. That’s not okay. Their rights and safety matter, too.

    I do think overweight people deserve compassion. There are few things I detest more than when people make fun of a fat person exercising. I do think doctors should recognize the person is under a lot of stress and having trouble coping. It’s not a moral failing. But all patients should consider how our problems may negatively affect others, and try to do something about it. Hospital personnel can be injured badly, e.g. dislocated shoulder, trying to assist and move a patient who is morbidly obese.

    I have severe fatigue with my disease which has made me run late for several doctors appointments because I had trouble getting ready, had to keep resting in between. Which adds a lot of stress for them and screws up their whole schedule. So, I had to learn to allow extra time to get ready, because of the problem I have. They should understand sometimes sick people are late, BUT it doesn’t mean I didn’t have to do something about it. Most of the examples you bring up are perfectly fine, it’s the “training” aspect with no consideration of the health professionals’ needs, that I can’t agree with.

    • JR

      I don’t think psychiatrists (though medically trained) generally perform pap smears, or draw people’s blood, or give someone a CT scan…

      But the people who do those tasks need to be trauma informed so they can help those who need those things done.

  • HR

    Excellent list. My other half, a chiropractor, and I began the day watching an Author@Google talk by Kelly McDonigal; we talked about how to best embrace her message in our practice, and then we commuted to the office which is in a gym where we watch people “exercise” … and eat fast food … and remain stubbornly fat, inflamed, ill, depressed.
    We have spent (invested? wasted?) an inordinate amount of time on the EHR, Meaningful Use, PQRS compliance issues and it would be ridiculous to say those efforts have made our patients healthier, or motivated. Or that it has improved our practice’s bottom line. It hasn’t. Mostly, the hype around these activities, and “Affordable Care” has just pissed me off.
    With an IT/marketing background, I am collecting ideas on how to get off insurance, to go to cash, and when I explained my mission to a billing specialist at another chiro office, she said, ‘yeah, well, and there goes my job.’ I love figuring out how to improve processes at the practice using technology, however it is with the goal of freeing up people to do things that really matter, like healing, not clinging to an outdated process and system that is horribly inefficient and only bound to get moreso come October with ICD-10. God help us.