Things you wish primary care doctors would know

[tim]

The following question was posted on a closed support group that I read on Facebook:
I'm applying for residency to become a family medicine doc. Chronic pain and illness is a huge part of taking care of patients, and I want to know your opinion on your healthcare experience. What did you like/dislike/need/receive/not receive from the healthcare field. What is a small thing that would have made a big difference? How can I become a great doctor for my patients? How can I teach others/emulate behaviors for others to become better doctors? Thank you!

I'm copying my reply here to save it for posterity:

I would love it if more doctors understood Health at Every Size (HAES) - specifically, the role of weight stigma, largely inflicted by the medical profession, as a barrier to health care and cause of stress-induced illness and shorter lives for many fat people. It would be great if they understood it comprehensively, but even if they just understood that there is no evidence that intentional weight loss improves health outcomes, that would be great.

Understanding that trans people are biologically the sex that we affirm ourselves to be would be great.

Understanding that the boundary between physical and mental illness is political, not scientific, would be great, as well as the role of abuse culture manifested through childhood trauma in causing both, and how widespread PTSD and CPTSD really are.

If you haven't, read everything by Paul Farmer that you can (especially _Infections and Inequalities_ and _Pathologies of Power_.)

Finally, I wish more doctors would treat a patient who does their own research on their own condition the way they'd treat a student they were mentoring, rather than shaming such patients for 'going on the Internet'.

If you have anything else to add, I'll try to pass it on to the person who asked, as best I can!

Comments

[azurelunatic]

My favorite doctors have been two doctors in different fields who told me essentially the same thing -- they may be the one with the medical degree and extensive training in the treatment of things, but I am the expert on living in my own body. They see me for a short appointment. I live in my body every day.

[cleverthylacine]

If I hadn't "gone on the internet" my celiac disease wouldn't have been discovered until I went into celiac crisis--apparently the TTG test produced an actual panic value because 2 doctors called me the day they got it to tell me to stop eating gluten NOW and not worry about the biopsy. This was a test I got by using the magic words "let's rule it out then" because I work for doctors. Most people don't know those magic words. For over 20 years I had been taking a ridiculous number of diabetes tests (protip: I don't have diabetes) because of my weight but was never tested for celiac because I'm adopted and it's a genetic disease--people either find out when they go into a crisis (their guts stop working entirely and they have to be hospitalised) or when a family member is diagnosed.

During that entire time I kept hearing that all my chronic pain and other issues would go away if I lost weight.

Everything got better when I stopped eating gluten. Ironically, it would all have gone away completely if I had stopped over 20 years ago when I first got sick. Even more ironically, I lost a lot of weight (though not as much as they wanted me to, LOL) because when your guts don't work right you are hungry all the time. It turns out that celiac disease is the root cause of nearly all my autoimmune issues, my infertility, my bad teeth and a whole lot of other shit. Some of them went on too long to reverse; I still feel a lot better, but if they had considered other potential diagnoses than "diabetes" I could've been healed completely long ago.

My comment would be:

1) always test anyone with chronic pain and mood problems for celiac because 1 in 133 people have it and most don't know;
2) consider other diagnoses than "you're too fat" for people who report chronic pain, especially in their LATE TEENS/EARLY 20s
3) not all fat people have diabetes, so don't stand there looking like a bump on a pickle when they don't have diabetes and you can't think of another explanatin.

I realise this is all HAES, but these are concrete examples.

[sasha_feather]

It's OK to say "I don't know", or that medicine doesn't have an answer. It is powerful to tell that to a patient and most doctors will not admit that they don't know.

[quartzpebble]

Currently on my mind: if a patient shows up with low-normal lung function and complains of coughing and pain while breathing after exercise in cold air, they may in fact have asthma and should not be given a rescue inhaler just in case and told "well, your peak flow looks fine, and no one likes breathing cold air." Also, not everyone is aware what wheezing actually feels like. I am not sure whether having a "normal" BMI and looking pretty active/"in shape" worked against me in this particular case or not.

After seeing a doctor who took this seriously ("How long have you had that cough?" "Oh, that's normal." "Coughing isn't normal," and "You're wheezing now and you don't know it...") I have *finally* been able to test peak flow after albuterol and guess what, I go from ~350 to >500!

Anyhow, I suppose the takeaways from that one are: cough-presenting asthma is a thing, just because someone has peak flow in the normal range doesn't mean that they won't respond to albuterol and don't have asthma, and there is a difference between breathing cold air being unpleasant while you're out in it and actively painful even after you come back inside. Oh, and one last thing: if someone is having problems complying with their treatment plan (and I hate the phrasing of "compliance"), make any options clear and don't add to any shame they may have for lacking the willpower/with-it-ness to take care of themselves. Work with them to remove barriers and don't just expect them to try harder on their own.

[megpie71]

A few from my own experience:

1) When I, as a mentally ill person with chronic depression, say I'm having trouble taking my medication on a regular basis, what I mean is there is an air gap between the thought "I should take my meds" and the chain of actions (get out of chair, walk to fridge, open fridge door, take medication packet off shelf in fridge door, open packet, locate blister-pack in use, locate next pill bubble on blister pack, remove pill from blister, replace blister pack in box, replace box in fridge door, close fridge, walk to kitchen sink, locate glass in cupboard below sink, fill glass with water, swallow pill, rinse down with water, put glass down on "dishes needing washing" side of sink) involved in taking those meds.

I do not mean "I'm not taking my meds because I want to stay sick". I do not mean "I'm not taking my meds because I don't like the way they make me feel". I mean: I am actually having problems, caused by my illness, with the whole process of connecting thought to action, and I would like some help with figuring out how to overcome this, please.

2) In any practice, a few of your patients will understand medical terminology. In any practice, a few of your patients will understand medical procedures. In any practice, a few of your patients will be as intelligent as you are, if not more intelligent than you are. In none of these cases are we doing it specifically to piss you off (although this may well be considered as an option in future).

3) If a patient tells you they've tried something you're suggesting as a treatment before (for example, losing weight) and it didn't work for them, believe them. It will save a lot of time, effort, and frustration on everyone's part. Other things which patients may have tried prior to coming to you: "thinking positive" to deal with depression; "being happy" to deal with mental illness; exercise, diet and so on to deal with persistent weight problems. Essentially, if you're looking at any long term condition a patient is just coming to you with, you'll get a lot of mileage out of asking "what have you tried already?" with regard to treatment.

4) Depressed people aren't miserable all the time. Depressed people are actually capable, in the most part, of simulating social happiness, smiling for cameras and so on. A fair old number of depressed people will do this in your rooms, to your face, because they've been brought up to believe it's not polite to inflict their bad mood on someone else. Don't take the presentation you're given in a ten minute or twenty minute interview that they've had time and warning to prepare for as indicative of their general state of mind.

5) No matter how ritzy the suburb your practice is located in, there's going to be at least one of your patients who won't fit the general demographic, and who will be needing subsidised, low-cost, or free medical services. You'll go a long way if you educate yourself about where the nearest ones to your practice are, and how to access them.

6) Above all else, please treat your patients as people.

[someonefromthewater]

This. Yes.

Still: the main issue I'm running into from the healthcare field seems to be systemic lack of availability and communication, particularly with specialists. Even if the doctors themselves seem like totally awesome if overworked people when you get them face-to-face, it's not much use if you can't communicate with them outside of scheduled appointments and it takes 3-6 months to schedule such appointments.

Also anything involving language like "women of childbearing age" and stupid medical decisions that prioritize reproductive viability over immediate wellbeing and safety without patient involvement.