Reality Check 2 Posted October 3, 2016 Author Share Posted October 3, 2016 not new issue but renewed today ----- 40ish female comes in to discuss "anxiety" - on an SSRI at moderate dose for >15 years. Old psychiatrist retired. Didn't get a new one. Sees a counselor. Says the counselor told her to come see me for lorazepam due to "stress". I ask what kind of stress... you will have to pardon me if I am just a bit perplexed because her situation does NOT sound much different from my daily life - but we all cope differently. She has kids growing up, she feels stress at work, she recently remarried a man with no kids (not me, long term single marriage). She is "busy" and her mind seems to be constantly in motion to her detriment. She has recently become more "panicked" feeling and is waking up at night. She worries all the time. She states she had to have a DNA test to find a workable SSRI - a cheek swab - PLEASE anyone with knowledge - enlighten me here. She says she failed multiple other meds and doesn't even want to be on meds but wants the lorazepam for her "stress". We spend about 25 minutes talking about panic, stress, sleep disorder, anxiety, etc. I give her the no holds barred low down on benzos and my concerns. I let her know that her counselor cannot prescribe and, if felt that strongly, should have called me about the situation. She is offended. I suggest a new psychiatrist and considering trazodone at night or possibly low dose Seroquel or another newer drug to augment her SSRI. NOPE. Not going to do it. "and if anything makes me gain weight, I will go over the edge". Her BMI is 23........ So, she left the clinic with no rx but strong suggestions to get a new psychiatrist (hers retired) and consider alternative meds. Benzos are not long term and I think 30 pills should last a full year for panic disorder after an initial trial. She is not enthralled. Says I am scaring her. I ask what her counselor mentioned about meds - short term, augmented behavior therapy, hypnosis, guided visualization. The horn must have been growing from my forehead. She will complain. My office manager will be worried about her saying negative things in the community. My boss doc might even be a little miffed because I didn't give her any (she said she didn't want them after all) and I will know I did ok and did the right thing but will still worry about perception. I am not past that "customer service" thing yet after all........................... dammit Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted October 3, 2016 Administrator Share Posted October 3, 2016 I am not aware of a DNA test for SSRI effectiveness. If there is one, it's news to me, and I'd like to hear about it. We could definitely use a test like that. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted October 3, 2016 Author Share Posted October 3, 2016 https://genomind.com/news/new-evidence-shows-genetic-testing-may-help-target-use-of-antidepressants-2/ http://www.mayoclinic.org/tests-procedures/cyp450-test/basics/definition/prc-20013543 This is what I have found so far. Still doesn't help me with this patient who is completely unwilling to try anything but a benzo............................. Link to comment Share on other sites More sharing options...
Katera Posted October 4, 2016 Share Posted October 4, 2016 Most people don't follow-up because they simply can not afford it. That's not your fault, but in a lot of cases it's not their fault either. Co-pays, deductibles and out of pocket expenses are just insane in this country. The prices the labs charge for basic testing would be laughable if they weren't so disturbing. I had a tiny basal cell removed off my shoulder a few months ago. With the lab price and the 2 minute scrape it was $1100. The entire thing took less then 5 minutes. A complete joke. So my advice? Document, but take care of your patients the best you can with the resources they have, and give them a brake. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted October 4, 2016 Administrator Share Posted October 4, 2016 Most people don't follow-up because they simply can not afford it. That's not your fault, but in a lot of cases it's not their fault either. Co-pays, deductibles and out of pocket expenses are just insane in this country. The prices the labs charge for basic testing would be laughable if they weren't so disturbing. Yes, yes it IS their fault. It's a combination of poor critical thinking skills, combined with the "out of pocket" nonsense thinking. If your car breaks, you take it to a mechanic who fixes it. If you want to reduce future costs, you invest in preventative maintenance. Human beings aren't particularly different, but our mode of thinking about it--that somehow, one shouldn't have to pay for healthcare--is. Everything costs something. Now, I could argue that "discounts" that Medicare/Medicaid require are part of the problem, but that's a separate issue. Most of the people who "can't afford" follow up are not starving, have smartphones, Internet, and Cable TV. Plenty of them smoke and drink, too. To be sure... there are some people who truly can't afford it, but when most Americans (who have health insurance, which is why they're in our offices in the first place) say they can't afford healthcare, what they really mean is the out of pocket price is higher than they're willing to pay. Link to comment Share on other sites More sharing options...
cbrsmurf Posted October 4, 2016 Share Posted October 4, 2016 Here's a better article on CYP450 drug metabolism testing: https://www.ncbi.nlm.nih.gov/pubmed/23588782 I remember I had a sales rep try to push this on me a while ago, but I honestly never thoroughly researched it and never used it in practice (I can't recall anyone I know who orders it either). All I really knew beforehand is that there are some ethnicities that can process certain drugs differently Link to comment Share on other sites More sharing options...
Reality Check 2 Posted October 4, 2016 Author Share Posted October 4, 2016 The psychiatrist who ordered this testing on her is someone I liked working with but never got the chance to discuss this with him before he retired. This patient cites a history of multi drug failure and intolerance and seems to be quite concerned with any perceived side effects. Part of the diagnosis of anxiety includes the fear of meds and fear of all side effects. A very hard barrier to overcome. I don't think I would use gene testing in practice as a family practitioner because of the time constraints. This patient frustrates me because I don't think her expectations of life are realistic and she is so completely unwilling to try anything or even see a new psychiatrist - the whole "just give me a pill (lorazepam)" thing rubs me the wrong way. Once again - I want to start handing out big girl panties...................... Link to comment Share on other sites More sharing options...
Katera Posted October 6, 2016 Share Posted October 6, 2016 Let's start talking statistics if you two want to continue on this subject. These are opinions about the scope of the problem. GREAT IDEA db_pavnp! @Rev Ronin...these are for you. Happy reading unless you dislike those finicky things called "FACTS".......Or perhaps you don't trust Gallop polls either? ;) http://www.gallup.com/poll/179774/cost-barrier-americans-medical-care.aspx or perhaps this? Why 1 in 3 Americans Is Scared to Go to the Doctorhttp://time.com/money/3611885/healthcare-costs-insurance-delaying-care/ Uninsured Americans aren’t the only ones delaying medical treatment. Some 34% of Americans with private health insurance say they’ve skipped out on care because it was too expensive, up from 25% last year. Additionally, 28% of households that earn $75,000 or more report that family members have delayed care, up from just 17% last year. One likely culprit? Rising out-of-pocket costs. Americans who get healthcare coverage through their employers have seen deductibles more than double in the past eight years. Mic drop. It's too expensive...Period. End of discussion. Not their fault. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted October 6, 2016 Administrator Share Posted October 6, 2016 People not prioritizing out-of-pocket healthcare spending simply proves my point. That people think healthcare out-of-pocket costs are too expensive isn't under contention, and the randomly survey'ed public's opinion on the matter doesn't establish anything other than their opinion. Mic drop? Please. As I've said in other threads, these sort of sound-bite-focused antics are far too commonplace in American society, and do nothing to actually establish constructive dialogue. If you want to infuse the discussion with facts, please feel free to do so. But don't confuse opinion polls, which are valid in their own right, with facts about the actual costs of healthcare. Link to comment Share on other sites More sharing options...
Maverick87 Posted October 6, 2016 Share Posted October 6, 2016 Threads like this make me happy that I'm out of family medicine and in a specialty. Just out of curiosity: if you all don't like the field, then why do you stay? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted October 6, 2016 Administrator Share Posted October 6, 2016 Just out of curiosity: if you all don't like the field, then why do you stay? Didn't say I didn't like it. Trying to get through to patients about how to help themselves is frustrating, but rewarding when one of them actually "gets it". Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted October 6, 2016 Share Posted October 6, 2016 One way to look at this is that I've always expected folks to have common sense and to utilize same. Regardless of population (rich, poor, insured, uninsured, black/white/green/striped), this seems to be the greatest determinate in whether or not as Rev says "they get it". You don't take your car to the shop, have them call you and say your brakes are the source of your problem and that they need to be replaced, and you reply by saying "just replace the battery". This unfortunately is how a not insignificant portion of the human population respond. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted October 6, 2016 Author Share Posted October 6, 2016 It is not that I "hate" family practice. It does get frustrating with varied populations, insurance restrictions and the US Healthcare System as it is. I got bored in Ortho because of my egomaniacal Napolean like surgeon and having a very very narrow scope of practice. Occ Med can get frustrating with workers' compensation bureaucracy. EVERY single facet of medicine can have its frustrations. Having this forum to vent and collaborate with colleagues is where we can air our outside voice and get some release and insight. My take on insurance and noncompliance -- Folks always want something for nothing. They think paying premiums covers everything. It doesn't. I have 20% COINSURANCE on top of deductibles. My family pays over $1600 per month for insurance through my husband's union job and the union dues contribute some to that. I get upset with folks who still get their nails done, hair extensions and processes, cigarettes, going to the casino, tattoos, special wheels on the car, car stereos etc etc etc etc but they say they CAN'T pay their copay or coinsurance. They will buy $150 a month in bizarre supplements and go to the chiropractor but still say they can't "afford" to come see me. It is a budget folks. You have insurance. There are copays. There is coinsurance. You KNOW you have to go to the clinic at least once a year for a physical - BUDGET FOR IT. If you have chronic diseases - you will be seen more often and that IS the standard of care. Kind of like paying your mortgage or paying for an oil change - medical care needs to happen. The existence or lack of insurance does NOT change the standard of care or how we do things ethically or based on medical evidence. So, if the actual number one reason folks don't comply is they think they can't afford it - well, their perspective and priorities don't match with medical treatment recommendations. I hate that some folks have been put in a situation where they have to choose between rent and their medication costs - there are truly patients who struggle with working class poverty. That is not who I am talking about now. Patient responsibility, personal responsibility, lack of education and understanding and just plain lack of caring are the problems, in my opinion. Link to comment Share on other sites More sharing options...
shani26 Posted October 22, 2016 Share Posted October 22, 2016 I like inner city medicine- able to establish relationships and see some good done. However still keeping my eyes open for a speciality I can see myself doing. Link to comment Share on other sites More sharing options...
Maverick87 Posted October 22, 2016 Share Posted October 22, 2016 I like inner city medicine- able to establish relationships and see some good done. However still keeping my eyes open for a speciality I can see myself doing. You'd be surprised at what specialties turn out to be interesting. When I was looking for work, I joined the practice that I thought would have the best environment. Interesting enough, it also turned out to be a very interesting specialty. Link to comment Share on other sites More sharing options...
shani26 Posted October 22, 2016 Share Posted October 22, 2016 I like inner city medicine- able to establish relationships and see some good done. However still keeping my eyes open for a speciality I can see myself doing. Link to comment Share on other sites More sharing options...
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