"Functional illnesses." What is your approach?

[hotsaws]

By "functional" illness, I'm referring to and lumping together a bunch of diagnoses: POTS, fibromyalgia, mast cell activation, chronic fatigue, multiple drug intolerances, EDS III, chronic itch, chronic pain, etc. (maybe IBS and interstitial cystitis and others I didn't list). Some of these might exist as a true organic disease in some patients but most of the time it's code talk for underlying psych issues. We have these patients in all of our varying specialties. I dread these encounters and they can be draining.

Curious to see what your approach is? Do you humor them and order some tests hoping to rule out whatever you know isn't there and relates to your field, so you can say bye bye without too much of a fight? Or if you're a PCP, do you just hand out referrals and hope for the best? Do you face the confrontation and suggest that it's in their head? Maybe prescribe some meds to target a specific symptom even though you know this isn't the core of the problem?

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[Crayola227]

By "functional" illness, I'm referring to and lumping together a bunch of diagnoses: POTS, fibromyalgia, mast cell activation, chronic fatigue, multiple drug intolerances, EDS III, chronic itch, chronic pain, etc. (maybe IBS and interstitial cystitis and others I didn't list). Some of these might exist as a true organic disease in some patients but most of the time it's code talk for underlying psych issues. We have these patients in all of our varying specialties. I dread these encounters and they can be draining.

Curious to see what your approach is? Do you humor them and order some tests hoping to rule out whatever you know isn't there and relates to your field, so you can say bye bye without too much of a fight? Or if you're a PCP, do you just hand out referrals and hope for the best? Do you face the confrontation and suggest that it's in their head? Maybe prescribe some meds to target a specific symptom even though you know this isn't the core of the problem?

I don't think of functional illnesses in this regard. And I would never suggest to a patient symptoms they feel are physical are only "in their head."

 

[chessknt]

I think it depends on what phase of the disease they are in. If this is someone who is repeatedly admitted for pseudo stroke or fibromyalgia pain crisis then you cant fix them as an inpatient, just don't play along and make them leave and expect 0 stars for that visit. I don't have any idea how to manage someone like that in the outpatient setting.

I think if it is someone who has been getting blown off (allegedly) and you take them seriously, perform any workup that hasn't been done and you think should be and, if negative, need to address the fact that there isn't a test that is going to diagnose a physical cause for their symptoms and that it needs to be addressed with a combo of PT and CBT. Some people need and benefit from medical cheerleading and if they have insurance I am sure someone can be found who will happily provide that.

 

[BorntobeDO?]

By "functional" illness, I'm referring to and lumping together a bunch of diagnoses: POTS, fibromyalgia, mast cell activation, chronic fatigue, multiple drug intolerances, EDS III, chronic itch, chronic pain, etc. (maybe IBS and interstitial cystitis and others I didn't list). Some of these might exist as a true organic disease in some patients but most of the time it's code talk for underlying psych issues. We have these patients in all of our varying specialties. I dread these encounters and they can be draining.

Curious to see what your approach is? Do you humor them and order some tests hoping to rule out whatever you know isn't there and relates to your field, so you can say bye bye without too much of a fight? Or if you're a PCP, do you just hand out referrals and hope for the best? Do you face the confrontation and suggest that it's in their head? Maybe prescribe some meds to target a specific symptom even though you know this isn't the core of the problem?

I would like to know also. From what I see in residency it’s just refer to every specialist and let them rule out the common things in their field. Which is a terrible waste of resources, but it seems like the patients at least like their PCM. I think at some point people just start giving low dose meds for symptoms in the hope that placebo effect will help you out. Naturopaths do this all the time with supplements. Except they act supremely confident in their made up diagnosis and are counting on placebo to bail them out. And when it does they have converts for life.

I don’t know what the right answer is. I know at night when I am getting hammer paged for 10/10 pain on a guy that already has a reasonable pain regimen and has been admitted for a month I just reach for 100mg of GABA to get them off my back. Surprising how often that works. Anyway, would love to here some others actual practice.

 

[Redpancreas]

By "functional" illness, I'm referring to and lumping together a bunch of diagnoses: POTS, fibromyalgia, mast cell activation, chronic fatigue, multiple drug intolerances, EDS III, chronic itch, chronic pain, etc. (maybe IBS and interstitial cystitis and others I didn't list). Some of these might exist as a true organic disease in some patients but most of the time it's code talk for underlying psych issues. We have these patients in all of our varying specialties. I dread these encounters and they can be draining.

Curious to see what your approach is? Do you humor them and order some tests hoping to rule out whatever you know isn't there and relates to your field, so you can say bye bye without too much of a fight? Or if you're a PCP, do you just hand out referrals and hope for the best? Do you face the confrontation and suggest that it's in their head? Maybe prescribe some meds to target a specific symptom even though you know this isn't the core of the problem?

Practically, it depends on what stage of training you are at. As a medical student/resident/fellow, let the patient vent to you about XYZ. Don’t expand on it with you’re attending unless you want them to think you think it’s a big deal. At the same time, think about what else could be in the differential. For example, I had a patient come in with a long history of IBS who self-assessed a recent change in bowel movements as due to eating a certain food and turned out he had something else. At the same time, you should anticipate what work up has been done already with the patient to work these issues up and you can buy time (a visit) by asking the patient to provide records from an outside facility which is part of their responsibility. As a resident, don’t pick up that patient and make sure they follow up with their PCP. These patients seem nice initially because they’re looking for a doctor to take interest in them and think they’re not high maintenance... but you better believe this will be the ones calling the hospital line and forcing the operators to page you while you’re on inpatient.

If you’re an attending, especially in private practice, you’re going to have to entertain them while upholding your principles and the standards of care. There are several academics who have carved out niches and study these disorders like fibromyalgia, interstitial cystitis, weird GERD/abdominal pain issues, etc. You can refer them to that provider after establishing a professional relationship/personal understanding with that physician. You can do this even as a specialist.

 

[hotsaws]

I am envious of the naturopaths and other alternative provider's ability to just prescribe placebo. We're stuck with our pseudo-placebos (gabapentin, Lyrica, an assortment of SSRIs/SNRIs, and maybe some vitamins/supps). They look them right in the eye and tell them about the "toxic mold" or whatever that we know is complete BS and then they treat it with voodoo. My experience is that most of these placebo treatments have a similar effect, ie they improve symptoms to some degree and do so for a finite length of time. The patient might maintain some relief but many end up about where they started and then seek out the next therapy or diagnosis.

I believe the patients just continue to be mismanaged because the real problem is mental/spiritual/social health in origin and that needs to be addressed. We just have such a taboo about that in our society, so when you suggest that, they hear "it's all in your head" and become offended and defensive. Some of them clearly have an underlying cluster B lean to them. Like someone else said, they will be calling the hospital and finding ways to page you at 2am. I think anyone who reacts with outrage when provided with reassurance that nothing serious is wrong with them raises an automatic red flag.

 

[hotsaws]

I don't think of functional illnesses in this regard. And I would never suggest to a patient symptoms they feel are physical are only "in their head."

How do you think of them? What is your approach?

I'm obviously cynical but I am totally open to anything to change my mind or help me better manage these patients.

 

[DrMetal]

By "functional" illness,

These are largely 21st century, first world problems, that are mostly a ramification of "too much medicine", "too much attention". Nobody in India right now is worried about fibromyalgia and chronic fatigue syndrome.

They're also diagnoses that we've made up, to code for it, and to make ourselves feel better.

Get psych involved: 99% of the time there's underlying mental health issues and personality disorders that haven't been properly addressed.

I don't think of functional illnesses in this regard. And I would never suggest to a patient symptoms they feel are physical are only "in their head."

Why not? Maybe not use the words "in your head", but I don't think there's anything wrong with explaining to a patient that's there no evidence of any real medical disease, you're surviving, ignore your vague/mild symptoms and move on with your life. (And that's the thing: they can't ignore their mild/vague symptoms. Every sensation is a tragedy in their mind. That's mental health pathology, needs to be addressed).

 

[hotsaws]

100% first world problems. The demographic that typically presents with it further supports that notion.

 

[MedicineZ0Z]

By "functional" illness, I'm referring to and lumping together a bunch of diagnoses: POTS, fibromyalgia, mast cell activation, chronic fatigue, multiple drug intolerances, EDS III, chronic itch, chronic pain, etc. (maybe IBS and interstitial cystitis and others I didn't list). Some of these might exist as a true organic disease in some patients but most of the time it's code talk for underlying psych issues. We have these patients in all of our varying specialties. I dread these encounters and they can be draining.

Curious to see what your approach is? Do you humor them and order some tests hoping to rule out whatever you know isn't there and relates to your field, so you can say bye bye without too much of a fight? Or if you're a PCP, do you just hand out referrals and hope for the best? Do you face the confrontation and suggest that it's in their head? Maybe prescribe some meds to target a specific symptom even though you know this isn't the core of the problem?

Family med. Mostly order some tests and don't refer out unless they want to be referred out. Then manage accordingly.

Occasionally there are some who have real pathology underneath that has been ignored. Usually, it's just psych.

 

[Slowpoke]

PM&R resident here, saw this thread serendipitously and wanted to join the discussion to provide any help. Our field, along with Chronic Pain share the responsibility of care for a fraction of the stated diagnoses (fibromyalgia, chronic fatigue and chronic pain). Symptom management is without a doubt difficult, as if it wasn't difficult enough we acknowledge that pain is subjective and the effort to de-escalate opioids creates a sense of worry among this population given their perceived necessity for symptom control from years of utilization. Typically I find many medication modalities to be ineffective, at times. Sometimes it is helpful to approach patients who's been labeled with a chronic disease and thereby chronic symptoms to identify parts of their life for which they want to improve functionally:
"The pain is the worse in the morning, and you have a hard time getting out of bed, you say?":
-Assess sleep hygiene
-Assess functional capacity to transition from bed to standing (?proximal muscle weakness, ?pain limiting hip movements, ?pain limiting back movements)
-Assess for underlying mood disturbance
etc

I tend to frame the way I add value into their care as focused on returning them to the activity they enjoy where the pain is more tolerable. I never make the promise of complete alleviation. The procedures I do facilitate this goal: hip pain? (assess and treat, eg greater trochanter bursitis > GTB ultrasound guided injection), pain limiting low back pain with radiation to one leg? (assess and treat, eg lumbar radiculopathy > transforaminal epidural steroid injection), proximal muscle weakness? (assess and treat, eg history of steroid myopathy > PT script to include hip girdle strengthening). Ultimately, these temporary methods to provide relief are aimed to allow them to do physical therapy in less pain to regain more function. Also, not all physical therapy places are created equal. I tell patients to avoid the places that are passive doing (massage, ice/heat packs, TENS) and aim for active doing (actual exercises, easy way to assess is to ask the patient what sort of home exercises were given to them).

Many of these discussions will, at one point, boil down to also increasing the amount of aerobic exercise (proven to be helpful for fibromyalgia and chronic fatigue, and depends for the reason for chronic pain).

 

[end stage fibro]

These are largely 21st century, first world problems, that are mostly a ramification of "too much medicine", "too much attention". Nobody in India right now is worried about fibromyalgia and chronic fatigue syndrome.

They're also diagnoses that we've made up, to code for it, and to make ourselves feel better.

Get psych involved: 99% of the time there's underlying mental health issues and personality disorders that haven't been properly addressed.

Why not? Maybe not use the words "in your head", but I don't think there's anything wrong with explaining to a patient that's there no evidence of any real medical disease, you're surviving, ignore your vague/mild symptoms and move on with your life. (And that's the thing: they can't ignore their mild/vague symptoms. Every sensation is a tragedy in their mind. That's mental health pathology, needs to be addressed).

word.

reminds me of tension myositis syndrome. i learned about it in the middle of med school. thought it was preposterous and john sarno was a quack. as a seasoned attending, i realize how brilliant Dr Sarno was.

 

[sloh]

I am envious of the naturopaths and other alternative provider's ability to just prescribe placebo. We're stuck with our pseudo-placebos (gabapentin, Lyrica, an assortment of SSRIs/SNRIs, and maybe some vitamins/supps). They look them right in the eye and tell them about the "toxic mold" or whatever that we know is complete BS and then they treat it with voodoo. My experience is that most of these placebo treatments have a similar effect, ie they improve symptoms to some degree and do so for a finite length of time. The patient might maintain some relief but many end up about where they started and then seek out the next therapy or diagnosis.

Just zonk 'em out!

 

[chessknt]

End stage fibromyalgia is direct admit to icu from clinic waiting room so that is the one case that is pretty clearly an emergency that can’t be blown off.

 

[Slowpoke]

End stage fibromyalgia is direct admit to icu from clinic waiting room so that is the one case that is pretty clearly an emergency that can’t be blown off.

Metastatic fibromyalgia*

 

[end stage fibro]

End stage fibromyalgia is direct admit to icu from clinic waiting room so that is the one case that is pretty clearly an emergency that can’t be blown off.

im glad people are finally recognizing this affliction, even if it is only a few clinical juggernauts on SDN. at my center, where awareness is high, it is a STEMI equivalent! door to opioid time is rigorously tracked. we even use the Germanotta protocol with opioid BZD soma cocktail infusion, 1:1 staffing, and allow for discharge after noon!

 

[fooli_doc]

As primary care, I give them the floor and l just listen for a little while longer than other visits. Try and figure out what testing they have had done/other physicians they have seen to date. Then I order some basic work up that seems reasonable if it has not been done before. I may call them personally to let them know what their negative testing actually means. It tends to be better received overall that way. Granted, you cannot sabotage yourself by calling certain extreme patients. I never say anything like "its in your head" or suggest psych eval if they are not already seemingly open to that idea. I think that's playing with fire. Honestly, a lot of these people don't actually need a psych eval. Its a 50/50 shot that its more traumatic to send them to someone who: 1) doesn't listen to them and they hate, 2) puts them on a med that the patient will say "just about killed me."

 

[sloh]

"...or suggest psych eval if they are not already seemingly open to that idea. I think that's playing with fire. Honestly, a lot of these people don't actually need a psych eval."

Agreed, while we can kind of joke around here it's "all in their head," I'm also not sure a psych eval would help. Just bringing it up could offend the patient.

 

[Crayola227]

I never argue with the subjective reality of the experience. I take it seriously, come up with a ddx, and then look over records/tests already done and then do any more as is reasonable. Most functional dx are diagnoses of exclusion.

I explain what makes functional disorder diagnoses different than other types of illness. For example IBS vs IBD. We can rule out major structural problems and that's a good thing, because the last thing you need is for your gut to feel awful because there's bloody holes in it, and that's something we generally find and address in a lot of ways.

With functional illnesses, I stress that while we don't understand them terribly well, we understand the things that AREN'T functional illnesses, and can find those things or rule them out. The good news is we can find dangerous or life threatening or treatable illnesses fairly well. So we can find out that you're NOT going to die from this or get cancer or a lot of really, really bad stuff. That is where we focus first. Not because functional causes don't matter as much for how they affect people. But we want to find serious things we can treat first.

Functional illnesses on the other hand appear to be more related to an issue with how the brain or other nerves or spinal cord or tissue locally functions, in ways that we can't currently detect very well, so we cannot determine the exact problem except to say, well, there isn't another issue, or something more concerning. We can scope the digestive tract and look at some things under the microscope, but other things we can't get down small enough to see exactly what it's doing and what has gone wrong to create symptoms.

The good news is something isn't so wrong that we think it's dangerous to your life. The bad news is that what is wrong is mild enough not to be currently detectable or life threatening, but that doesn't mean it isn't causing a great deal of distress.

When the problem appears to reside in the function or the nerves, the other good news is that things we know contribute to overall wellness can help improve function. The brain processes all discomfort and most symptoms, so there are ways to affect that. Certain medications, exercise, etc etc. Nothing is going to be a magic bullet and we need to combine all these factors to get the most improvement we can.

It's not too difficult to have fairly quick discussions about why not to do certain tests or treatments, either.

There are enough well-meaning people who are truly suffering that this approach is good. Others might be more cluster B as stated, but focusing on that with them isn't that great.

In my experience when a physician doesn't want to order a test or treatment a patient wants, unless we're talking controlled substances, I've generally not seen them do their best to explain reasoning for not doing so that discusses why it won't achieve what the patient is hoping to achieve in a way that is clear and easy to understand and commonsense. Focusing on how it's in their head or a waste of resources isn't compelling to most suffering patients, and why would it be? Usually you can come up with better reasoning from the patient's point of view for why it isn't best for the patient and their goals.

Whatever you choose to do or not do, the reasoning you give should always be based on believing the patient, and that you're doing your best to achieve what the patient wants based on how we know the human body works.

At the end of the day, most of these patients I don't think they are consciously choosing their suffering. Our job is to persuade them to affect the factors they can affect, and get out of their own way wherever possible. Counseling isn't to convince them it's in their head. If a parent died talking about it would help, not because it brings them back to life, but because it might help you learn to cope. Ultimately that is what is involved in having a functional illness. Modifying what can be modified and also living as best as you can, knowing it may not be the same.

Exercise may not cure your IBS, neither will counseling. However, it's still worth trying to be as healthy as possible, the exercise should help, but on the chance it doesn't, it won't be wasted effort. Last thing you need is heart disease down the road. As for counseling, that can help in a lot of ways. So I focus on what interventions might do for a functional illness, acknowledge that it's still tough, but also point out it will still benefit the patient. Sometimes patients need to be reminded to focus on their health outside the functional illness. Any illness can create tunnel vision for a patient.

I don't think enough we tell patients that everything reasonable has been done (and it has), we've gotten some answers (what it isn't), that they are safe from some things although they are hurting, and pain and dysfunction is a reality of life that must be accepted in many cases. If it was structural, we could go in and do a surgery, for example. Some things with a molecular basis we understand, we have drugs for. For functional illnesses, we have to focus on ruling out things we can do those things for, and then after that what about health we can modify, and improving function.

Physicians seem quick to blame the patient, when there are a lot of things we don't fully understand, and frankly there's a lot of instances where whatever is wrong is wrong and it isn't going to be fixed or even well managed.

I think our psychiatrist and neurologist friends are better at these conversations.

 

[Crayola227]

I've gotten a lot of flack from docs before for the fact I will focus on the following, but with these patients I use wellness techniques that emphasize exercise/stretching where possible, diet, drinking water, and I like supplements like melatonin, vitamin D, multivitamins. Massage, chiropractic, acupuncture, anything low risk they can afford that provides them subjective benefit.

I am usually able to persuade patients to take tylenol and ibuprofen where appropriate - that's a different conversation. I'm also happy to recommend meds that usually aren't too dangerous and may be worth a try - gabapentin, lyrica, SSRIs, etc. Between all that I can get some placebo effect if the patient is open-minded enough, but it completely depends on therapeutic alliance.

A patient that feels their suffering is believed, is not considered imaginary in any way, basically when they feel that you are NOT doing certain things that it comes from dead-ending in diagnosis or treatment options, and NOT from you not believing their suffering, blaming them, or withholding mostly because of cost, but because of direct risk to them - that patient will have a more open mind to the possibility of the above interventions helping them.

If they don't think you are acting in what they consider good faith as I've described, you'll get nowhere.

Some patients may be "malignant headcases" and that's mostly sad for them, and frustrating for the time I have to put on a customer service face and deal with them. Even most of these have some underlying issue causing them distress that they don't consciously intend to have, and I use rationalization to try to deal with the counterprojection that is sure to happen.

And then I take tylenol for the headache and eat some vitamin D gummies for a pick me up and get some placebo. Physician heal thyself first.

 

[sloh]

Massage, chiropractic, acupuncture, anything low risk they can afford that provides them subjective benefit.

I'm also happy to recommend meds that usually aren't too dangerous and may be worth a try - gabapentin, lyrica, SSRIs, etc. Between all that I can get some placebo effect if the patient is open-minded enough, but it completely depends on therapeutic alliance.

This is where I have hang-ups as a physician. If we promote these interventions knowing that the effect is mostly due to placebo/contextual factors, how does this make us different from “alternative” med grifters?

 

[VA Hopeful Dr]

This is where I have hang-ups as a physician. If we promote these interventions knowing that the effect is mostly due to placebo/contextual factors, how does this make us different from “alternative” med grifters?

Agreed. I won't stop people seeing their chiropractor/acupuncturist/whatever, but I can't in good conscience recommend it.

 

[Crayola227]

This is where I have hang-ups as a physician. If we promote these interventions knowing that the effect is mostly due to placebo/contextual factors, how does this make us different from “alternative” med grifters?

For me, I don't think melatonin or vitamin D or multivitamins are purely placebo. I forgot to add fish oil to my list. A lot of times they're indicated anyway for some other reason. And I've talked to some patients that initially we thought some of these things were amazing but then the data didn't really back some of it up. But that's where I'm a maverick and feel that they still make sense to take, if you're willing to risk paying for something that may have little benefit. Of course I discourage large doses of say vitamin E, because there was evidence of maybe some harm. Same with megadoses of many vitamins, including vitamin C (can theoretically cause stones in the wrong person).

I think what I listed are generally "good" for many patients, and while I don't have evidence they help chronic pain or fibro or whatever, it's possible they may get other benefit or placebo out of it.

Lastly, the most ethical way to prescribe anything is to explain risk/benefit, and if you think it's most likely something might improve symptoms just because the patients believes it might, to explain that as well. Some studies have shown placebo still works even if the placebo is explained to the patient. That makes it something ethically available as a tool to the physician, because you can have an informed consent discussion around it.

As far as chiropractic, again, I don't think we understand how it works. Some of the evidence suggests it does NOT work the way some think (popping bones out of place into place) but there is evidence of some subjective improvement despite that, although they've generally found it to be pretty time limited. I think the pain gate theory of how high velocity low amplitude adjustments may be doing that makes the most sense here.

I personally enjoy and see chiropractors for certain issues and believe in it for certain problems, and to me the good ones feel adjustment is an intervention with time limited effect, are open about this, and the bulk of the visit focuses on sound musculoskeletal medicine techniques for the patient to do at home (exercises, stretches, ergonomics, posture) that can be done cheaply, and no witchy herbs.

I'm not sure what putting a needle in someone does, but I imagine it can do something. Here, I don't know that I recommend it as much as I feel comfortable after doing a work-up telling a patient I've run out of options for them, and this is something where the biggest risk is generally paying for something and not seeing benefit. But a lot of people swear by it. It could be placebo, I don't know. I don't recommend it much as I don't recommend against it. To my knowledge to this day the only decent evidence for acupuncture is post-op nausea or infertility.

Being "open-minded" to the witchy woo of chiropractic adjustment and acupuncture needles, can also give me the leverage with some patients to steer them away from herbs and homeopathy and naturopaths, which I generally find actually dangerous or very risky philosophies.

What makes me not a "grifter" is a few things, which is 1) being upfront with patients about the evidence base on these things (so you don't oversell it as a cure, still practicing evidence-based medicine, still informed consent about real benefit/risks/possibility it's placebo), and 2) not making any money off it (I don't sell them supplements and besides a visit where I am truthful and discuss the evidence, I'm not making any money on any of this).

 

[Crayola227]

This is where I have hang-ups as a physician. If we promote these interventions knowing that the effect is mostly due to placebo/contextual factors, how does this make us different from “alternative” med grifters?

I have to add, the short answer here, has to do with the evidence and what you mean by "recommendation". If you are honest with a patient about the limits of your knowledge and the evidence, and are fully open and honest that it could be contextual or placebo, and they may be spending resources on something that may not have a scientific basis....

Sometimes people need something to do or to buy something, because there is a therapeutic element to feeling like you are "doing" something, and I would also say that is very American. Acknowledging this simple fact as a physician and using it to improve a patient's function or subjective experience doesn't make you a grifter unless you're not upfront, profit, or encourage something dangerous.

I don't have an evidence base for telling someone to watch an uplifting movie or eat some ice cream after a break up, but I do that too. Only a Sith deals in absolutes. Medicine is an art and we also have to deal in anecdotes. What makes us different is having a true awareness that is what we are doing when we do it, and considering the risk/benefit to the patient, and not making decisions that line our pockets.

Sometimes I wonder if the patients taking my advice are having benefit specifically for their illness. Maybe not. I still feel good about them getting more exercise or drinking more water. If they like going to the chiropractor, that's not much different than if they liked going to a hairstylist as long as they don't get crappy herbs.

 

[nexus73]

This is where I have hang-ups as a physician. If we promote these interventions knowing that the effect is mostly due to placebo/contextual factors, how does this make us different from “alternative” med grifters?

The physician has been trained to do an appropriate history and physical, generate a rational differential dx, and knows to order the tests to rule out the "treatable" disease. They don't jump to chronic lyme dz. Functional diagnoses are diagnoses of exclusion.

The trick is that when you don't find anything and the patient is still having symptoms, it shifts to the art of medicine. Because something is going on, and maybe it's psychiatric but the patient isn't ready to hear that. If you just dismiss it as all in their head, it does no good, the patient probably leaves and never comes back, and goes against the first do no harm mantra. And for many functional illnesses you can ethically recommend healthy diet, hydration, exercise, social interaction, vitamins etc. It's not like that stuff is going to hurt. And in time maybe the patient does agree to see a psychiatrist or therapist.

 

[hello1234!]

I’m a PCP and here is my approach.
When doing an exam I tell the pt what I’m evaluating for, when I order studies I explain why and what I’m hoping to rule out. It makes the pt feel like you are taking their concerns seriously, and helps the visit go much faster. And the most important part is I tell them what to expect if everything I order is normal.
Also, towards the end of an appt I often ask what their biggest fear is about their medical concerns(pts often don’t volunteer this without prompting) and the answer can be illuminating.

 

[sloh]

For me, I don't think melatonin or vitamin D or multivitamins are purely placebo. I forgot to add fish oil to my list.

I did not take issue with vitamin D or multivitamins in my original post where I quoted specific parts of your post. That said, the benefits from those tend to be overblown.

I think what I listed are generally "good" for many patients, and while I don't have evidence they help chronic pain or fibro or whatever, it's possible they may get other benefit or placebo out of it.

Lastly, the most ethical way to prescribe anything is to explain risk/benefit, and if you think it's most likely something might improve symptoms just because the patients believes it might, to explain that as well. Some studies have shown placebo still works even if the placebo is explained to the patient. That makes it something ethically available as a tool to the physician, because you can have an informed consent discussion around it.

Fair enough. I think we share different philosophies on the practice of medicine and that's fine. I'm not as comfortable knowingly embracing placebo. I come at this from my specialty, PM&R, where many sham controlled studies are showing that our most common procedures are nothing more than placebos at best, and can be harmful in the long run.

And as far as placebos working even if the placebo is explained to the patient, here's a clarification of that:

"Here is the information the patients in the study received:

"placebo pills, something like sugar pills, have been shown in rigorous clinical testing to produce significant mind-body self-healing processes.”

“either placebo (inert) pills, which were like sugar pills which had been shown to have self-healing properties” or no-treatment.”

As you can see, the patients were clearly primed and hence the treatment received was no longer an inert placebo, but a strongly influenced contextual effect that possibly could and actually did influence the patients expectations."

As far as chiropractic, again, I don't think we understand how it works. Some of the evidence suggests it does NOT work the way some think (popping bones out of place into place) but there is evidence of some subjective improvement despite that, although they've generally found it to be pretty time limited. I think the pain gate theory of how high velocity low amplitude adjustments may be doing that makes the most sense here.

I usually recommend against HVLA especially in the neck to patients. IMO, the risks do not outweigh the benefits.

(stretches, ergonomics, posture) that can be done cheaply

There actually hasn't been much evidence that focusing on stretches, ergonomics, and posture make much of a difference and it borders on fear mongering.

Are you sitting comfortably: the myth of good posture

While more than 2.5m people in the UK suffer with back pain, there is little evidence linking the condition with slouching or bad posture

www.theguardian.com

Being "open-minded" to the witchy woo of chiropractic adjustment and acupuncture needles, can also give me the leverage with some patients to steer them away from herbs and homeopathy and naturopaths, which I generally find actually dangerous or very risky philosophies.

These chiropractors and acupuncturists are often times the very same clinicians who promote herbs, homeopathy, naturopathy.

2) not making any money off it (I don't sell them supplements and besides a visit where I am truthful and discuss the evidence, I'm not making any money on any of this).

You're still making money off the patient visit though.

 

[sloh]

You can ethically recommend healthy diet, hydration, exercise, social interaction, vitamins etc. It's not like that stuff is going to hurt. And in time maybe the patient does agree to see a psychiatrist or therapist.

In my original post, I did not question the benefits of exercise and social interaction.

I've also seen hydration/drink more water mentioned a couple times in this thread. Drinking to thirst is fine, even for athletes.

You Don’t Need Sports Drinks To Stay Hydrated

Christie Aschwanden’s new book, “Good to Go: What the Athlete in All of Us Can Learn from the Strange Science of Recovery,” is available this week. In it, she e…

fivethirtyeight.com

"Yet everywhere I look, it seems that people are telling me to drink more water. In his best- selling 2017 book, “The TB12 Method,” New England Patriots quarterback Tom Brady presents his magic hydration formula — drink at least one-half of your body weight in ounces of water every day. “At 225 pounds, that means I should be drinking 112 ounces a day, minimum,” he writes. (Brady also contends that “the more hydrated I am, the less likely I am to get sunburned,” a claim disputed by scientists.) If our bodies are so good at adapting to moderate fluid loss and letting us know when we need to drink, why are there still so many messages out there urging us to drink before we feel thirsty?

An obvious explanation for this is that most of what we hear about hydration comes from companies and researchers with a vested interest in making it all seem complex and highly scientific. The current guidelines from the ACSMand the National Athletic Trainers’ Association have been updated to warn about hyponatremia, but they still promote the ideas that thirst is a poor indicator of hydration and that more than a 2 percent body weight loss should be avoided. The ACSM, NSCA and NATA all receive funding from sports drink makers, as do some of their members. If staying hydrated were as simple as just drinking to thirst, you wouldn’t need expert advice or scientifically formulated products like Gatorade.

From a biological perspective, it’s hard to imagine that the human body is so delicate that it can’t function properly without scientists (or football stars) swooping in with calculators to tell us how to keep it running properly. “You have to trust your body,” Knepper says. Humans have evolved to survive exercising without chugging water or sports drink on some rigid schedule. “You get clues about what you need if you listen to your own body,” he says. “You don’t have to know chemistry to survive.”

After examining the science, I can’t help thinking we’ve made hydration unduly complicated. I take my dog running with me most of the time, and I’ve never measured the color of her pee or forced her to drink (as if I could). I make sure she has regular access to water, but she doesn’t always take it. At times, she won’t drink at all during a long run, and on those occasions, she always goes straight to her water dish when we get home and slurps until she’s satisfied. I’ve never had to give her an emergency IV for low fluid levels. If drinking to thirst is good enough for her, it’s probably good enough for me too."

 

[Crayola227]

In my original post, I did not question the benefits of exercise and social interaction.

I've also seen hydration/drink more water mentioned a couple times in this thread. Drinking to thirst is fine, even for athletes.

You Don’t Need Sports Drinks To Stay Hydrated

Christie Aschwanden’s new book, “Good to Go: What the Athlete in All of Us Can Learn from the Strange Science of Recovery,” is available this week. In it, she e…

fivethirtyeight.com

"Yet everywhere I look, it seems that people are telling me to drink more water. In his best- selling 2017 book, “The TB12 Method,” New England Patriots quarterback Tom Brady presents his magic hydration formula — drink at least one-half of your body weight in ounces of water every day. “At 225 pounds, that means I should be drinking 112 ounces a day, minimum,” he writes. (Brady also contends that “the more hydrated I am, the less likely I am to get sunburned,” a claim disputed by scientists.) If our bodies are so good at adapting to moderate fluid loss and letting us know when we need to drink, why are there still so many messages out there urging us to drink before we feel thirsty?

An obvious explanation for this is that most of what we hear about hydration comes from companies and researchers with a vested interest in making it all seem complex and highly scientific. The current guidelines from the ACSMand the National Athletic Trainers’ Association have been updated to warn about hyponatremia, but they still promote the ideas that thirst is a poor indicator of hydration and that more than a 2 percent body weight loss should be avoided. The ACSM, NSCA and NATA all receive funding from sports drink makers, as do some of their members. If staying hydrated were as simple as just drinking to thirst, you wouldn’t need expert advice or scientifically formulated products like Gatorade.

From a biological perspective, it’s hard to imagine that the human body is so delicate that it can’t function properly without scientists (or football stars) swooping in with calculators to tell us how to keep it running properly. “You have to trust your body,” Knepper says. Humans have evolved to survive exercising without chugging water or sports drink on some rigid schedule. “You get clues about what you need if you listen to your own body,” he says. “You don’t have to know chemistry to survive.”

After examining the science, I can’t help thinking we’ve made hydration unduly complicated. I take my dog running with me most of the time, and I’ve never measured the color of her pee or forced her to drink (as if I could). I make sure she has regular access to water, but she doesn’t always take it. At times, she won’t drink at all during a long run, and on those occasions, she always goes straight to her water dish when we get home and slurps until she’s satisfied. I’ve never had to give her an emergency IV for low fluid levels. If drinking to thirst is good enough for her, it’s probably good enough for me too."

The only issue with drinking to thirst is that it operates on the kind of feedback loop that you could be quite dehydrated yet not feel thirsty. I had clinical heat exhaustion (was quite delerious) and was more interested in sleep than water, I had to be woken up and harassed to drinking it despite needing it.

People can be subclinical in this regard. If you have chronic constipation, as many Americans do, then right there you have a symptom that it is reasonable to treat by drinking more water. Same with dry mouth, dry eyes, chapped lips, fatigue, lightheadedness, headache, nausea, the list goes on.

So if you feel entirely fine and have no symptoms that might be eased by drinking more water, then no, you probably don't need to do anything. But is that who we're talking about in this thread? No, we're talking about patients with any number of not well localized symptoms that reasonably might feel better if they drink more water.

9/10 when I talk to someone, they don't report drinking any water at all, and they only report drinking absurd amounts of pop. These same patients often feel awful.

Fact, stopping drinking 2L of pepsi a day and replacing some of that, going from NO water to some amount of water a day instead, will not only make you healthier, it will make you feel better as well.

 

[Crayola227]

I did not take issue with vitamin D or multivitamins in my original post where I quoted specific parts of your post. That said, the benefits from those tend to be overblown.


Fair enough. I think we share different philosophies on the practice of medicine and that's fine. I'm not as comfortable knowingly embracing placebo. I come at this from my specialty, PM&R, where many sham controlled studies are showing that our most common procedures are nothing more than placebos at best, and can be harmful in the long run.

And as far as placebos working even if the placebo is explained to the patient, here's a clarification of that:

"Here is the information the patients in the study received:

"placebo pills, something like sugar pills, have been shown in rigorous clinical testing to produce significant mind-body self-healing processes.”

“either placebo (inert) pills, which were like sugar pills which had been shown to have self-healing properties” or no-treatment.”

As you can see, the patients were clearly primed and hence the treatment received was no longer an inert placebo, but a strongly influenced contextual effect that possibly could and actually did influence the patients expectations."



I usually recommend against HVLA especially in the neck to patients. IMO, the risks do not outweigh the benefits.



There actually hasn't been much evidence that focusing on stretches, ergonomics, and posture make much of a difference and it borders on fear mongering.

Are you sitting comfortably: the myth of good posture

While more than 2.5m people in the UK suffer with back pain, there is little evidence linking the condition with slouching or bad posture

www.theguardian.com

These chiropractors and acupuncturists are often times the very same clinicians who promote herbs, homeopathy, naturopathy.

You're still making money off the patient visit though.

Yes, and it's fine to do so as long as whatever you tell the patient is accurate. You're being paid for truthful advice. Telling patients the reality that there isn't good evidence for chiropractic treatment, that some adjustments may be dangerous and best avoided, and it may not work, and it has risks which a good chiropractor can describe better than I can. But I think some of what they recommend makes sense and has a low risk of harm. If something isn't harmful but it also isn't tested/backed up by evidence, then it's up to one's own judgement what they want to try for a problem that we don't know how to make better for them. Some people find that it helps, this is a true statement.

Eh, the placebo study I'm thinking of didn't use language like that. It was a much more dispassionate and clinically accurate definition of placebo. Still worked. I don't know that the context has to be any stronger than being given a pill, being told there's no scientific basis to it working beyond the fact that the simple belief it might help symptoms can be enough to make some people feel improvement. This is just a true statement and I don't see overselling or priming to it. What you quoted I agree is much more leading.

When I pointed out that HVLA adjustments giving some patients a sense of subjective improvement, and that this might be consistent with a pain gate theory of pain relief, that was not the same thing as me saying I recommend neck adjustments. I'm saying that some features of chiropractic treatment might make some patients feel better, and the mechanism may not be any bunk theories proposed so far, but might be some other mechanism we don't understand or haven't thought of or can't test very well.
My understanding is that doing a good sham is difficult for acupuncture and most adjustment techniques.

I don't recommend any adjustments. However I feel comfortable telling a patient who has deadended all other reasonable advice, that keeping in mind the risks of chiropractic treatment, that it is something some patients have reported benefit from. I'm not opposed to it, but where we differ I guess is that barring money, witchy herbs, I think it's reasonable to try when other options have been exhausted.

The chiropractic practice where I live has been consistently good. I knew several students at the local chiropractic school when I was a med student, and I was honestly impressed with their curriculum and approach. Most chiropractors have at some point floated something past me I thought was crap (so have NPs and PAs) but most of them have had a pretty clinically sound approach to most things I've discussed with them. None of the ones I know or have seen do the witchy herbs or homeopathy, and that's the rule where I am, however I know the chiropractic herb peddlers do exist. I've also worked with some of my patients' chiropractors and the communication has been good. I haven't had any contradict anything I was doing with a patient. I get this may not be the norm, but it represents to me what I think chiropractic could and should be.

If you're in PMR or you're a PT, that might change your perspective because of what you have to offer, but for everyone else in medicine what we have to offer patients for musculoskeletal pain is pretty minimal.

It probably doesn't help I've been popping my knuckles and most other joints in my body since childhood. I go to chiropractors. It feels good.

You'll never have a double blinded study about jumping from planes with parachutes, where one arm jumps without parachutes. I don't think there's much reason to do a study to show that eating chocolate gives chocolate lovers pleasure.

The bottom line with adjustments comes down to how well tolerated are they. Most are very well tolerated. If people like them, good for them.

I'm not here to convince people things they think work don't work, even if the science says it shouldn't, unless it's dangerous or the patient bemoans the money. It's not a problem to be solved if they think acupuncture helps their joint pain.

 

[Crayola227]

There actually hasn't been much evidence that focusing on stretches, ergonomics, and posture make much of a difference and it borders on fear mongering.

This doesn't make a lot of sense to me. And I still don't see recommending someone try these things for reports of somatic pain that doesn't respond to other interventions, where there is much risk of harm in trying them. If your body hurts, I have no idea why you wouldn't try movement based solutions, changing up what you are usually doing, to see if it helps.

It's pretty clear that a great deal of musculoskeletal pain comes from overuse, and being in the same position for many hours, like a long haul trucker with low back pain, could represent a kind of overuse injury.

So you don't recommend they find ways to be in other positions, or exercise, stretching?

 

[Crayola227]

I did not take issue with vitamin D or multivitamins in my original post where I quoted specific parts of your post. That said, the benefits from those tend to be overblown.


Fair enough. I think we share different philosophies on the practice of medicine and that's fine. I'm not as comfortable knowingly embracing placebo. I come at this from my specialty, PM&R, where many sham controlled studies are showing that our most common procedures are nothing more than placebos at best, and can be harmful in the long run.

And as far as placebos working even if the placebo is explained to the patient, here's a clarification of that:

"Here is the information the patients in the study received:

"placebo pills, something like sugar pills, have been shown in rigorous clinical testing to produce significant mind-body self-healing processes.”

“either placebo (inert) pills, which were like sugar pills which had been shown to have self-healing properties” or no-treatment.”

As you can see, the patients were clearly primed and hence the treatment received was no longer an inert placebo, but a strongly influenced contextual effect that possibly could and actually did influence the patients expectations."



I usually recommend against HVLA especially in the neck to patients. IMO, the risks do not outweigh the benefits.



There actually hasn't been much evidence that focusing on stretches, ergonomics, and posture make much of a difference and it borders on fear mongering.

Are you sitting comfortably: the myth of good posture

While more than 2.5m people in the UK suffer with back pain, there is little evidence linking the condition with slouching or bad posture

www.theguardian.com

These chiropractors and acupuncturists are often times the very same clinicians who promote herbs, homeopathy, naturopathy.

You're still making money off the patient visit though.

"O’Sullivan’s advice is equally direct. “If you don’t have back pain, then do not give your posture one second’s thought – think about being healthy. Sleep deprivation and stress are more important than the lifting you do. Stress has a strong inflammatory role; it can make muscles tense. Most people don’t get that their back can become sore if they are sleep deprived.”

However, it is true that once you have back pain, then your posture may indeed affect it. Sitting for a long time is best avoided. “After someone has back pain, I would suggest they go to get a bit of advice from a qualified person about how can they can move with more confidence and less pain,” says O’Sullivan. “It is trial and error, but would involve exploring which way of bending is the most comfortable.”

So, again, we're not talking about people that feel fine. We're talking about people who are suffering. It's reasonable for them to consider how they are holding or moving their body and how that affects their discomfort.

The article had a rigid definition of posture.

I would say that if moving your chair height, or when standing squeezing your shoulder blades together relieves your discomfort, then do it. If "good posture" doesn't make you feel better, don't focus on it.

It's like that classic joke where the patient says "Doc, every time I press on my elbow here it hurts," and the doc says "My advice: stop that!"

 

[VA Hopeful Dr]

Yes, and it's fine to do so as long as whatever you tell the patient is accurate. You're being paid for truthful advice. Telling patients the reality that there isn't good evidence for chiropractic treatment, that some adjustments may be dangerous and best avoided, and it may not work, and it has risks which a good chiropractor can describe better than I can. But I think some of what they recommend makes sense and has a low risk of harm. If something isn't harmful but it also isn't tested/backed up by evidence, then it's up to one's own judgement what they want to try for a problem that we don't know how to make better for them. Some people find that it helps, this is a true statement.

That's cute

 

[sloh]

the mechanism may not be any bunk theories proposed so far, but might be some other mechanism we don't understand or haven't thought of or can't test very well.

I agree with this and if this is how the intervention/option is presented to patients, that's fine. That's just not how the large majority of chiropractors construct their narrative though—what is not unusual is I'll get a patient who comes in thinking their body is all out of whack with a diagram marked up in a bajillion different ways their body "out of alignment", there are subluxations, and the patient should return every week to get "fixed." The nocebo effect is strong.

The chiropractic practice where I live has been consistently good. I knew several students at the local chiropractic school when I was a med student, and I was honestly impressed with their curriculum and approach. Most chiropractors have at some point floated something past me I thought was crap (so have NPs and PAs) but most of them have had a pretty clinically sound approach to most things I've discussed with them. None of the ones I know or have seen do the witchy herbs or homeopathy, and that's the rule where I am, however I know the chiropractic herb peddlers do exist. I've also worked with some of my patients' chiropractors and the communication has been good. I haven't had any contradict anything I was doing with a patient. I get this may not be the norm, but it represents to me what I think chiropractic could and should be.

That is good this is your experience but I would say those chiropractors you have worked with are an exception to the rule.

If you're in PMR or you're a PT, that might change your perspective because of what you have to offer, but for everyone else in medicine what we have to offer patients for musculoskeletal pain is pretty minimal.

I agree there and this is my large criticism of my own very specialty. Most of the interventions we deploy on patients are at best placebos and in the long run harmful. What works the most is exercise, weight loss, a healthy diet; and addressing psychosocial stressors (although this is a difficult needle to move as a physician). It doesn't sound sexy or glamorous but I'd rather be up front about that.

You'll never have a double blinded study about jumping from planes with parachutes, where one arm jumps without parachutes. I don't think there's much reason to do a study to show that eating chocolate gives chocolate lovers pleasure.

Slightly off topic but I don't think the parachute analogy holds for much of medicine. Especially when effect sizes are modest-marginal (which most of medicine is), and especially when clinical endpoints are subjective (pain, mood), we need blinded/sham-controlled RCT's.



ORBITA is a great example of this.

"Symptomatic relief is the primary goal of percutaneous coronary intervention (PCI) in stable angina and is commonly observed clinically. However, there is no evidence from blinded, placebo-controlled randomised trials to show its efficacy."

Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial

In patients with medically treated angina and severe coronary stenosis, PCI did not increase exercise time by more than the effect of a placebo procedure. The efficacy of invasive procedures can be assessed with a placebo control, as is standard for pharmacotherapy.

www.thelancet.com

Subacromial decompression as well:

"In conclusion, we showed that, in patients with persistent subacromial shoulder pain due to impingement, improvement in Oxford Shoulder Scores with arthroscopic subacromial decompression did not differ to that achieved with arthroscopy only (placebo surgery). Although both types of surgery provide greater symptom improvement than no treatment, this difference was of uncertain clinical significance. The findings (which should be communicated to patients during the shared treatment decision-making process) question the value of this type of surgery for these indications, and might discourage some surgeons from offering decompression surgery and dissuade some patients from undergoing the surgery."

Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial

Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. The difference between the surgical groups and no...

www.thelancet.com

The bottom line with adjustments comes down to how well tolerated are they. Most are very well tolerated. If people like them, good for them.

Yes, if it feels fine like going to a masseuse and getting a massage feels good, more power to them. I'm just not cool with the narrative that clinicians (especially chiropractors and acupuncturists) use to convince patients they need their services. It creates a vulnerable mentality and as I said above nocebos the patient. It seems like you've interacted with more competent and truthful chiropractors.

 

[sloh]

"O’Sullivan’s advice is equally direct. “If you don’t have back pain, then do not give your posture one second’s thought – think about being healthy. Sleep deprivation and stress are more important than the lifting you do. Stress has a strong inflammatory role; it can make muscles tense. Most people don’t get that their back can become sore if they are sleep deprived.”

However, it is true that once you have back pain, then your posture may indeed affect it. Sitting for a long time is best avoided. “After someone has back pain, I would suggest they go to get a bit of advice from a qualified person about how can they can move with more confidence and less pain,” says O’Sullivan. “It is trial and error, but would involve exploring which way of bending is the most comfortable.”

So, again, we're not talking about people that feel fine. We're talking about people who are suffering. It's reasonable for them to consider how they are holding or moving their body and how that affects their discomfort."

"Sitting for a long time is best avoided" is different from overemphasizing posture and how someone should exactly sit in a chair. The general consensus from MSK clinicians who are up to date with the evidence is that it doesn't matter much how you sit and that the body will tell you through discomfort that you should change position or just get up and move around—and more importantly the way you sit isn't a major determinant of overall chronic pain, especially low back pain. And even with bending, much of the feared lumbar flexion is overblown.



Much of O'Sullivan's advice is on movement and exercise; and movement and exercise as ways to build confidence to violate prior ingrained beliefs that "X" is dangerous and will cause pain or the body is vulnerable. I completely agree with this.

 

[sloh]

9/10 when I talk to someone, they don't report drinking any water at all, and they only report drinking absurd amounts of pop. These same patients often feel awful.

Fact, stopping drinking 2L of pepsi a day and replacing some of that, going from NO water to some amount of water a day instead, will not only make you healthier, it will make you feel better as well.

Yes, if that excessive pop consumption is contributing to an overall bad diet, caloric excess, weight gain, excessive body fat which are highly associated with pain—I agree, it should be cut down or eliminated.