I do what I can. I have a hammer and the problem has a nail component so I do some nailing and something use the hammer as a shovel or mattox, even though that's not how it's designed. How many times a day do I say "There's only so much medications can do," meaning that we both know what the real problem is, but sometimes the goal is to tolerate the current situation until the patient can wiggle out of it.
The situation I see with SSRIs in my practice frequently is people who are in relationships they might like to leave and might be better off leaving (or might be better off staying, I can't predict the future), but my observation (based on seeing this play out over and over) is that an SSRI will allow them to tolerate staying. Is this necessarily good or bad? I don't know, but I do try to pull this topic into the open so at least they're making an aware decision.
>Are these band-aids that shift systemic problems onto individuals?
Yes — if the person leaves thinking “my suffering is all my fault and responsibility” when it’s actually largely a societal issue.
>Or are they reasonable tools to try to help resolve suffering?
Yes — if it’s understood that they’re treating a symptom and not the disease. Or to put it another way, they can take some of the stress off and provide more cope. But cope isn’t a cure, it’s more like a vehicle to help you get to where you can chip away at the actual disease (in concert with others).
>What are the forces that make us reach for biomedical treatments even for problems that aren’t exclusively biomedical in nature?
One of them is the way the system is split up into so many little chunks. When a person is depressed, has no money, has no social life, has no job, a doctor can prescribe for the depression but not the rest of it. Why aren’t there more places/organizations a person can go to get help with all of those things at the same time? Do individual providers understand this and at least point patients to other resources they might use to tackle the rest of it?
This is so well said, Stef. I grapple with all these questions multiple times a day. I do try to help point my patients to social services, but our social workers can only do so much in a society that has decided we don't believe in a social safety net.
I think the answer is both/and. In both mood and weight loss visits, I will ask what patients are seeking and often will say something like "I think many of the symptoms/conditions you're experiencing are in part because of the current life stressors/environmental factors and might resolve without them. Unfortunately, those factors aren't under my control. Here are the tools I can offer that might help you feel better and/or prevent complications of your condition." If there are social work resources or talk therapy that I think can help, I offer those referrals as part of the shared decision making around medical treatment options. I think for the most part patients understand the limits of what doctors can do, and in bringing up the issue at a medical visit they are wanting to talk about the medical treatment or wanting the validation of their doctor about the symptoms. So I think it'd be wrong not to offer the treatment, it'd only be a problem if we were pushing the medical treatment if it weren't within their goals.
Doing my best! I absolutely feel the internal conflict you wrote about so beautifully though, especially in the cases where it does seem quite clear that the symptoms are arising due to a particular terrible situation (panic attacks due to an abusive relationship or due to worries about immigration enforcement these days). As much as I hate all the paperwork that comes with our job for all time it takes, there are a few cases where it does actually let me address the cause - I have written for medical exemption from the citizenship test for 2 patients who qualified, and it allowed one to get a transplant and the other reduced panic attacks related to immigration status which were huge wins though their stories remain complex.
I think your experiences (and those of your friend) are baked into our American culture. As a society, we are much less interested in changing the framework we live in to solve problems. Problems are always an individual's fault and they must individually fix themselves. Smaller countries, with more homogeneous populations, seem to have done a much better job at creating a framework that supports human health.
We were talking about this in my clinic yesterday. Some of our discussion centered around how daily life is so fast, with so many decisions, and so much complex nuance with consequences, that the nervous system is simply not evolved to handle at the modern pace. Does that make it a biomedical problem?
It made me reflect back to old health sanitariums where patients would go for hot baths, walks in the sunshine, rest, nutrition and then would stay a few months. To me this seems like a path for allowing the body to heal itself. But I realize it doesn’t solve the societal injustices and that some pharmaceuticals do make daily life more bearable.
These bandaids DO help. Your caring helps. And your writing about them helps us, as a society, to see the problems that must be fixed. Keep spreading your words!
This is a thoughtful post and I appreciate doctors who are willing to have these conversations and engage with us, so thank you!
I may be oversimplifying Ozempic (active ingredient and dosage designed to regulate blood sugar in type 2 diabetes, which may have a weight loss effect) vs the other GLP-1s (designed specifically for weight loss), but I was a little surprised when you stated that you approach medicine with an anti-diet framework, but then said that in the cases of cardiometabolic diseases (abnormal blood sugar, abnormal blood pressure, abnormal liver function, or sleep apnea) you would "enthusiastically" recommend a GLP-1.
I can understand recommending Ozempic for type 2 diabetes, but apart from that, it sounds like you are saying that weight causes elevated blood pressure, abnormal liver function, or sleep apnea, when in fact, it is perhaps more accurately correlated. So is it a good idea to prescribe a GLP-1 designed just for weight loss to address these health issues? I agree with your stance that people should have bodily autonomy and if they want an appetite-suppressant, then they should probably be given access to it. However, what I think is lacking is doctors being educated about eating disorders and disordered eating and knowing how to screen and obtain a history from a patient. Prescribing a GLP-1 for weight loss by framing it as necessary to improve cardiometabolic health may not be the best strategy for overall health.
Hi Jen! Thanks for this. GLP1s seem to have effects on metabolic dysfunction in the liver, cardiovascular health, and kidney health independent of weight loss. (As in, your liver inflammation can improve even if you don’t lose weight.) So as an anti-diet doctor, I frame my treatment goals around those metrics rather than achieving a certain BMI. (“The purpose of this medication is to decrease liver inflammation;” NOT “the purpose of this medication is to make you lose weight.)
And I agree that it’s critical to proceed with caution in people who have an eating disorder history. I try to screen my patients for eating disorders (although I’ll note that US Preventive Services Task Force does not actually endorse universal screening) and talk with them about goals, expectations, and mental health history. I don’t think an eating disorder is necessarily an absolute contraindication to a GLP1, but I carefully explore risks and benefits in anyone with an eating disorder diagnosis.
Another wrinkle to all this is that I think eating disorders are wildly underdiagnosed.
Thank you so much for replying and helping me sort through all the information out there! I think framing the possible benefits for GLP-1s through a lens of improving lab metrics and leaving weight loss out of the conversation is awesome and I wish more doctors would do that.
Would you mind sharing the research that brought you to the conclusion that GLP-1s can help with liver inflammation, lower blood pressure, etc? I want to make it clear that I'm asking for this not from an adversarial stance, but out of curiosity because thus far I have been avoiding these drugs, scrapping them up to essentially just a new appetite suppressant. But, if there are actual benefits independent of weight loss, then I might actually consider them. The only research I've been able to find that claim these benefits have been funded by the pharma companies, so I'm hesitant to trust those studies.
This was an excellent read. Getting stuck in one silo when you need another is such a challenge. Also, I loved the Bee Sting, too. Highly recommend Nesting by Roisin O'Donnell. I think you might like it. It's a novel about another systemic problem -- the housing shortage in Ireland.
Do you really think GLP-1s are helpful for sleep apnea? It surprised me to see that.
I have a sleep apnea diagnosis that coincides with post menopausal weight gain. However, it's also true that I've snored and/or slept with my mouth open since I was 10 years old, and spent most of that time in a straight sized body. Although it was a difficult adjustment, I now love love love my CPAP machine and would take that any day over GLP-1 side effects.
Most depression diagnoses by GPs are wrong... Do you routinely diagnose adjustment disorders? PDs? Have you read the critical literature pertaining to SSRIs? It's hard to take a dr seriously who is oblivious to their critiques.
But absolutely you're right that medicine medicalizes social ills.
That makes so much sense! I definitely appreciate the expertise of my psychiatric colleagues. (My mom is one!) I also fully acknowledge that a 15 minutes appointment (where the patient also wants to talk about back pain, and their mammogram, and their statin) is patently not enough time to make a thorough psychiatric diagnosis.
Unfortunately it’s a 6+ month wait time for psychiatrists that take public insurance, so harm reduction is the name of the game. <3
Well, thoughtful thoughts. Much appreciated. I think you've identified some quandaries deep in the grey area, and the discussions will be important. Critical even. I wouldn't expect answers, and if any show up, before long they will soon morph into something else. But the willingness to sit with the tension, to keep the convo going, to find the answers that create balance for today - ahhh - good job.
Psychologist here, trauma specialist. One foot firmly in the biomedical sphere and one foot firmly out. SSRI's are a godsend to many people, not just for people with depression but also for those with complex PTSD, which presents differently. RFK is going after them. Right now, let's focus on reasons to maintain access.
The hammer/nail problem has been there as long as there have been doctors and patients. “You change the things you can change.” That being said, the reason doctors get together in professional organizations such as AMA and county medical societies is so, collectively, we can get the bigger problems fixed. Reference my essay #1, which speaks the values and goals of my county medical society.
Are there downsides to providing medical solutions to problems that are clearly beyond medical in scope?
I do what I can. I have a hammer and the problem has a nail component so I do some nailing and something use the hammer as a shovel or mattox, even though that's not how it's designed. How many times a day do I say "There's only so much medications can do," meaning that we both know what the real problem is, but sometimes the goal is to tolerate the current situation until the patient can wiggle out of it.
The situation I see with SSRIs in my practice frequently is people who are in relationships they might like to leave and might be better off leaving (or might be better off staying, I can't predict the future), but my observation (based on seeing this play out over and over) is that an SSRI will allow them to tolerate staying. Is this necessarily good or bad? I don't know, but I do try to pull this topic into the open so at least they're making an aware decision.
Love the way you frame this. I do what I can.
Thank you. I think that might be my epitaph actually, “she did what she could.” I could do worse.
😍
>Are these band-aids that shift systemic problems onto individuals?
Yes — if the person leaves thinking “my suffering is all my fault and responsibility” when it’s actually largely a societal issue.
>Or are they reasonable tools to try to help resolve suffering?
Yes — if it’s understood that they’re treating a symptom and not the disease. Or to put it another way, they can take some of the stress off and provide more cope. But cope isn’t a cure, it’s more like a vehicle to help you get to where you can chip away at the actual disease (in concert with others).
>What are the forces that make us reach for biomedical treatments even for problems that aren’t exclusively biomedical in nature?
One of them is the way the system is split up into so many little chunks. When a person is depressed, has no money, has no social life, has no job, a doctor can prescribe for the depression but not the rest of it. Why aren’t there more places/organizations a person can go to get help with all of those things at the same time? Do individual providers understand this and at least point patients to other resources they might use to tackle the rest of it?
This is so well said, Stef. I grapple with all these questions multiple times a day. I do try to help point my patients to social services, but our social workers can only do so much in a society that has decided we don't believe in a social safety net.
I think the answer is both/and. In both mood and weight loss visits, I will ask what patients are seeking and often will say something like "I think many of the symptoms/conditions you're experiencing are in part because of the current life stressors/environmental factors and might resolve without them. Unfortunately, those factors aren't under my control. Here are the tools I can offer that might help you feel better and/or prevent complications of your condition." If there are social work resources or talk therapy that I think can help, I offer those referrals as part of the shared decision making around medical treatment options. I think for the most part patients understand the limits of what doctors can do, and in bringing up the issue at a medical visit they are wanting to talk about the medical treatment or wanting the validation of their doctor about the symptoms. So I think it'd be wrong not to offer the treatment, it'd only be a problem if we were pushing the medical treatment if it weren't within their goals.
spoken like a good primary care doc :)
Doing my best! I absolutely feel the internal conflict you wrote about so beautifully though, especially in the cases where it does seem quite clear that the symptoms are arising due to a particular terrible situation (panic attacks due to an abusive relationship or due to worries about immigration enforcement these days). As much as I hate all the paperwork that comes with our job for all time it takes, there are a few cases where it does actually let me address the cause - I have written for medical exemption from the citizenship test for 2 patients who qualified, and it allowed one to get a transplant and the other reduced panic attacks related to immigration status which were huge wins though their stories remain complex.
I think your experiences (and those of your friend) are baked into our American culture. As a society, we are much less interested in changing the framework we live in to solve problems. Problems are always an individual's fault and they must individually fix themselves. Smaller countries, with more homogeneous populations, seem to have done a much better job at creating a framework that supports human health.
Yes... Totally agree. And so I think people reach for medical solutions because they appear in reach...
We were talking about this in my clinic yesterday. Some of our discussion centered around how daily life is so fast, with so many decisions, and so much complex nuance with consequences, that the nervous system is simply not evolved to handle at the modern pace. Does that make it a biomedical problem?
It made me reflect back to old health sanitariums where patients would go for hot baths, walks in the sunshine, rest, nutrition and then would stay a few months. To me this seems like a path for allowing the body to heal itself. But I realize it doesn’t solve the societal injustices and that some pharmaceuticals do make daily life more bearable.
These bandaids DO help. Your caring helps. And your writing about them helps us, as a society, to see the problems that must be fixed. Keep spreading your words!
Oof. So true. 😕
This is a thoughtful post and I appreciate doctors who are willing to have these conversations and engage with us, so thank you!
I may be oversimplifying Ozempic (active ingredient and dosage designed to regulate blood sugar in type 2 diabetes, which may have a weight loss effect) vs the other GLP-1s (designed specifically for weight loss), but I was a little surprised when you stated that you approach medicine with an anti-diet framework, but then said that in the cases of cardiometabolic diseases (abnormal blood sugar, abnormal blood pressure, abnormal liver function, or sleep apnea) you would "enthusiastically" recommend a GLP-1.
I can understand recommending Ozempic for type 2 diabetes, but apart from that, it sounds like you are saying that weight causes elevated blood pressure, abnormal liver function, or sleep apnea, when in fact, it is perhaps more accurately correlated. So is it a good idea to prescribe a GLP-1 designed just for weight loss to address these health issues? I agree with your stance that people should have bodily autonomy and if they want an appetite-suppressant, then they should probably be given access to it. However, what I think is lacking is doctors being educated about eating disorders and disordered eating and knowing how to screen and obtain a history from a patient. Prescribing a GLP-1 for weight loss by framing it as necessary to improve cardiometabolic health may not be the best strategy for overall health.
Hi Jen! Thanks for this. GLP1s seem to have effects on metabolic dysfunction in the liver, cardiovascular health, and kidney health independent of weight loss. (As in, your liver inflammation can improve even if you don’t lose weight.) So as an anti-diet doctor, I frame my treatment goals around those metrics rather than achieving a certain BMI. (“The purpose of this medication is to decrease liver inflammation;” NOT “the purpose of this medication is to make you lose weight.)
And I agree that it’s critical to proceed with caution in people who have an eating disorder history. I try to screen my patients for eating disorders (although I’ll note that US Preventive Services Task Force does not actually endorse universal screening) and talk with them about goals, expectations, and mental health history. I don’t think an eating disorder is necessarily an absolute contraindication to a GLP1, but I carefully explore risks and benefits in anyone with an eating disorder diagnosis.
Another wrinkle to all this is that I think eating disorders are wildly underdiagnosed.
Thank you so much for replying and helping me sort through all the information out there! I think framing the possible benefits for GLP-1s through a lens of improving lab metrics and leaving weight loss out of the conversation is awesome and I wish more doctors would do that.
Would you mind sharing the research that brought you to the conclusion that GLP-1s can help with liver inflammation, lower blood pressure, etc? I want to make it clear that I'm asking for this not from an adversarial stance, but out of curiosity because thus far I have been avoiding these drugs, scrapping them up to essentially just a new appetite suppressant. But, if there are actual benefits independent of weight loss, then I might actually consider them. The only research I've been able to find that claim these benefits have been funded by the pharma companies, so I'm hesitant to trust those studies.
Here is a good one: https://www.nejm.org/doi/full/10.1056/NEJMoa2413258
This one says in the conclusion (Funded by Novo Nordisk; ClinicalTrials.gov number, NCT04822181.), but thank you for replying.
This was an excellent read. Getting stuck in one silo when you need another is such a challenge. Also, I loved the Bee Sting, too. Highly recommend Nesting by Roisin O'Donnell. I think you might like it. It's a novel about another systemic problem -- the housing shortage in Ireland.
ooooh thank you for the rec! :)
Do you really think GLP-1s are helpful for sleep apnea? It surprised me to see that.
I have a sleep apnea diagnosis that coincides with post menopausal weight gain. However, it's also true that I've snored and/or slept with my mouth open since I was 10 years old, and spent most of that time in a straight sized body. Although it was a difficult adjustment, I now love love love my CPAP machine and would take that any day over GLP-1 side effects.
It depends on the patient! I'm so glad CPAP is helping you. ❤️
Most depression diagnoses by GPs are wrong... Do you routinely diagnose adjustment disorders? PDs? Have you read the critical literature pertaining to SSRIs? It's hard to take a dr seriously who is oblivious to their critiques.
But absolutely you're right that medicine medicalizes social ills.
That makes so much sense! I definitely appreciate the expertise of my psychiatric colleagues. (My mom is one!) I also fully acknowledge that a 15 minutes appointment (where the patient also wants to talk about back pain, and their mammogram, and their statin) is patently not enough time to make a thorough psychiatric diagnosis.
Unfortunately it’s a 6+ month wait time for psychiatrists that take public insurance, so harm reduction is the name of the game. <3
Well, thoughtful thoughts. Much appreciated. I think you've identified some quandaries deep in the grey area, and the discussions will be important. Critical even. I wouldn't expect answers, and if any show up, before long they will soon morph into something else. But the willingness to sit with the tension, to keep the convo going, to find the answers that create balance for today - ahhh - good job.
Psychologist here, trauma specialist. One foot firmly in the biomedical sphere and one foot firmly out. SSRI's are a godsend to many people, not just for people with depression but also for those with complex PTSD, which presents differently. RFK is going after them. Right now, let's focus on reasons to maintain access.
yup
The hammer/nail problem has been there as long as there have been doctors and patients. “You change the things you can change.” That being said, the reason doctors get together in professional organizations such as AMA and county medical societies is so, collectively, we can get the bigger problems fixed. Reference my essay #1, which speaks the values and goals of my county medical society.
🔥🔥🔥
I would love to check myself into a sanitarium 😎