You’re all set to play a more active role in your mental health care. You’re ready to learn, become more engaged in decision making, and make sure you don’t get lost in the shuffle. But you can’t do it alone. Your family doctor will be a critical ally on your journey.
They may be the only one helping you right now. Or, you could also be seeing a mental health specialist. If so, your family doctor’s involvement shouldn’t stop just because someone else is involved.
In this chapter, you’ll see how working with your family doctor will improve your mental health treatment. You’ll also learn how to make this relationship productive and beneficial. Keep in mind some basics:
Your family doctor may be the best mental health expert you have. Psychiatrists may have greater expertise, but family doctors do most of the heavy lifting. They most likely know your whole story and understand your needs better than anyone else in the system.
A little knowledge is a dangerous thing. You’ll learn a good deal about mental health and its treatment in this book, but it only scratches the surface. It’s no substitute for the training and experience of a good family doctor. Be open-minded. You may not have the answers.
Let’s start by examining the family doctor’s role in mental health care. You’ll then see how their jobs have changed, leaving them struggling to manage your care the way they once did. Finally, we’ll show what you can do to fill some of the gaps in care that have developed.
We’re acutely aware that not everyone has a regular family doctor. Or, perhaps you have one who has less than stellar knowledge of mental health. We’ll have some advice for you as well.
Family doctors are the front lines of the healthcare system. They diagnose and treat problems across all areas of medicine, including mental health.
If you have an excellent family doctor, you know the difference they can make. They catch what others might miss and direct you to the most suitable treatment or resource. They go the extra mile if the situation demands it. They connect with you as a real person, somehow keeping your story separate from the hundreds or thousands of other patients they see.
Let’s explore some of their roles and responsibilities in the healthcare system.
Family doctors provide a broad perspective on your health that specialists cannot. All doctors start their training by learning all areas of medicine. The surgeon with no bedside manner once worked in a psychiatry unit talking to people about their feelings. The crooked sewing job on your incision came from a student doctor who became a psychiatrist. However, family doctors are the only ones who continue to see cases covering all areas of medicine throughout their careers. They treat most routine cases and only refer some to specialists.
That includes routine mental health cases. We told you earlier that mental health is involved in around 20% of all visits to family doctors. While there are many different mental illnesses, some are more common than others. Straightforward forms of anxiety and depression are seen frequently. Family doctors are far more likely to treat those and refer uncommon, severe, or exceptional cases to psychiatrists.
Family doctors are likely to be familiar with the symptoms and the typical or expected course of common mental illnesses. They’re comfortable with medications such as standard antidepressants. However, some family doctors are more familiar with, capable of, and skilled at dealing with mental health problems.
Family doctors play two crucial but complementary roles in the healthcare system: advocate and gatekeeper. As advocates, they work on your behalf to get the care you need. This includes basics such as sending you to a specialist, ordering lab tests, and prescribing medications.
Great advocates go beyond the basics. They know all the resources in your area. They might twist someone’s arm to get you into a program, write letters to apply for benefit programs, or ask an insurance company to keep you on disability. They’ll find shortcuts through the healthcare bureaucracy if you need them.
At the same time, family doctors keep you from getting care you don’t need. In most systems, you need a referral from a family doctor to see a specialist. That way, specialists aren’t flooded with minor, uncomplicated ailments, but can see the patients who most need them. Many programs with limited capacity need a doctor’s referral for the same reason. Family doctors do not order unnecessary blood tests or an expensive MRI scan when a simple X-ray will do. Requiring a doctor to sign off helps keep these growing expenses slightly contained.1
Family doctors judge how acute your situation is. This affects both the care offered and how quickly you’ll receive it.
They watch for signs of illnesses that need urgent treatment. If not treated, they could lead to serious injury or death. Most people know that sudden, crushing chest pain signals the immediate need for help. Family doctors recognize more subtle but still dangerous warning signs. For less acute things, they may just watch or try a few interventions, knowing that if they don’t work, you’re not going to be worse off for the effort.
They also prioritize referrals to specialists. How they rate the severity of your condition can make a big difference when you’ll be seen. We’ll talk much more about this in the next chapter.
Family doctors connect you with other parts of the healthcare system, such as specialists and labs. They make sure your care plan stays on track. They keep an eye on the big picture. If something goes awry, they’ll notice and intervene. Or, that’s the theory.
If this sounds a lot like patient navigation, which we discussed in chapter 5, you’re right. This is one of the many things family doctors used to do but increasingly can’t manage. We’ll explain why next. Many of them still try to coordinate everything, but it’s rarely possible. The reality is that you can no longer count on family doctors to completely guide and coordinate all aspects of your health care.
Being a family doctor is not an easy job, and it’s getting harder. There are two main reasons. Family doctors have increasing demands on their time. They also have more and more health information to keep track of. They’re perpetually running behind and usually working ridiculous hours. They face alarming quantities of stress. It’s no surprise that family doctors have high rates of mental illness themselves, including addiction and suicide.2
Something has to give. Inevitably, this will leave gaps in your care. Could you fill those gaps? (Hint: yes.) You need to understand what is being dropped. You also need to contribute in a way that doesn’t make your family doctor’s job more difficult. Both require a better understanding of their challenges.
Increasing demands on family doctors’ time results in shorter appointments and less time for other patient-related activities, such as writing a detailed referral letter or calling a colleague for advice. Your family doctor’s ability to advocate for you is usually one of the major casualties. Their ability to effectively coordinate your care is another.
The other main challenge family doctors have is severe information overload. Doctors excel at remembering and organizing copious amounts of information. Otherwise, they’d have flunked medical school. Even so, they have limits. What’s changed? Peoples’ ability to process and organize information has evolved slowly over thousands of years. But, the volume of information has exploded over the last few years, thanks to computerization and the internet. It has overwhelmed everyone’s ability to evolve and adapt.
Information overload is a problem for family doctors not only because of the things they don’t know. It also actually changes the way they think. When there’s too much information to hold in your brain at once, you naturally look for ways to simplify it. Your brain copes by focusing on the small problem in front of you. What suffers is broader, big picture thinking.
This doesn’t mean your family doctor is looking at one symptom in isolation from your overall health and care plan. It does imply that broader thinking now requires a deliberate, conscious effort. This takes more time, and they are more prone to make mistakes.
Time pressures and information overload come from many places:
Older and sicker patients. Demographics and medical advances have resulted in more seniors than ever before. In general, care needs rise with age, often due to chronic diseases, e.g., hypertension or diabetes. These place a growing burden on family doctors. Worse, more people now develop these illnesses at a younger age than ever before.
Complexity of treatment. Medicine has not become simpler over time. New tests and medications result in better treatment for patients. Unfortunately, doctors need time to stay abreast of new information. Keeping up to date in all areas of medicine is impossible.
Paperwork and administration. The amount of paperwork required of doctors has continued to grow. It’s needed to order a test or comply with regulations. It’s needed by specialists, employers, governments, and insurance companies. Family doctors spend several unpaid hours per day on paperwork after they finish seeing patients. Clinic practices are also changing from solo doctor to team-based care, adding to the administrative burden.
Electronic medical records. Moving from paper to electronic charts has its benefits, but saving time is not one of them. You may not like your family doctor spending your whole appointment with their nose in a laptop, but they hate it even more. These programs are poorly organized and epitomize unfriendly design. They turn quick and easy tasks such as writing prescriptions into an endless stream of mouse clicks.
Not enough time in the day and too much stuff to keep track of. Who doesn’t have those problems?
Don’t think for a second that family doctors aren’t frustrated about shortened appointments or their inability to think through your case at a deeper level. They went into medicine to help people. They’d love to do more if only they could.
So, what is being sacrificed?
Patient education. What does a diagnosis mean? How will it affect you? What else could you do to help get better?
Managing expectations. How long will a medication take to work?
Verifying comprehension. Do you understand the question you’ve been asked, or the directions you’ve been given?
Thoroughness. Are they properly reviewing your symptoms or oversimplifying questions to save time?
Alternatives. Are the prescribed treatments the only options or even the ones most likely to be helpful?
Big picture. Is a focus on the details causing them to miss broader fundamentals?
Discernment. What are the meaningful differences between alternatives, e.g., antidepressants?
Up-to-date knowledge. Is advice based on current information?
Optimization. Is your care plan regularly reviewed, e.g., are medications always added, but seldom stopped?
Here are some examples of how these challenges can potentially affect your healthcare. We’ll revisit a few of these in a later chapter and show how things can improve when you take a more active role in your care.
Your doctor tries you on an antidepressant and books a follow-up in three weeks. At that visit, you complain of nausea and brain fog. They stop the antidepressant due to side effects. Because it’s such a short appointment, you do not discuss that you only filled the prescription three days ago due to your anxiety. You miss out on a medication that could have worked very well once your system got used to it.
Along with your low mood, you mention being always tired and having memory problems. They prescribe you an antidepressant and, two months later, a different one. Neither help. What they didn’t do is check your iron level. They did not identify a common and easily fixed explanation for your symptoms.
Your doctor has you try three antidepressants then gives up. Unfortunately, they were the three least likely to have helped your symptoms.
Your family doctor recommends a counselling program, which you pay for out of pocket. Unfortunately, the type of treatment offered isn’t designed to treat your form of illness.
Your family doctor refers you to a local mental health clinic. They hold a quick intake appointment and put you in an eight-week mindfulness course. While interesting, it doesn’t address your symptoms. Your family doctor meanwhile assumes the clinic took care of your mental health and doesn’t pursue any other treatments.
Your doctor refers you to a psychiatrist with a 12- to 18- month-long waiting list. When asked what to do in the meantime, they shrug and say, “I’ve already referred you to someone.”
Your family doctor is incredibly short on time and has to keep track of information for well over 1,000 patients. You, on the other hand, may have too much time on your hands.
This sounds like a golden opportunity. If you can learn about parts of your illness and treatment, and track aspects of your care, it will free up your doctor’s time. They can spend more of their time with you improving your care rather than asking or answering routine questions. Even if it takes you 25 times as long as it would take them, you’ve got the time and they don’t. You’ll still end up further ahead.
Can you learn enough from a modestly sized book like this to be helpful, without needing 10 or more years of medical education? Absolutely.
Later chapters will discuss specific things you can do to help your family doctor provide you with the best care they can. But first, here are some general principles to keep in mind as you help your family doctor help you.
Always remember that your family doctor is the one with the medical education and experience. That doesn’t mean they’re always right. But if they give you some definitive information or direction, start by assuming they know what they’re talking about. You may suspect there’s more to it than what they’re saying. You may also doubt if they’re entirely correct or up to date in an area that you’ve read a lot about. If so, there are good and bad ways to deal with those situations.
Good ways include asking questions:
“Interesting. I’d like to find out more. Where do you suggest I look?”
“I’ve heard other doctors approach it differently. What are the advantages and disadvantages of your approach?”
“I trust that what you’re telling me is the most likely case. Are there any other possibilities, even if more unlikely?”
“I saw this recent article in The Lancet. Would it apply to me?”
“Do you mind if I bring in what I found for us to discuss?”
But there are also bad ways to question your doctor:
“I read on the internet that…”
“But Dr. Phil said…”
“My friend tried Gwyneth Paltrow’s coffee enema…”3
At all times, respect their key limitations: time and information overload. If you have many things to discuss during a short appointment, be willing to schedule one or more follow-ups. If they have things they need to go through with you, preempting part of your agenda, there’s a reason for that, too. Let them know your agenda items so you can plan together how to manage time most effectively.
If you’ve done some research, don’t drop a pile of papers on them and expect them to read them. Whatever information you’ve found, spend some time to make it quick and easy for them to absorb. Make it concise, summarize it, or highlight the most important parts.
Your family doctor takes appointment notes from their perspective. You should take notes from your perspective. As we’ve said, a paper notebook keeps everything in one place. It also beats having an appointment where you and your doctor spend the whole time typing instead of speaking to each other. If you keep your permanent notes in electronic form, update them after the appointment.
If you have questions, write them down before you see your doctor. That way, you’ll remember them more easily during your appointment. If you get answers to those questions, information, or directions during your appointment, write them down. If you’re supposed to follow up on something six months from now, write it down. Every once in a while, flip back through your notes and see if anything that should have been done was accidentally dropped.
Some people have difficulty talking, thinking, and writing at the same time. Do you feel anxious around doctors? If so, ask a friend or family member to come to the appointment with you.
If you have several people supporting you, the odds are all of them aren’t going to come to every appointment. Consider keeping your notes in a shared document using tools like Google Docs. It’ll save you time and energy as compared to telling everyone individually what happened. Their different perspectives might raise new ideas or questions.
Open and honest communication is fundamental. Your family doctor is trying to help you get better. They need to know what is going on.
Be open and honest about what you’re experiencing, how bad it is, and the effect it’s having on you. Tell them about all your symptoms, no matter how embarrassing (they’ve heard it all before). Talk about the most troublesome things first. If you have many minor concerns, give them a concise, point-form list on paper that they can quickly skim. Some may seem trivial to you but may be important or raise further questions for them.
Keep your family doctor apprised of significant changes to your symptoms. This includes long-term symptoms becoming better or worse, or new things happening that weren’t there before. Changes in your symptoms may suggest a progression of your illness. That might result in adjusting your treatment or even a call to the specialist to see if they could get you in sooner.
It would be great if everyone had an excellent family doctor. But, in countless places, many people do not have a regular family doctor at all. Using the various tools and techniques in this book will be easier with a good family doctor on your side. You can use them without one, but it will be more difficult.
For millions of people, it’s impossible to find a regular family doctor. Despite that, you should still have some access to a doctor through a walk-in clinic or comparable facility in your area.
If that’s your situation, try as best as you can to go to the same clinic all the time. Consider it your medical home. You may see a different doctor each time, but you will end up with a more-or-less complete medical chart there. If you receive care from other facilities, ask them to send a copy of your records to the clinic you use.
Working with a doctor who doesn’t know you and may not see you again has its challenges. You need to do more work before every appointment. You need to be more concise and know what you want out of each appointment. Be explicit about your goals. Bring everything you need for them to help you. If you come across as well-prepared, confident, and organized, and make reasonable requests, most doctors will give your request serious consideration.
Family doctors can’t know everything, and each has interests and skills in different areas. If you get the sense yours is less than current in mental health, what you’ll learn here can make a substantial difference.
Without your involvement, they may be familiar with only a few treatment options, possibly ones that shouldn’t be at the top of the list. They’re not trying to be unhelpful. They’re probably just fuzzy on the differences between various antidepressants, changes in the DSM, etc.
Bring them some logical and evidence-based suggestions along with supporting information, e.g., a medication’s prescribing information. More likely than not, they’ll be willing to go along with your suggestion or, at least, look into it. What they learn from you might even help with other patients.
It shouldn’t happen, but it does. Everyone knows there is stigma about mental health. It exists among doctors, too. Some would rather spend their time dealing with real illnesses. Others are insecure about their lack of knowledge and try to hide it. A very few think that mental illness is a made-up problem.
Patients have reported being told by family doctors, “You’re fine, there’s nothing wrong with you,” or “Suck it up, life is hard sometimes.” One recommended, “Just go to church and pray more.” Some patients feel belittled or worse. Sometimes the doctors are right, and you are fine. Normal ups and downs are part of life and don’t necessarily mean you have a mental illness. But they should be able to explain that to you. If you describe how your symptoms are affecting your life and you’re still dismissed, this may signify a deeper problem. Talk it over with people you respect, from a variety of backgrounds. Do they think you’re overreacting?
The few doctors who are openly dismissive of mental health will be hesitant to refer you to someone for help. (Sometimes though they refer quickly, so that someone else has to deal with it.) They’re less likely to order tests or help you with medications, even if you present a good case. Family doctors who stigmatize patients with mental health concerns may assume everything is all in your head. Dozens of studies have concluded that people with mental illness receive poorer medical care overall.4 That’s a serious problem.
Few people have the luxury of shopping around for a different family doctor. If you are one of the lucky few, consider it. Otherwise, make the best of a bad situation. Respect their time and come in with simple, concise requests. Be appreciative when they help you a bit, even if you’d like to strangle them. Don’t waste your time telling them in excruciating detail things you know they’re tuning out or getting annoyed by. Find a way to a common understanding, even if it’s far less than you’d like (and deserve). And keep your eyes open for other options. Is a good walk-in clinic better than what you have now?
Family doctors train in all areas of medicine including mental health. They deal with mental health frequently and treat many cases without outside assistance.
Family doctors have several responsibilities within a broader system. They evaluate the urgency and therefore the priority of your case, advocate for you to access certain programs, and act as gatekeepers to keep you from using scarce resources you don’t need.
Medicine has become far more complicated, and family doctors face severe time pressures, information overload, and stress. To cope, they focus more on what’s immediately in front of them but have a harder time tracking the big picture.
If you have time, you can help them with your care. For this to work, you need to have an open and honest relationship, respect their expertise, and be conscious of the difficulties they face.
In the USA, the main gatekeeper is usually not doctors, but insurance companies. They decide if tests will be paid for or not.
Self-referral for diagnostic tests or other expensive services in the USA results in overuse of services, though many of the costs are born by those who purchase these services. Doctors more worried about liability will also order more unnecessary tests, known as defensive (or CYA) medicine.
Hendee WR, Becker GJ, Borgstede JP, Bosma J, et al. “Addressing Overutilization in Medical Imaging.” Radiology. 2010;257(1):240-245.
https://doi.org/10.1148/radiol.10100063
The Choosing Wisely initiative helps patients and doctors identify and reduce the use of unnecessary testing.
http://choosingwisely.org↩
Doctor burnout is a growing problem. It has received more attention lately, at least within the medical community. In the USA, much of this stems from a loss of autonomy and greater administrative demands as healthcare organizations grow. For example, great effort is put into meeting new documentation requirements that add little to clinical care but are needed for billing and compliance with meaningful use legislation.
The work that doctors do is stressful enough. The medical culture makes it worse. There is intense competition to both enter and then succeed in medicine. Needing help is seen as a weakness and can, at times, have damaging career consequences. With few perceived options but easy access to pharmaceuticals to self-medicate, addiction and suicide are common. Numbers vary, but suicide rates are roughly 2-3x the general population.
For those interested, a good starting point is the online doctor community KevinMD.
https://kevinmd.com
Pamela Wible is the most visible advocate for addressing doctor suicide. Her blog and TED talk are good introductions.
https://idealmedicalcare.org↩
Yes, it’s a real thing. If you’re interested in exploring what can happens when celebrity culture meets health advice, we’d highly recommend health science expert Timothy Caulfield’s 2015 book, Is Gwyneth Paltrow Wrong About Everything? When Celebrity Culture and Science Clash.↩
Unfortunately, there is a large and varied body of research correlating mental illness (even, e.g., mild major depressive disorder) with poor physical health. Some of this work looks at health outcomes, e.g. five-year survival rate after a cardiac event is lower for those with mental illness. Patients with mental illness are less likely to follow their treatment plan, likely contributing to this statistic. Other studies look at how often particular interventions are offered and find that people with mental illness are less likely to undergo a procedure like cardiac catheterization after a heart attack. Studies have found that the rates of certain common lab tests for physical health conditions can be lower in those with mental illness. Some of these studies focus on severe mental illness while others are more broad. Many use very large healthcare databases, while others use specific patient demographics (e.g. patients in Veterans hospitals).
Determining the exact reasons why patients with mental illness receive poorer physical health treatment is decidedly tricky. There are many potential confounding variables. Nevertheless, the data is pretty strong across a wide range of medical environments. Stigma among many healthcare providers against those with mental illness likely plays a role.
Of the hundreds of papers available, we’ve included a very small selection of papers addressing these topics.
Druss BG, Bradford DW, Rosenheck RA, Radford MJ, Krumholz HM. “Mental disorders and use of cardiovascular procedures after myocardial infarction.” Journal of the American Medical Association. 2000;283(4):506-511.
https://doi.org/10.1001/jama.283.4.506
Druss BG, Bradford DW, Rosenheck RA, Radford MJ, Krumholz HM. “Quality of Medical Care and Excess Mortality in Older Patients With Mental Disorders.” Archives of General Psychiatry. 2001;58(6):565–572.
https://doi.org/10.1001/archpsyc.58.6.565
Frayne SM, Halanych JH, Miller DR, Wang F, et al. “Disparities in Diabetes Care: Impact of Mental Illness.” Archives of Internal Medicine. 2005;165(22):2631–2638.
https://doi.org/10.1001/archinte.165.22.2631
Mitchell AJ, Malone D, Doebbeling CC. “Quality of medical care for people with and without comorbid mental illness and substance misuse: systematic review of comparative studies.” British Journal of Psychiatry. 2009;194(6):491-499.
https://doi.org/10.1192/bjp.bp.107.045732
Jones S, Howard L, Thornicroft G. “‘Diagnostic overshadowing’: worse physical health care for people with mental illness.” Acta Psychiatrica Scandinavia. 2008;118(3):169-171.
https://doi.org/10.1111/j.1600-0447.2008.01211.x↩
Now Available! A MSP-supported live course for BC residents based on the book. [Mar/2023]
While you can read it for free online, there are conditions on sharing it with others (see below). You can also still purchase copies in paperback or e-book (PDF, Kindle, Kobo, etc.).
Now Available! A MSP-supported live course for BC residents based on the book.
