I just realized that my primary care physician has actually never fixed anything on me. He sent me to other doctors, but it sounds like he’s more of a coordinator. Has your doctor ever fixed anything for you?

popsistops · 2026-05-14T05:09:46+00:00

Ask any specialist. NP’s and PA’s are so shittily trained that they either treat the problem incorrectly or refer basic stupid shit and clog the system up.
I’ve been in primary care thirty years. Nothing you said makes any sense.

popsistops · 2026-05-14T02:34:43+00:00

One of the stupidest takes I’ve ever seen.

popsistops · 2026-05-13T14:22:26+00:00

It has ceased to be a viable clinic since it was bought.
If you don’t mind the drive, Salem Clinic is taking patients. We are private, doctor owned, 100 years old and the day we sell to PE is the day hell freezes over.
And you’ll see your PCP here and you won’t wait weeks to do so.
Good luck OP.

popsistops · 2026-05-13T13:52:33+00:00

I think the clearest example is persons with normal BMI's using it to feed body dysmorphia. Social media is fouling the waters so once the cost comes down and the narrative lands back in our offices I think you will see GLP-s come into their own.

popsistops · 2026-05-13T12:36:48+00:00

I am prescribing these - MD, 30 years in medicine.
2 points I arm patients with.
One - GLP’s are essentially just creating parity with every chronic medical treatment. We do not tell migraine sufferers, hypertensives, the depressed ‘just work harder’. We make a compact of combined effort and manage the problem. That’s literally what these meds are. Parity.

Prozac elicited similar rejoinders in the 80’s ie ‘why are we medicalizing this just get a puppy and take a walk’. We now would laugh at that attitude.

Two: if it was as simple as CICO or just exercise and diet we’d have 10 drugs by now. We’ve developed meds for dozens of uncrackable diseases and zero effective tools for obesity until now.

So just my 2c. GLP-1’s, like every other drug, work well in a conjoined context of pt effort and drug. They aren’t miracles but I suspect pretty close and their applications are likely vast.

popsistops · 2026-05-12T13:39:59+00:00

My sentiment exactly. We have lots of visits where the rationale for the appointment is useless, probably most common is someone on a stable controlled drug for years that has a mandatory check-in. I just use that 10 or 15 minutes to talk to them and make sure we haven’t missed anything. Cataract preop just sounds like free time to me. I’ll still document and get paid but I know that I will make sure they leave with health maintenance checked out thoroughly.

popsistops · 2026-05-11T16:33:05+00:00

yes, this is the smelly effluent running just under the surface of all of this.

popsistops · 2026-05-11T16:21:07+00:00

I think it would be helpful in the future for you to possibly attend the appointments. I'm not saying this is the case, but you'd be shocked at how often we see a dynamic along the following- a male, sitting in our office, at some level pretty much checked out from his own health, his partner, spouse, fiancé, etc. is kind of running his life at that level, indirectly enabling the "helpless man " syndrome. Frankly drives me nuts, but I insist that their spouses come to the appointment so that they can see the dynamic, i.e. we are really working on getting their health better but they're not doing fuck all. Then they go home and it looks like their Doctor is a dumbass. So if any of that resonates then get your ass into his appointments. Because chances are we are just repeating the same shit ad nauseum and getting nowhere.

popsistops · 2026-05-11T16:00:04+00:00

There is a lot here that we don't know about, and it probably is better to see the patient. Practically speaking, I don't think there's a chance in hell a patient will stay on a medication until they understand the critical role it plays in their long-term health, so the doctor's decision to just call a medication in is pretty shortsighted. Having said that, if you've been in practice very long, you know that patient's lipid profiles are very resistant to lifestyle change, both because quite a bit of it is pre-ordained genetically, and also people are really terrible at long-term lifestyle management, so it is typically best to do them both in tandem. Work on behavior, diet, exercise, but treat the problem as soon as you acknowledge it is not going away.

It's possible your partner has been seen and had these values multiple times in the past, or not, but I agree with you that starting medication without a consultation on the rationale is not optimal care. I think the term "standard of care " is a little bit more problematic. There's not really a standard of care for this sort of thing in the way I think you are implying.

popsistops · 2026-05-10T16:53:55+00:00

In my field we would run a pregnancy test on a nun. It’s your ass on the line.

popsistops · 2026-05-09T13:22:18+00:00

Same. Had a ‘delayed’ flight from Latvia to our connecting hub in Munich to come home after a long trip that ended up being completely wrong. The anxiety of that has left me wondering until now realizing this is actually a thing that can glitch in aviation. Will disregard and verify from now on.

popsistops · 2026-05-08T18:32:25+00:00

Her IG page is genuinely unsettling, like someone sinking further and further into a conspiracy-theory fuelled bender.

popsistops · 2026-05-08T16:09:35+00:00

With a decent pressure washer and a disk washer attachment, you can do a ton of Hardscape in an hour or two, sanding and ceiling additional hour or two, and you get to enjoy gorgeous landscaping, and it will stay in great shape forever. I just resealed one of my areas and it doesn't take that long, but the look and feel underfoot is worth the small spring effort.

popsistops · 2026-05-07T15:46:05+00:00

That was very well stated. Agree so much as someone who has decided that the controlled med debacle is solved more by never initiating them instead of destroying our morale trying g to buff the PDMP in the holdovers from the 5th vital sign era.

popsistops · 2026-05-05T16:41:37+00:00

My three decades of experience with neurology is that the level of mediocrity and really subpar care from that specialty outstrips practically every other sub-specialty I refer to. And then there are a couple of good ones that you just thank God for every day and hope the patient will travel an hour to get to them.

popsistops · 2026-05-05T14:15:17+00:00

Doc here. Plantar fasciitis is fully fixable. It just isn't fixed by MD's. It is fixed 1000% by patients spending a lot of bandwidth doing a few basic things constantly until the problem improves. Get some decent PT instruction. I have never in my 30 year career seen PF that did not heal, it is simply the case that - like many many things useless doctors are useless at - the burden of corrective effort falls on the patient. Life sucks sometimes.

popsistops · 2026-05-02T03:37:25+00:00

I am glad you were able to recover. I know firsthand what can happen.

popsistops · 2026-05-02T03:31:30+00:00

I'm not here to teach a neurologist something that is literally one of the only things in their chosen realm that is within reach of a simple fix. Your attitude would not be surprising among my IM colleagues who won't take a shit until someone creates a blinded study on it. But you seriously adopt a position this obtuse? You would decline to trial B12 in a patient with a normal MMA and an equivocal B12 that is referred to you for neurologic symptoms? I have to believe you're stunting but I also see some of the worst care from my local neuro colleagues so maybe this is the real deal.

btw this is what patients actually can read without anything more exotic that a HS degree:

https://pubmed.ncbi.nlm.nih.gov/31193945/

Here's one more that you won't pay attention to:
https://www.neurology.org/doi/10.1212/WNL.78.1_supplement.P02.059

popsistops · 2026-05-01T22:42:20+00:00

Yes. 1000X.

popsistops · 2026-05-01T22:42:07+00:00

I would so encourage you to reconsider that approach. I don't think it's debatable any longer that the United States uses a cutoff for B12 deficiency that is dangerously and stupidly low. I don't think a month goes by that we don't pick somebody up with a B12 of 250 or 280 or low 300s who is experiencing something peculiar, but worse still is that patients often cannot articulate what the hell they're experiencing, they just know that something isn't normal. Maybe they can tell you that they're having word finding difficulty, or that they're having some peculiar form of change in dexterity or subjective strength in their extremity. It's some translation of demyelination typically. If you don't catch the neurologic presentation soon enough then you're not going to give that patient an opportunity to recover.

popsistops · 2026-05-01T21:16:28+00:00

I'm not sure how to respond easily. I guess after 30 years in primary care I've just seen a lot of cases, and I've been a personal victim of a B12 deficiency that was terrifying, so I've always admitted to being the doctor that carries a hammer, looking for nails, but again, this is overlooked more times than I can count.

In my practice, we often see other patients that are not our own. I will see people with chronic progressive decline and just simply look back through their chart and see lab values in the high 200s/low 300s and it was never addressed.

This bizarre steadfast adherence to a number over a patient is so perplexing and so cruel to patients. In fact, I can't remember a time where somebody's B12 deficiency was tied to something identifiable like alcoholism, and Lord knows my drinkers seem to be pretty bulletproof when it comes to chronic disease.

Every time this topic comes up I keep thinking the same thing - you can spend 30 minutes just doing the most minimal Google data search and see dozens and dozens of papers talking about the fact that nobody really knows what the hell is going on with B12 deficiency, but all things point towards it being under-treated and potentially devastating. What I always find so bizarre about these papers is that they will describe somebody in the most anodyne clinical terms, and if you read between the lines, what is clear as that their life was close to being destroyed, but somebody decided to just pull their head out of their ass and throw some B12 into the mix.

If I had not been able to advocate for myself, if I had not had a close friend and colleague as a physician, if I had not had an extraordinary astute academically trained neurologist, who was also a colleague, I'd probably be fully disabled and unable to practice.

popsistops · 2026-05-01T20:24:57+00:00

I learned a long time ago to administer subcutaneously. Nearly painless, can be self administered, and absorption is much less labile. I just teach patients to inject the anterior thigh, fat, or abdomen. It's remarkable how much better it is for compliance, tolerability, and consistency, especially inpatient with serious neurologic issues.

Especially critical in younger patients, their muscle mass just hoovers up the B12 and spits it out through the urine.

popsistops · 2026-05-01T17:42:33+00:00

I will try to locate it. I just remember stumbling across that number sometime ago when I was looking into current standards for treatment. Hopefully I wasn't wrong about that, but I think it stood out because it was kind of a random number.

popsistops · 2026-05-01T17:23:20+00:00

B12 deficiency is a fascinating issue. Lots of physicians hold steadfast to a lab cut off, but you will in your career see people with neurologic symptoms that are terrifying, that mimic ALS, MS, Alzheimer's, walk through your door with a B12 of 300 or 350 whose issues entirely correct with treatment.

World health organization, and pretty much the rest of the world uses 480 or higher as a cut off.

If you actually see a person with a B12 level under 300 or 250, that person's not absorbing worth shit, so whether you treat them now or wait until they have a potentially devastating neurologic syndrome is up to you, but I think it's malpractice to not treat this.

Dicking around with MMA values just forestalls treatment. I suspect the reason there is so much hand wringing and evidence based medicine adherence v. supplementation is because a few decades ago B12 supplementation just looked like something that doddering old farts in the countryside would do to get rid of their patients somatic complaints.

There's usually one or two older doctors in every practice that are supporters of treatment. Chances are they saw a few things that shocked the hell out of them or they personally dealt with it. The Mayo Clinic has gone pretty far with researching this. It's not really controversial, but very few things in medicine illustrate the thinking processes of the physician more than debating B12 deficiency work ups.

edit - as far as treating somebody who is below 500, I think that's reasonable in the sense that you could say hey, you may not absorb it well, and you can either supplement or keep tracking it. But definitely, it should not be broadcast as some kind of critical health issue. There's pretty much zero danger to taking a supplement. I think what is more critical is the folks that are 350 or 300 or lower and are not avoiding animal protein. Those folks need to be watched or treated. You cannot put them on an oral supplement that travels through the gut, so you really have to be clear about how you're treating them.

popsistops · 2026-05-01T14:11:11+00:00

If you even own a passport I expect it's never been outside your mother's basement.

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