Practitioner Question of the Month – April 2017

Lorraine Love asks:

“Why did you put her on a herbal antimicrobial protocol for SIBO when the SIBO test was negative? What amounts do you consider high dose HCL/bile/?

Is there a risk to giving HCl long term? How do you wean someone off (tried bitters/ACV/etc.)?

If you can’t give examples of specific products, giving dosages/amounts of ingredients would be important.”  

Good questions Lorraine, let’s break these down.

“Why did you put her on herbal antimicrobial protocol for SIBO when the SIBO test was negative?”

• If you read the case study write-up, you find your answer. J
  • “Even though she has tested negative recently for SIBO, there may be another form of dysbiosis present; SIFO or H2S SIBO or fungus….”
• At this point in time I am looking to symptomatic response and not treating based upon labs.

“Is there a risk to giving HCl long term? How do you wean someone off (tried bitters/ACV/etc.)?”

• In my opinion, yes, the same risks that we see in people with hyperacidity: reflux, esophageal damage, gastritis, and/or ulcers.
• I usually just have someone slowly decrease their dose over time to find the minimal dose needed. Most are able to come off HCl, some do better on small dose (500-1500mg/meal).  I have used bitters in the past, but just haven’t found them absolutely necessary. I cut them out of my model to simplify things, partially because I found some patients reacted negatively.  One could make an argument for bitters, but I am always looking to consolidate to the most effective therapies, and this was not one of them.

“If you can’t give examples of specific products, giving dosages/amounts of ingredients would be important.”

• I would love to provide every detail in these case studies, but it’s a balancing act between detail provided and price for subscription. The feedback is noted and at some point I hope to have another level of subscription for in depth protocols and other resources.

Sometimes it’s better to say less during patient communication. 

You have probably heard the saying, “if you give someone an inch they will take a mile.”  I thought of this today when I was teaching a SIBO clinical training podcast along with Dr. Siebecker.  I couldn’t believe how many questions the audience of healthcare providers had about compliance with SIBO breath test preparation diet.  It seems many practitioners were struggling with compliance with the prep diet and/or searching for answers to a litany of questions regarding if certain ‘exceptions or modifications’ could be made.

I almost never have to deal with this in my office, so it struck me as odd.  After thinking on it for a moment, I realized what was likely happening. The provider issuing the test was likely spending too long explaining the test, and especially explaining the prep diet.  Sometimes when you, or your staff, spend too long on something and cover it in too much detail, it can invite patient questions.  This is not a bad thing, it’s just human nature.  But there are some items that are so simple, the answer is always the same.  So when you over-explain it (give an inch), the patient takes a mile of questions.  This ultimately does you both a disservice because you waste time fielding questions that always bring you back to the same answer.

I am very brief in my explanation, “The test kit comes with instructions regarding a preparation diet that must be followed. Please read the instructions carefully and make sure to follow them.”  Done.  It is really that simple.  I am not brief on purpose, there was just never any need for me to narrate to them what they would be reading momentarily on the instructions.  What I now realize is by being brief I set the expectation that the prep diet is not up for negotiation, which it really isn’t because the test was validated using the prep diet.

Consider this in areas wherein you are constantly bogged down by questions that always have the same answer.

Another quick example of this was something I noticed with my medical assistant or my office administrative assistant. When we would be checking out a patient, I would notice that it would sometimes take as long for my staff to check out a patient I just finished with as it would for me to complete the office visit with the patient I was currently seeing.

So it may be a 25-minute patient visit that I would have, and I’d come out of my office and notice that one of our staff was still checking out the patient from before.

Now, that really shouldn’t happen. And I noticed this enough times where I went back to a concept that we have discussed previously and asked the staff what was going on. Did this seem to be inefficient? And of course, the answer was yes. I asked them what aspect of the checkout was taking the most time, and they informed me that it was answering questions regarding their treatment program.

Now, here’s where the explaining too much, or the over explaining, comes in. I always explain the treatment program to a patient during our visit. However, for some reason, my staff got it in their heads that they should then again be explaining the treatment program during them checking the patient out. What this did was create a whole series of questions that the patient had that the staff was trying to answer that they weren’t equipped to answer.

And as soon as the patient felt like the staff was giving them a non-confident answer, they were flooded by even more questions, because as soon as the patient would sense some type of lack of confidence in the staff’s answer, the patient would doubt the answer and ask more follow-up questions. And it was just an absolute nightmare!

So I covered with the staff that it’s not your job to reiterate the patient treatment program. That’s what we’ll do during our consultation. Your job is simply to handle the logistics of scheduling their follow up, financials, answer any general logistical questions that they have. And all the clinical stuff are things that we’ve just discussed and/or can be discussed at their next follow up. So that additional factor was another example of how over-explaining or giving an inch can result in a mile of questions.

And ultimately, all these things are not done to try to shortcut a patient. We always want to be as available for a patient as we can. But when questions always have the same answers, or when it’s not even worth getting into a question because the answer is the same as the instruction sheet right in front of them, or when a staff member is being put in the position to answer a question they’re not qualified to answer, these are all examples of how you want to be a bit more brief and say less, and therefore have fewer questions.

And you can make things in your office much more efficient for you and much more efficient for your patients and make sure you spend your time on giving them the information that is most relevant to their care.

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