How Internists Think About Complex Illness with Dr. Matthew Watto (EP 133)

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Dr. Matthew Watto: [00:00:00] Sometimes you just have to like practice based on a hunch and you know, of course, you're trying not to harm the patient and you're letting them know, uh, here's in theory why this may or may not work. Here's what we know. Here's what we don't know. The risks, the benefits. But that's, that's kind of how you have to practice

Dr. Linda Bluestein: every bendy body to the bendy bodies of the Hypermobility MD podcast with your host and founder, Dr. Linda Bluestein, the Hypermobility MD. Today I am so excited to speak with Dr. Matthew Watto. Dr. Watto is an internist and he is a co-host of the podcast, The Curbsiders. It is important to have empathy, compassion, and understanding for your internist so that you can learn how to work with your doctor and get better care.[00:01:00] 

Dr. Matthew Watto is an internal medicine nerd, clinician, educator, and podcaster. He is a clinical associate professor of medicine at Sydney Kimmel Medical College, an adjunct associate professor at Uniformed Services University, and has received numerous teaching awards. In 2015, he co founded The Curbsiders, a weekly internal medicine podcast that uses expert interviews to bring listeners clinical pearls, practice changing knowledge, and lots of bad puns.

The Curbsiders team uses its platform with over 100, 000 active monthly listeners to bolster frontline clinicians caring for millions of patients across the United States and internationally. This is such an important conversation because for so many people, their internist is going to be their primary care doctor.

And so it's essential to work with your primary care doctor in a way that can get you the care that you need. As always, this information is for educational purposes only, and it's not a substitute for personalized medical advice. Stick around until the very end. So you don't miss any of our special hypermobility hacks.

Here we [00:02:00] go.

Okay, well, I'm so excited to be here with Dr. Watto today. How's your day going? 

Dr. Matthew Watto: My day is going well, and, uh, I don't know if I, you weren't prepared for this. I didn't talk to you about this ahead of time, but, uh, on, on our show, we, uh, the curbsiders, we always do like a pun to start it off. I just feel like it starts things off with a good energy.

So, um, I typed into chat GPT. Can you give me some puns based on. You know, flexibility, hypermobility, and, um, I promise they're not, you know, I, I think they're, they're not great, but we'll, you know, we'll try them out. Okay. And if you hate, I think it'll be good. If you, if you like puns, it'll be good. If you hate puns, it'll be good because it's, you know, all right.

So first one is, um, people say I'm too flexible, but it's not my fault that I like to bend the truth. All right. So that one's not, that's not great. Um, and then the other one is I, I told my wife I was too flexible and she said, that's a stretch. [00:03:00] Yeah. So chat, chat, GPT is still working on it, but, uh, you 

Dr. Linda Bluestein: know, 

Dr. Matthew Watto: usually like I, we started off doing puns that were related to the topic at hand and then.

After getting to hundreds of episodes in I just now I just try to find any pun that is uh, You know just any pun that makes me that makes me chuckle But for for today, I tried to keep them relevant to the topic. 

Dr. Linda Bluestein: I I appreciate that I have heard that on your show and uh, I think that's a cool way to start.

I like it 

Dr. Matthew Watto: Yeah, I think, you know, you gotta, you gotta come into it with a good energy, excited to record. So, uh, thank you so much for having me and I'm excited to talk with you. 

Dr. Linda Bluestein: Yeah. I'm super excited to talk with you because I know so many people are so frustrated how to get better care, how to work with their internist in a way that.

You know, it's really helpful for them. And I know that you talk about so many amazing topics on your podcast, curbsiders. It's such a great show. I know I've learned a lot from listening to it and I hope people will go check that out. We'll be sure to link your show in the show notes so people can check [00:04:00] out your podcast also, because it is really important and you cover so many great things.

Dr. Matthew Watto: Yeah, I appreciate, I appreciate you saying that. And I, I mean, I think much like your show, we try to make it practical. We try to make it pertinent to like our audience has these pain points, so to speak. You know, they're seeing patients with certain complaints. Um, they might not know how to handle it. So we try to get an expert in that can teach us.

How they would handle it that way in primary care, or we have hospital medicine shows too, we can sort of, you know, help people help their patients more. So it's, it's a really great format to do that, which is why I think podcasting works so well for, for medical professionals. 

Dr. Linda Bluestein: Yeah. Podcasting is, I think, a great way to teach for sure.

So, um, can we start out by talking about what. An internist does and what role they might play in the person who has a connective tissue disorder, like hypermobile Ehlers Danlos or hypermobility spectrum [00:05:00] disorder. And, you know, oftentimes they're trying to assemble their team if you will. And I think it would be important for people to understand right off the bat what what that means and what kind of a role that person might play.

Dr. Matthew Watto: Yes. Okay. It's a little hard sometimes to like. Explain an internist to people. They're like, what do you do? And I, so I usually either say just like, I'm a primary care doctor. Sometimes I work as a hospitalist or I might say to them, well, you know, if someone's admitted to the hospital, we take care of pretty much anyone who's not on a surgical service.

So we can take care of just any host of things, high blood pressure, diabetes, cholesterol, infections, heart failure, kidney failure, uh, just really a lot of, you know, work sort of like the. Undifferentiated physician. And then you can go into. You can become a kidney doctor, you can become a heart doctor, um, you can become a lung doctor, all those things from starting as an internist.

So it's really a, you're, you're kind of a generalist, but you see adults, you don't see kids and you, you see pregnant women, but you're not, [00:06:00] you're not taking care of pregnant women in the hospital the way a family medicine physician would be. 

Dr. Linda Bluestein: Right. So that's an important distinction between an internist and a family doctor, right?

The family doctor will handle all ages and whereas internists are going to be managing adults. Yes. 

Dr. Matthew Watto: And I should say to your audience, like in this full disclosure, we have very poor training in hypermobility, Ehlers Danlos, like we've heard of it. Um, we, we know it's out there. I was talking to my partner on curbsiders who has, you know, throughout his career at some points he's had actually just ended up with like a panel, a lot of patients with hypermobility and, and pain from that.

So he, he's a little more familiar with it than I have been, but it's something that. I think internists should know more about like, there's, there's definitely training gaps in like when I was going through training, there was no training in addiction medicine. That's actually becoming fixed very rapidly.

Now, a lot of internists are getting just because there's so many patients that need our help [00:07:00] that we've just sort of by default become comfortable with addiction medicine. And I think, You know, for hypermobility, that's maybe something that internist should should become more or they should become more familiar with that.

But you're training in med school. I can't remember a single a single lecture and then going to national conferences for the past 89 years. I. I don't remember. I know. I haven't attended a lecture and I probably would have if I saw it because it would be such a unique topic. 

Dr. Linda Bluestein: So I would love to connect with you offline about that because I would love to submit a lecture to do it.

One of those conferences, because That's so important, like up to 3 percent of the population may have hypermobile EDS or HSD. And so this is a huge percentage of people because I'm sure they're overrepresented actually in your clinics. It's not 3 percent of the visits. They're probably many, many more than that because they're having so many different symptoms and problems.

So internists definitely need to be as familiar as possible. And what I say all the [00:08:00] time is, you know, these patients are coming to your clinic. You probably just don't realize it and no one else has made that association either. Sure. I. I personally have hyper mobile EDS and I had been to, you know, my physical medicine and rehabilitation doctor.

I've been to multiple orthopedic surgeons. And even if they did measure my joint range of motion and they would say, oh, well, it's way higher than normal. They would never say what that could possibly mean or think. Okay. Well, this person has complaints in other parts of their body. You know, maybe I should refer them to a rheumatologist or whatever, which ultimately that's how I got diagnosed.

But I do think it's, it's such an important thing for people to recognize because unlike the myth that there's nothing you can do, there really is a lot that you can do. So the internist Which is why I'm excited to have you here. The internist can really play a very significant role in the care of these patients.

And I try to explain to patients all the time, you know, you can't expect the internist to be an expert in this because they have to be an expert in so many things. They have to know, like [00:09:00] you said, you know, how to manage high blood pressure and diabetes and acute things like acute infection or whatever.

But having some awareness, I think, would be really important. 

Dr. Matthew Watto: I think that's true. And, you know, part of what. What has made me like do a podcast on internal medicine for the past nine years is that I just learned that okay So many patients they're waiting to see a specialist or they just don't have the relationship with a specialist and when we can really Learn the majority of the workup get them like 80 percent of the way there for a lot of topics Start the workup We can interact better with the specialists if we have like just at least a core baseline knowledge of things Um, I think that is, you can definitely expect that from your internist or we should, we should aim to get there for this, for this condition where someone like myself, like, you know, this has kind of spurred me to start doing more learning on this, uh, when, when you reached out to me, because I, like I said, I admitted, I, it's not something I knew [00:10:00] much about, I've heard about it.

But, uh, it is something that I think could easily we could do a lot better than we are now, because right now we're doing terribly. So, you know, it's like we could definitely do better. 

Dr. Linda Bluestein: Yeah, yeah, I agree. I think there's so much room for improvement. And again, it just, you know, I tell people when they say, Oh, my gosh, my doctor didn't know how to pronounce it, or they were looking it up on Google.

And I was like, that's great that they were looking it up on Google. And if they didn't know how to pronounce it, like, that's okay. That doesn't mean that they're not going to be able to help you. 

Dr. Matthew Watto: Yeah, absolutely. 

Dr. Linda Bluestein: So when you are, uh, I guess not just you, but in general internists that are within the insurance, um, accepting world, how long would you say the average appointment is for a returning patient and for a new patient?

Dr. Matthew Watto: Yeah, it's definitely variable. I can tell you in my experience. For returning patients. It's usually 15 to 20 minutes. [00:11:00] Um, and then for new patients, you might have 30 40 or if you're lucky, you might have an hour. But most places are like 30 to 40 minutes with a new patient. And the. I think in some clinics, like some family medicine clinics, I've heard, uh, them say you have five or 10 minutes and I've, I've had some patients that are physicians even say that like they, they went to their, you know, their primary care and the primary care said, okay, you're here for a physical, we can't talk about any acute complaints and they sort of limit that visit I've been, because I've always worked in academic medical centers, You have a little bit less of that pressure to see high volume.

So I've always had like the luxury of having a little bit more time with my patients. So like, I think 20 to 40 minutes in 20 minutes, I can usually do a follow up if I've done a bunch of preparation ahead of time. And then, you know, if you run a little over, it's okay. Um, in 40 minutes, you can, again, if you've done your work ahead of time, [00:12:00] like whatever you can learn about the patient before they get there, you can do a pretty good visit in 40 minutes and address like a couple of cute concerns and So I, but I, I think any, once you start to get down into those, like 20 minutes or less, if someone has a bunch of complaints or they have like a big emotional thing to talk about, it's just unrealistic and the person's not going to feel heard, probably leaving that visit.

Dr. Linda Bluestein: Yeah, and I've definitely been on the receiving end of that. Like you said, you're coming in for a, you know, just a general checkup and you have a. Pressing concern and nope, can't talk about it right now. And that that's always challenging. So, so you just brought up about academic medicine. So what are the different types of practices and why is that important for patients to 

Dr. Matthew Watto: understand?

So, uh, in academic medicine, it probably means if you're seeing someone who's in academics, it probably means they're spending a lot of their time with trainees, whether they're medical students or medical residents. So they're not going to be. In clinic eight or [00:13:00] nine half days a week, they might only be there for five or six, um, days, like a half day sessions and they're going to, so their, their time is going to be a little bit more fragmented.

Um, but they might have less of a time pressure depending on where they work, they might have less of a time pressure to see that high volume because they're not expected to be these sort of like workhorses, um, sad as it is in medicine, it's like. Uh, this is my cynical view of, of how the system largely works is like if you're primary care, they want you to see as high volume as possible as many patients as possible because that's They don't, you don't get reimbursed a lot per patient.

So they, they just want you to see a lot to make a lot of money. And then, uh, and then for, for surgeons, like you want to keep all your surgeries booked, you know, max out as many surgeries as possible, as many procedures as possible. Keep, if you own the CAT scan machines and MRI machines, keep them running like 24 seven.

Um, unfortunately that's kind of how things are incentivized. [00:14:00] And, um, some, some practices you can tell you can feel that when you're there, you know, that they're just, you know, rushing through things as fast as they can. I like to think that some of the practices I've worked in because of academics, they're a little bit sleepier.

You get a little bit more time with the patients, um, it might be frustrating that you can't see the, like, if you call for a same day visit, I think that's always hard in any practice, but that might be hard. So we do more telemedicine for some of that stuff, um, just to try to like, at least have that contact with the patient and make them feel like, even if you can't see them in person that day, you, you do a telemedicine, so.

Did that answer your question? I mean, I could I could go on about this stuff forever. 

Dr. Linda Bluestein: Yeah. Yeah. No, that's okay. So, so you're an academic medicine. So you're in an institution where medical students and residents, et cetera are being trained. So that's different from a private practice where different there could be different types of private practice.

But like you said that. Depending on who's overseeing [00:15:00] the clinic that there could be that higher volume type situation. So I guess I'm thinking for a patient who's trying to figure out who they should see. Are there certain questions that they should ask if they feel like, you know, I'm kind of complicated and, or I really want to have more time with my doctor.

Are there certain questions that you think they should be asking when they're investigating different doctors that they might want to consider? Yeah. 

Dr. Matthew Watto: I think they, I think they definitely should ask about the, um, how long that you get for new patient visits and follow up visits. Because if they're 30 minutes for follow up and 60 minutes for new patient visits, you know, that's better.

They have more time with your physician is better. I think they, um, you can ask things about like, Is this a training site? Because sometimes if, if doctors have trainees following them, they might have, they might kind of have a slower schedule and more, more time to spend with the patient to allow for having that trainee there.

Um, and then there's concierge practices. They might, sometimes they call it direct primary care. [00:16:00] Usually that's where you have a, some sort of a fee that you pay, almost like you can think of it like a retainer might be 2, 500 a year. And that doesn't, uh, that, that means so if, uh, if an internist has a panel of a thousand patients and each one of them is paying them 2, 500 as a retainer that allows them to only see 10 or 11 people a day, they can see, they can spend an hour per patient.

They usually guarantee seeing you within 24 hours. Obviously you have to be privileged enough to be able to afford the retainer, but those practices, like if you're someone who's complicated and you have the means, those are often good to look into because you have a lot more access and your internist might even follow you.

Like if you get hospitalized, they might come visit you in the hospital, which is not a common practice anymore. 

Dr. Linda Bluestein: Right, right. Medicine has changed so much since I graduated from medical school and you went through residency and everything. Yeah, it used to be that your primary care doctor did follow you into the hospital, right?

And then now we have [00:17:00] hospitalists who stay in the hospital. Well, they don't, I almost made it sound like they live in the hospital. They don't, they don't live well. They might feel like they live in the hospital. But, uh, I remember I was, yeah. When I was interviewing, I think my husband interviewed there. I didn't, but I don't know if you've heard this cause you're probably a lot younger than I am, but at Baylor, apparently they had a line and you weren't allowed to cross that line.

If you were like a surgical resident, supposedly you weren't allowed to cross that line except for like once every six weeks. I don't know. That's that. That's what I know. Yeah. Yeah. Crazy. Things have changed a lot. That's for sure. So, um, you know, the, the hospitalists now, right. They work at the hospital.

They don't have. Yeah. Their own patients, if you will, they don't have their own practice, but but right. So that's a huge advantage if you are complicated. And if you can afford it, if you do get hospitalized that again, you can ask those questions that that person might actually come and see you in the hospital and help guide your care.

Dr. Matthew Watto: And there's a couple rare groups [00:18:00] now that that will still follow their own patients in the hospital. So you could ask about that. You know, like if I get hospitalized, will the will this group follow me in the hospital? Um, there that is still around a little bit, but it's it's really not common. And the hospitalists are they basically.

The admissions come through the ER, they get, if they're not going to surgery, they get, they go to a medical service and then the hospitalists just kind of get randomly assigned patients. And if you're unfortunate enough to be in the hospital all the time, you might start to get to know some of the hospitalists, but there's really not the continuity there.

Right. And in general, I would say the. The communication to primary care physicians is not is not great. Like sometimes they'll call you as a primary care physician, but you know, I work as a primary care physician and it's it's super rare for me to get a call from a hospitalist. I may sometimes I may reach out to them because it's often my patients are being admitted to the same hospital.

My clinic is attached to you. [00:19:00] But, uh, I think communication in general and healthcare could be a lot better. And if, if people were incentivized to talk to each other more, but it's, it's, it can be hard to get a hold of some, like somebody else. And so, but I'm pretty liberal with giving my, like, just calling somebody or texting somebody and saying, here's my cell phone, please call me back.

I want to talk to you about this patient. And I think that's, we need more of that. 

Dr. Linda Bluestein: Yeah, definitely. And it's also interesting because my husband, who's a urologist when he retired, his practice actually started doing a Euro list. So like a hospitalist, but for urology. So 

Dr. Matthew Watto: wow. 

Dr. Linda Bluestein: Yeah. Yeah. So things have evolved even within some of the specialties where they have somebody who You know rather than going back and forth because that would happen to him all the time if he was on call You know, he'd be in the clinic and then he'd have to run over and then run back and it was just incredibly disruptive So then, you know, his whole clinic would be delayed for the rest of the day So maybe he would [00:20:00] have a longer time blocked out for people But now all of a sudden, you know staff is going to leave at five o'clock So now you have to get all of these people in before before the end of the day, which is tough 

Dr. Matthew Watto: Yeah, so I mean I will say to the patients that are listening I think everybody that goes into medicine, I mean, there's, there's better ways to make money in the world.

Like everyone that goes into medicine goes in, like wanting to take care of people. Right. And then the system just sort of warps things and changes, changes things. And, and you're just part of a system that's, it, it should be patient centered. It should be all like geared towards patient outcomes. And maybe health systems will like tell you that's their motto and everything.

But unfortunately at the end of the day, like a lot of things are just incentivized. Against the patient and and so it's it is tough. It's a challenge for us even trying to like you come in with this like you want to do right by patients, but it's it's just hard in the system. You only have so much [00:21:00] time in a day and you're feeling rushed this pressure.

To get people out of the hospital, see as many patients a day as you can and it, it definitely erodes the quality of care. So that's, that's how it is. Hopefully it will change. 

Dr. Linda Bluestein: Yeah, no, I totally agree. And I think the other thing that's really challenging is at least for me when I was working as an anesthesiologist fairly early on in my career.

I was raising children also. So with the spare time that I had, you know, I was with my family and I was working, but I was working full time. So I wasn't able to do as much reading. And of course I did all the mandatory, you know, CME hours and I'd go to conferences and things like that, but it's not like now where I don't have children at home anymore.

So I can spend a lot more time reading and I can do a lot more of the things that I feel like do enhance my ability to. Take good care of my patients, but you know, when, when doctors are young and they're fresh out of training and they probably have a massive amount of debt, so they often end up taking jobs that, you know, [00:22:00] will help them pay off that debt.

And I think a lot of patients, you know, they, especially the complex chronic, chronically ill patients really get caught in the middle of that. And they really suffer the most because it's just, it's just so challenging. Those doctors, like you said, they're seeing a high volume of patients, you know, they're not able to kind of take care of themselves because they're.

You know, raising Children or whatever. Yeah. Yeah. So I think it's important for people to understand that because I agree every medical student that I've ever worked with and I've taught in a medical school not too long ago. Um, they like you said, they want to take care of people. They their heart is absolutely in the right place.

But the training and and the systems that we work in just are really damaging for that. Yeah. Well, let's talk about often are called like practice extenders. So, uh, physicians assistants or nurse practitioners. So I feel like this is also evolved over time where they didn't used to really be around at all as far as I know, but [00:23:00] now, you know, there's a lot of physicians assistants and nurse practitioners and there's different types of practice models that I feel like people will have.

Sometimes they might see that person first and then they see the physician and other times that's all that they see. And I, and I believe there's probably differing state Regulations, depending on how much independence they can have. Do you think that there's a way to help patients know when It's a good idea to see a nurse practitioner or PA and have that person kind of Guiding your care versus when now you really need to have a physician, um involved 

Dr. Matthew Watto: sure and I I should say that we have We we have in our audience at curbsiders a ton of physician assistants and nurse practitioners pharmacists um people that are just like super curious the same way we are trying to trying to learn how to better take care of their patients and um I think what, what part of what I've, part of what I've learned is there's, there's a huge spectrum, just as [00:24:00] there is with amongst doctors.

There's a huge spectrum of like, what was their prior experience? What was their training like? Because. If, if you're in a residency program, which I've, I've worked in for the past 13 years, um, the, a residency program, they have a group of people. It's like a committee of people that follows all the residents in the program, make sure they're meeting milestones.

You get all these evaluations, you sort of evaluate their clinical performance and you're making sure they're meeting milestones to go forth and in in some of the nurse practitioner physician assistant programs, um, they don't have, it's a little bit less decentralized, so they might not get the same quality of feedback and they're not spending as much time in that like training environment.

So a lot of them, I think a lot of the reason they love our show so much is because. They come out and they're like, Oh my gosh, I learned a lot, but I feel like I have so much more that I want to learn and I want to take the best care of my patients. So they're consuming like all these [00:25:00] podcasts to try to learn about all these conditions and they're reaching out to us with questions and everything.

So I think like it just depends. Um, I, I don't think there's any difference in, in intelligence. There's a difference in how long someone's been in training and in general, the way a lot of practices work is like, let's say a cardiology practice. They have nurse practitioners, physician assistants who will see a lot of their follow ups, they'll manage heart failure, they'll manage certain things like atrial fibrillation, and um, they will, they will see a lot of the follow up patients.

A lot of the times if it's a new patient with a lot of undifferentiated symptoms, that person's gonna see the cardiologist first and then they'll see the nurse practitioner. Um, in some of the internal medicine practices I've worked, the nurse practitioner, It's you don't really have that much different between the patients that they might get and the patients that the physician would get and, um, hopefully the practices are collaborative.

So if someone feels they're over their head, they can sort of hand it off to another person, but I [00:26:00] wouldn't, I don't think you can really say, like, just going in the door that I need an N. P. or I need a M. D. D. O. P. A. I think you just have to meet the person because. You might, you might like the, the NBPA might do a much better job than the MDDO.

It just depends on what's going on and what you need. So I think you kind of have to shop around. Like, I don't know that you can tell until you've met the person. 

Dr. Linda Bluestein: Right. Well, the one thing that I often ask when I'm needing to go into a new practice, I often will ask, well, how long has that person been doing this particular thing?

Because of course, you know, if I suddenly wanted to. Practice orthopedics. You know, I can't do that. I can't just suddenly switch from being an anesthesiologist doing pain medicine to doing orthopedics. I'd have to go back and do another training program. Whereas, you know, like you said, the training is a little bit different in that regard.

So, um, I've worked with P. A. S. in orthopedics [00:27:00] who are phenomenal. In fact, I've I've worked with somewhere like basically they were doing the surgery and the orthopedic surgeon is kind of but but part of it is because they were in that specific specialty for that many years. So they got incredibly good at it.

So I think that's an important thing to ask because sometimes, you know, If they did podiatry first, and then maybe they did, you know, cardiology and then maybe maybe they've done a few different types of. Specializations or maybe they did internal medicine and then they did a specialization. And if they're relatively young, then I think maybe that's an important question to ask and can be helpful sometimes.

But you're right if they have which is very common, right? They'll have often more time to spend. With you, a lot of the practices are set up that way. And so that can be really, really beneficial because then you can actually get more of a deep dive into the things that are really problematic for you.

Dr. Matthew Watto: Yeah. Yeah. I mean, I think in just [00:28:00] any medical practice, hopefully when you're working with somebody. They're listening to you. They have the humility to recognize when they're in over their head and they, they need to call from help, call for help or, or get a consultation, um, to help you out. And, and I think that that goes for whether it's a physician or an advanced practitioner.

And, um, yeah, we're always like, I'm always like a little anxious talking about this topic because I don't, I, I just want to make it very clear that I think like, there's no, you know, I'm just like very supportive, everybody practicing to the top of their capability and their, you know, where they can safely practice and, and over time that, that, that will go up, but, you know, people can gain more independence, can gain more skills.

That's true for anybody in any job. 

Dr. Linda Bluestein: Right. Absolutely. And like you said, that's something that you don't necessarily know right away, but once you meet the person and you get to know them a little bit, that's very, very helpful. 

Dr. Matthew Watto: Yeah. 

Dr. Linda Bluestein: [00:29:00] So yeah. Totally agree. We are going to take a quick break and when we come back, we are going to talk about chronic pain or I like to call it persistent pain.

So it doesn't sound quite so, uh, dreary, um, but we're going to talk about persistent pain and the role that the internist can play in the, in the patient's care. So we'll be right back.

This episode of the Bendy Bodies podcast is brought to you by EDS Guardians, paying it forward in the Ehlers Danlos Syndrome community, patient to patient for the common good. I am proud to serve on the inaugural board of directors for EDS Guardians, a small charity with a big mission and a big heart.

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Okay, we're back with Dr. Watto, and I'm so Interested to hear what you think about the role the internist can play in people with persistent pain. You know, oftentimes they don't know that joint hypermobility may or may not be a factor. Like I didn't know for decades that, uh, this was something that was playing a role for, for me.

I did ballet growing up and it was very helpful to be super bendy, you know, but, uh, as I got older, of course, I started running into more problems. A lot of people will. Initially, see their internist when they are having pain. Of course, it could be acute or it could be chronic. But what do you think is the most helpful way that the patient and the [00:31:00] internist can work together?

Dr. Matthew Watto: All right. I've I've been thinking about this topic a lot lately because this is this is something that I lecture on in my day job and something that when I first entered practice out of residency, I was very uncomfortable. Managing chronic pain, and so I really wanted to learn as much as I could about it, and one of the first episodes we did in the podcast was fibromyalgia with a fantastic Dr.

Klawe from, um, University of Michigan. I know him 

Dr. Linda Bluestein: well, yes. So, he's, 

Dr. Matthew Watto: he's a great guy and, and taught me a lot about this, uh, chronic pain and, you know, from there I've just sort of tried to, tried to keep up with things. But I will say that, uh, hypermobility is something that I'm going to have to add, I'm going to have to add that to my, like, sort of history when I'm, when I'm, uh, taking a history for pain.

But I do think that it's really important for anyone with chronic pain. I always tell them, listen, like you, you, you've had this pain for a long time. It's going to be, it's going to be [00:32:00] hard. It might take us a little while to figure out, like, What's going to make you feel better? Is there an underlying cause that we can identify or not?

And, um, but I'm going to work with you. I think you just have to give the patient that like, okay, this, this person is going to partner with me. They're with me for the long haul. We're going to. We're going to figure this out and I will see them frequently. Maybe it's once a month, maybe it's every, every three months, but it's not someone that I'll see like once a year and just throw some meds at them and tell them they're gone.

And I am usually talking about, I'm taking like a full history. And you know, this, this bio psychosocial model, I think is Um, I don't think it's outdated. I think it's it's you can't just I think what most physicians are trying to do is just address the biological piece of it. They're not asking anything about the patient's social history.

They're not, you know, assessing their mood and their sleep and all these other things that factor into pain. So I always try to like. Really go in depth. Like who is this person? What's gone on with them medically? [00:33:00] What's going on with them emotionally? What's their home environment their work environment like and and that is may you may have some clues there that help you out 

Dr. Linda Bluestein: Yeah, no, I totally agree I feel like with the bio psychosocial model that there are people who are very much practicing the biologic side and there's people who are practicing the psychosocial side but Blending those together is what's really important and the approach that I take, I have an acronym for it.

It's men's PMMS and those letters stand for movement, education, nutrition, sleep, psychosocial modalities, medication supplements. So those are the eight parts that I try to incorporate into every comprehensive treatment plan because like you said, it's not. Here I'm going to write you a prescription and your pain is all going to be gone.

That's not how that works. Unfortunately So do you see patients with chronic pain very often 

Dr. Matthew Watto: all the time? Yeah, I mean, it's you know, it's Fortunately, it's not every single person I see because I think it is [00:34:00] I'll be honest it's it's emotionally draining for us to to see patients with chronic pain because the patients have that feeling of helpless and often there's like this transference of like You're like, Oh my gosh, like I I'm trying my best.

I can't even in some cases you can't think of things or you're suggesting things, but they're not working. So it's it's hard on all parties involved. Um, but yes, I think any physician that's practicing primary care, you're you're going to have patients with chronic pain in your practice. And whether it's like migraine headaches or fibromyalgia or, um, just chronic joint pains, there are some people have chronic back pain.

You know, those are, those are some of the really common ones. Um, like I said, I'm probably gonna, I think everybody, uh, all my internist friends have to reexamine their panels for like, who might have hypermobility that we're missing in the panel. But yes, we definitely are. It's something we see and we and we think about.

Yeah. And 

Dr. Linda Bluestein: the symptoms that can come along with the connective tissue disorders [00:35:00] are so widespread. So people will come in and they'll be complaining of, you know, fatigue or, you know, dysautonomia type symptoms. They may or may not meet the criteria for POTS postural orthostatic tachycardia syndrome. But, you know, they may They have orthostatic intolerance.

So, you know, they get dizzy when they stand up. They've got the black shades, you know, coming in. They're pres, synable, or perhaps they actually even have syncope. Mm-hmm . Um, and, you know, uh, GI problems. So you see a lot of, you know, gerd, uh, small intestinal bacterial overgrowth. You see diarrhea, constipation, food intolerances, allergic type phenomena.

You know? So if a person comes in with these complaints, you know, oh, I feel fatigued. I'm so, so tired. I have all this pain. And I have this problems with my stomach and you know, so oftentimes I feel like the Internist, especially if they have a shorter amount of time, you know, they're going to be pretty overwhelmed with with all of that um, so I I love that you're already thinking about ways to screen for this population because um, You're you're right.

It's it's [00:36:00] uh, it can be really exhausting But at the same time when you can work with that person and actually help them feel better and help some of these really complex Cases it's so rewarding for you and for them, you know, because they've been sick for such a long time So they're so happy if they can finally start to feel better as i'm describing that Type of patient that, uh, that I see all every, every day that I'm seeing patients, which I have a very small, uh, part time, you know, medical practice.

So does that sound familiar? Are you seeing people that kind of fit that description? Do you think? 

Dr. Matthew Watto: Yeah, I, and definitely, you know, you get a lot of patients, um, like irritable bowel syndrome. Um, of course, GERD, GERD is, is super common. Um, small intestinal bacterial overgrowth. That's actually something we're working on an episode now, like where I, it's a topic I feel I need to do more learning on, but yeah, there, I had never really before, like listening to some of your shows to kind of learn about [00:37:00] this.

I had not really made that connection with hypermobility at all. And like I told you, I was not really thinking about hypermobility for most of my patients. And it's not for whatever reason, I don't, I don't know how many patients make the connection either. It's, it's not like people are coming in like, Hey, I'm double jointed.

And I have, um, I have chronic pain. Do you think there's a relation to it? Like, I think no, they're not. It's just not in the public awareness enough for people to be like coming in with those, with those kinds of complaints, which, Um, I guess like the work you're doing is helpful because now I think, you know, you're spreading awareness of it and uh, eventually like more people are going to learn about this and hopefully you'll make more diagnoses and be able to help more people.

But yeah, absolutely. I mean, there's so many, um, so many times you get this constellation of symptoms. And you're trying to figure out like what could this be you do lab testing? And I think what probably your audience knows is [00:38:00] that if you order conventional labs Thinking of only conventional diagnoses a lot of times they're going to just come back normal and then you're going to say Oh, well, like The workup we've done is normal.

So I don't know what to tell you, you know, and I think a lot of people have probably run into that. 

Dr. Linda Bluestein: Yeah, they definitely have run into that. And it's true for labs. And it's also true for imaging, right? So because imaging is most of it done statically and often it's done in a position that is not the position that Exacerbates the person's problem.

So they could be getting a supine MRI, for example, um, or, you know, some other study and, and really what they need is something that shows the motion. And, um, and yes, it's really, really fascinating because I feel like if we just changed the way that we described things, rather than saying. You know, basically are implying your labs are normal.

Your imaging is normal. It must be in your head. I don't believe you. It must be in your head. But instead, if we were to say like what you just said, you know, [00:39:00] for the things that we were screening for with the labs and the imaging, we didn't find anything, you know, worrisome there, but but I believe you and I'm going to help you with your symptoms that you're that you're struggling with.

Um, and we can always with that. Dig deeper if we need to later, but you know, let's start working on some things that we can try or whatever. So they feel like they're being supported and and not, uh, you know, x rays were normal. Therefore, you're fine. And it's like every test has limitations. We don't tell people that.

Dr. Matthew Watto: My, my friend, uh, Dr. Iris Wang is a GI doctor and, uh, she, she actually does like hypnotherapy for irritable bowel syndrome and, um, dyspepsia and a bunch of like, sort of disorders of the gut brain, um, interaction. And she, she tells, she tells her patients, she says, listen, uh, I'm going to do some testing. I, I think what you have is irritable bowel syndrome.

I expect this testing is going to [00:40:00] be. Normal, but that doesn't mean there's nothing wrong. Like I think you, you know, so she sort of, she, she kind of says like the testing being the testing being normal tells me that I think I know what's going on with you and I know how to treat it. So, um, I, I think that, that, that is like, like you're saying we, we need to reframe things and, um, that's, I think what's really frustrating for a lot of patients is.

Because there's uh, and I think we've learned about this in the past five years at least I have where A lot of people are trained in medical school, you're basically told, like, follow the party line, you know, what these big organizations, if it's in an expert guideline, then that's, you know, then that's, you got to follow that, uh, don't, don't think for yourself, and I think people are starting to more think for themselves and just say, well, wait a minute, uh, these big organizations, they get things wrong sometimes, and Uh, it, the scientific method is such that [00:41:00] like you need to constantly say like, oh, there's new information.

I can change my thinking based on this new information that I've learned. And I think medicine in general needs to get, get a lot more humility and, and start to like, accept that and, and not, that shouldn't be controversial to say that, but I feel like, um, you know. I don't want to, I don't want to get into talking any politics about anything, but I just think that, uh, if you ask me, like, what has changed most about how I think about the world and, and my profession in the past, like five years, it would be just sort of like investigating things for myself.

We, we do a journal club on curbsiders where just because that new drug got approved and they had positive result, like results, I'm very skeptical, like whether or not I'm actually going to prescribe it for my patient. Cause I know. It is very easy to make a trial a positive trial. And do we care about the end points that they pointed to?

And [00:42:00] so, uh, you know, that's, that's where I'm at. And that's why, um, I, I like. As a person and as a physician, I like to constantly learn more constantly evolve and don't don't hold on too dearly to any of my current beliefs because they might change. 

Dr. Linda Bluestein: I think that's such a great attitude to have. And, you know, there's no FDA approved treatments for hypermobile EDS.

So if we were to just go strictly off of that, we would not. Prescribe anything. And that would be an insane way to go. Correct. It would be ridiculous because in the meantime, people are suffering and there are things that we can use that we can extrapolate from other conditions. And I just think, you know, yes, there's it's important to read the double blind randomized controlled trials and and be looking at the evidence.

But, you know, it doesn't all have to come in that form of a study. Yeah. You know, big, big study. And like you said, two things can get approved that are not necessarily the best idea. Um, [00:43:00] and sometimes I say, you know what, let's, let's wait a little while and see if things as they're prescribed to more people, there's much larger numbers, even though, you know, obviously they went through phase one, phase two, phase three, but now let's see as it gets applied to more people, are there other things that are going to come up that maybe are side effects that We would really, really want to avoid.

So, yeah, I, I think those are really good points. 

Dr. Matthew Watto: And, and part of the, and part of the thing that we need to realize too is, is like, you know, there's just certain, it doesn't, if it doesn't make sense for a trial to be done financially, if there's not like then, then a lot of the time the trial is not going to be done or it's too expensive and, and, you know, it's not going to pay dividends down the line.

So they won't do it, even if it would. Ultimately, give us good information and help benefit patients. So sometimes you just have to like practice based on a hunch and, you know, of course, you're trying not to harm the patient and you're letting them know, uh, here's [00:44:00] in theory why this may or may not work.

Here's what we know. Here's what we don't know the risks, the benefits, but that's, that's kind of how you have to practice. And if there's no. You know, if there's no real strong trial to guide like what you're doing, you just have to, that, that's the best that you can do and you're essentially running an experiment on the patient with their consent and trying something and, um, and then you're reassessing.

And I think that's, that's the way to go. 

Dr. Linda Bluestein: Yeah. And I don't remember what the percentage is in terms of how much we're using things off label, but it's very, very high, right? So the drug gets approved for some other condition. Like you said, the drug company doesn't pay. Tons and tons of money to go back and get it approved for another indication because that's really, really expensive and oftentimes not necessary.

So we can prescribe things for a different condition, like you said, with the patient's consent and and all of that. So it doesn't mean that the drug isn't safe. It just means that maybe it's not, you know, it didn't go through those steps for that [00:45:00] particular condition. So that's that's an important distinction.

And I also want to come back to something that you said earlier about the testing and things like that. So One thing that I feel like gets misunderstood a lot is functional. GI problems or I was diagnosed once with like a functional knee problem. Um, I've been diagnosed with hyperalgesia of my gastrointestinal tract.

Um, and functional GI problems. I feel like people automatically in their heads go to, Oh, it must be in my head. Now, of course, at the end of the day, that's where we sense everything, right? So, so, but in my head or in my brain or in my head versus like I made it up or two different things. So when it comes to.

Functional gut problems, for example, or other functional disorders, would you agree that that's related to the function, not the structure? And so we should not be assuming that all this doctor saying it's in my head. 

Dr. Matthew Watto: Oh, yeah, and you, I think, like, [00:46:00] you know. Take what take it for what you will but you should reach out to dr iris wang she's like fantastic she wrote a children's book called boo can't poo it's like a kids it's a kids book to help uh you know kids with bowel movements but um she's she's hilarious and she's like the expert on this but um yeah like like i was saying the.

The testing, the testing, they, they're looking for, they do an endoscopy, they're looking for structural problems. They can do biopsies, but it's not, they're, they're not necessarily watching how your stomach moves and how it distends when you, when you eat something. So. It's it's hard. Um, and you know, she would be the one to be able to tell you because she alluded to me last time I spoke with her about this topic that maybe there are some things in research where they're trying to like be able to better make like diagnosis of functional dyspepsia, but where where people feel.

Like they feel full too early or they're feel uncomfortable when they're eating. And it's the way that the, the function of the stomach is, is just [00:47:00] not functioning the way, the same way. And they might be hypersensitive to stimuli that really don't bother other people. And that is a physical thing. It's just, we just don't have tests to measure it.

So, um, that, you know, that, that's kind of her world, but yeah, absolutely. I mean, these it's dynamic studies are a lot harder to do, you know, I think that's it. Like we have. We have a barium swallow, which is where you're in an x ray machine and you swallow some radio opaque Liquid and then they can watch it travel down and that's one of the few functional GI tests that I can think of.

I know they have another one where they have, they put like a balloon with saline into the rectum and then they have the person try to pass it. And I think you're sitting on like a glass toilet or a see through toilet and sounds, uh, I hope I never need that study, but it is like they have some functional tests, but you can imagine like.

A lot of people aren't signing up for that one. Uh, so, so it is hard, but [00:48:00] these are very common. Um, they can be treated and, uh, it, but it's just like the conventional test. You're, you're, you're not going to see that, but it's, it's very well documented that this is, they call it disorders of gut brain interaction.

And it's like, you know, we, we talked about the biopsychosocial model, um, for this, it's like, there's just the signaling between the brain and the gut is just kind of, it's for whatever reason, it's. It's not working the way it should. It's become sort of, um, maladapted and so normal stimuli that wouldn't bother.

Some people are causing you a great pain and it and that's the way it is. And I hadn't 

Dr. Linda Bluestein: thought about this before, but a lot of my patients have had gastric emptying studies. So, you know, you eat radioactive oatmeal or eggs or whatever, and then they're watching that pass through the GI tract. So that's another Functional type of study, but of course, we know that the sympathetic nervous system, which is the fight, flight or freeze and the parasympathetic nervous system, which is the rest digest, restore are going to affect the function of [00:49:00] your gut.

So, if you're particularly anxious when you go on to have that test, is that going to alter your results? 

Dr. Matthew Watto: Yeah, good point. Good point, you know, that test, I have ordered it for patients and sometimes it's like a, you know, pretty much a slam dunk, like it shows gastroparesis, but, uh, it's other times you can almost just from the clinical history, you get a pretty good sense if someone has gastroparesis or not, but that, that, that is it.

And that condition can really be terrible for people. It's, it's some of the most uncomfortable patients I've seen have had that, uh, have had that condition. 

Dr. Linda Bluestein: Yeah, interesting. And what about long COVID? Do you see a lot of long COVID? Have you found any, uh, not to, not to completely pivot, but, um, you know, a lot of people with hypermobile EDS or HSD or, and or dysautonomia or mast cell activation syndrome, a lot of them either have had it?

Yeah. You know persistent symptoms related to covid or they had a covid infection [00:50:00] and that really just You know led to a spiral of their of their other symptoms So is that something that you've seen very much of in your patients and have you been able to successfully treat that at all? 

Dr. Matthew Watto: So I was, I'll be honest, I haven't seen as much for, for as much as I've read about it.

We've, we've done curbsiders episodes on it back, uh, you know, back at, it's been a couple of years at this point. Um, I haven't seen a ton in my practice. I definitely have had. Patients that had weeks to months of protracted brain fog and just, you know, uh, respiratory cardio pulmonary symptoms after a case like dizziness and things like that after a case of COVID, but it's been less than less, I guess, uh, as we get further out from like OG, what I call OG COVID, like the original like big, bad version.

Cause back then I was seeing a lot more of it. Um, yeah. And I think it's probably I'm sure for your, your practice, like you're probably almost like [00:51:00] a specialist, like you're going to see more like a cardiologist is going to see more heart failure and a fib than I am because people are like, kind of know to go to them for that.

So I, I don't see as much right now. Um, but I guess that's, that's both fortunate and unfortunate, uh, but how about you and your practice? Is it still a pretty common diagnoses? 

Dr. Linda Bluestein: Yeah. Yeah. It's, I see it quite commonly, less so less, I would agree that less so in the last couple of years, but definitely.

People are reporting that, you know, I was doing quite well until something specific. So it could be a concussion or a car accident or, you know, something like that, or it could be that they, that they got COVID. So, um, yeah, it, it varies with the, with the person, but yeah, I'm still seeing a fair, a fair bit of that.

Dr. Matthew Watto: Yeah. And that, I mean, that's another one of those ones where one of my big takeaways from our discussion with the expert on that was that like you, you sort of prepare the person ahead of time. Mike. We're gonna [00:52:00] do testing it, it very well likely will be that the testing doesn't find a specific thing, but that doesn't mean what you're experiencing is not real.

It just means that, um, our, we don't have the right test to, to diagnose it and we're still gonna work to treat your symptoms and get you feeling as good as we can. And there, there were most of the big, I'm, I'm in the Philadelphia area, so. The big hospitals there each had like their own long COVID clinic, which was usually multidisciplinary between like cardiology, pulmonary, phys, physiatry, those kinds of things.

Dr. Linda Bluestein: We kind of started out this way, but I want to circle back to this, the healthcare system and how patients can work as well as possible with their internist and with their whole team. So what problems do you see arise when people are seeing doctors from, you know, multiple different. Healthcare systems.

And what can be done to try to mitigate that? 

Dr. Matthew Watto: Well, I would ask your [00:53:00] physician to have a conversation with your other physician or, you know, nurse practitioner, PA, whoever it is, because I do think that making people talk to each other can definitely help the situation. So if I'm seeing somebody and.

They're maybe they're upset or they're telling me they don't understand what's going on or I don't understand what's going on with the specialist they're seeing. I will call that office, leave my cell phone number and say, please call me. I would just like to talk it through so that I can better work with you and better counsel the patient because I think sometimes people they use a whole bunch of medical jargon when they're talking to people or they don't take the time to explain it.

And so I usually will try to do that. So I think asking your physicians is important. Okay. To talk to each other would be important. Um, there are there. And then if, if you know that there's no electronic records connection, but the Philadelphia area has a record sharing, um, between most of the major health [00:54:00] systems, which is helpful.

Uh, but if you know that you're outside of that system, making sure you get the copies of the images and the office notes, and so that you can bring them to your physician, that's really helpful for, for us so that we can. You don't have as much information as possible when we're trying to tell you what to do.

Dr. Linda Bluestein: Yeah, I suggest that people have several different documents. So like a, you know, medical binder that has every Significant, you know doctor's note right the full encounter note just not just the summary but the full encounter note All the imaging studies, especially if they were positive, but you know any imaging studies I can and have a tab like a tab for imaging and then have no know if it's in reverse order or you know Uh, you know, oldest to newest or whichever order you're going to do it in, um, and, and like lab results and, and things like that, but then also have like a one sheet summary that has your medications, your allergies, your most significant [00:55:00] diagnoses with an ICD 10 code, if possible, you know, but.

But you know, it's, it's hard. We put a lot on the patients, especially, you know, like I mentioned, I have a very small practice, so I'm not an epic. I can't afford epic. It's way too expensive. Um, I have an EMR, but it's, it's called Serbo and, but it doesn't integrate with anything else. So the patient really is that continuity, that thread.

So if they can be the one to have their history and all of their documents as organized as possible, then we're not having to, you know. Wait till we, you know, might consider getting another, you know, MRI of the brain or something when actually they had that done. Not that long ago. So I think it's, that's very important.

Um, and then sometimes people get conflicting recommendations. So besides talking to each other, which of course, and that's absolutely ideal, but do you have any other suggestions for patients if they've seen multiple different people and they're not on the same system and they say, No, I don't have time.

I can't I can't talk to your other five doctors. Um, [00:56:00] but but they've gotten some different recommendations Any 

Dr. Matthew Watto: thoughts? Yeah, that that's challenging because I mean you can see Like you can just see in general in life right now what's going on like in our country that like with this The same set of facts, you can get very different opinions, right?

And there's no magic about medicine that like medicine will have the same kind of thing. Like you can give the same set of facts to multiple different people and they will come to different conclusions and make different recommendations. So you have to understand that. Um, and so it's good to get a second and third opinion, but you just have to understand they might not all be the same.

And Yeah, at some point you're going to need to make a choice who do who's giving you the better vibe Like who do you who makes the better case for why we should do one thing or another? So that that's I would just say that to patients Um, I think if you have like a good internist or just like kind of like a [00:57:00] quarterback doctor that you know Or or advanced practitioner that you trust I think like sort of, let's say you're, you need an ankle surgery or something and you're getting two different opinions.

Well, maybe you talk with your internist about it and maybe your internist can help you and maybe they need to make a call and talk to one of those people. I think that's the way to go. It's I think it's if you have nobody that you trust that you have a long term relationship with in medicine that can advise you it's, it's hard to know what to do 

Dr. Linda Bluestein: and patients often want to know when they should switch doctors.

And, you know, I often say, well, if you're feeling like he's just not that into you, that's just like the movie in the book, um, that that's, that that's a sign, but do you have any tips for when people might know this isn't a good fit might be time to look for somebody else. 

Dr. Matthew Watto: Well, Yeah, I, I, I would say that he's just not that, that, I mean, you really boiled it down there.

There's not, there's not a [00:58:00] whole lot to say beyond that, but I think If you feel like they're not listening to you, if they feel, you know, maybe, maybe some people want a physician that's more directive and is just telling you what they think you should do. Um, we talk a lot about in medicine now shared decision making where you, you, you're sort of admitting to the patient, look, like, here's, here's the facts, you could do this, you could do that.

Maybe you say. I think this would be best to do for these reasons. Um, I, I don't have a problem giving the patient like in you, if you were my family member or if I was in your shoes, here's what I would do. And, but I think pushing the, if they're constantly pushing you to do things you don't want to do.

Or they're not listening to you, then I think then it's probably time to, to move on because it's like the, the paternalistic medicine days I think are, are largely gone in this country. I know, um, I, I've worked with a lot of international trainees and in some other countries, uh, it's still very [00:59:00] paternalistic and I think that's a function of that.

The public is just not their health. Literacy is way low. Like, so it's like only the people in medicine know anything about health in certain places in the U. S. People have such access to information that your average health care consumer is savvier. And that's why shared decision making here makes more sense.

Dr. Linda Bluestein: I'm so glad you pointed out about working with international trainees. So yeah. We did a survey recently for the podcast listenership and surprisingly, this surprised me 20 percent of the listeners were healthcare professionals, which I was very happy about. It was really happy about that. Yeah, but a lot of people also requested to talk more about.

International problems and you know, I've only ever practiced in this country. I do have patients that have come to me from other countries, but I otherwise don't have a lot of exposure. You know, when you travel, you obviously if you happen to travel some to a different country, usually or not, hopefully [01:00:00] not exploring the health care system when you're traveling.

But do you have any particular Tips, I guess that would be different for people. And of course, we don't have the time to go into like a whole bunch of different countries. But for people that are living outside of the U. S. I actually had a patient or actually, I guess, technically, she's a client because they do coaching also working with clients.

If they can't come to see me in person in one of the states that I'm licensed in, then I was. Yeah. Meet with them online and she had moved from canada to the u. s And she was raving about the health care in the u. s. She was like it is Amazing and she's going on and on about all these things that in canada She doesn't have access to and how if you have eds in canada They basically tell you you know at some point it's going to become a palliative situation you go on Like their version of hospice and then you die and she's like what i'm in my 30s, you know And she's a health care professional herself So do you have any?

Um Thoughts for people that are listening that are in a different country [01:01:00] 

Dr. Matthew Watto: As 

Dr. Linda Bluestein: as 

Dr. Matthew Watto: healthcare professional or as well. I'm sorry. 

Dr. Linda Bluestein: I should say as patients. I'm sorry 

Dr. Matthew Watto: as patients. Yeah Huh? Well, I mean the you know You would if you listen to some some sources the people would tell you we have the we have a healthcare system that spends too much money for that for the outcomes we have but I I think What, what you will get in the U S you definitely, you have the power, more power as a consumer, you know, there's a lot of, um, I guess in general, in the world, money opens doors to doors to places.

But I think like, like I was saying in the U S. The, we have this, hopefully, if you're seeing somebody, uh, if you're, hopefully you're seeing someone who is going to provide, provide patient centered care, there's a lot of easier access to specialists than in, um, in places with a nationalized health system.

They control how many specialists they have, so there's less specialists, so there's longer waits. If you want to get an elective surgery, there's much longer waits in the U. [01:02:00] S. It's less. I don't, I can't say I know that much more about, uh, international, you know, how, how we differ from other international places.

I know our drug prices here are way more expensive, which is a shame. Um, just the way that I guess, uh, people are able to negotiate the, the big payers are able to negotiate drug prices is different. So you can expect to pay more for your medications in the U S but you'd have quicker access to specialists and surgeries.

Yeah. You know, if you're waiting a couple of years for a knee surgery, you could probably come here and get it done right away. Uh, so those are, those are some of the things. Anything else you want me to comment on? This is not an area that I would consider myself an expert on by any stretch. 

Dr. Linda Bluestein: Sure. Well, I'll ask you the next question because as we're wrapping up here and you can incorporate that international perspective if it, if any of it happens to strike you.

So, um, what about how patients can help you help them? We've talked about the. Crunch for time and how [01:03:00] complex things have gotten and regulations. And so if it's you or another internist, what can patients do that can really help them get better care? I know we've touched on this a little bit already, but yeah, anything else?

Dr. Matthew Watto: Yeah, I, I do think it helps when patients bring a list of questions because, you know, sometimes patients will, for whatever reason, they will forget to ask something that was most important to them, maybe because the physician jumps into the visit and says, Oh, let's talk about your blood pressure when really you came in.

You wanted to talk about your knee. So I would bring a list and I would, the, I would give your most important complaint up front, even if you're embarrassed to share that complaint, because you don't want to like, bring that up when the physician has their hand on the door about to leave the room. Um, that does happen a surprising amount.

The other thing I would like to say is, um, there's a great doctor, Dr. Saul, uh, Weiner, who, uh, he wrote a book called on becoming a healer. He's a physician. I believe he's in the Chicago area [01:04:00] still. And, um, he, his research focuses on, um, like. When physicians are ignoring patient complaints or things patients say so a patient will say so here's that one of his examples in his book is like a woman came in with back pain and She mentions when she's talking to the physician She says oh I haven't been able to go get my imaging test because I was taking care of my son and the physician says, okay All right.

Well, please go get the imaging test. Well If you had asked about, wait a minute, tell me about your son. Oh, my son, he's 27 years, cerebral palsy. I have to lift them out of bed five times a day. So like, you know, if your physician doesn't know that you have a 27 year old son that you're lifting out of bed five times a day, They might not realize that that's why you have back pain.

And, um, you know, that's just one example of many about like, your physician should be listening to you, but also, um, sometimes you have to guide them a little bit because. [01:05:00] You know, people are in a rush. Not everyone's taught to be a great listener. Everyone's and it actually in the long run, it saves everybody time to just get those kind of things out there.

Dr. Linda Bluestein: Yeah, I love that. That makes sense. And we will. Find that book and link that in the show notes because I think that sounds like a really great book for the listeners to, uh, 

Dr. Matthew Watto: yeah, check out and you and your, um, clinician listeners. It's a, it was, it's a really good book. Uh, just kind of reminding you why we do what we do and, uh, reminding you to listen to your patients because they are giving you.

A lot of the answers and if if you're not paying attention you you miss it 

Dr. Linda Bluestein: Yes, that is so so true. So true. I will definitely check out that I will definitely buy that book myself So it sounds like a great read. 

Dr. Matthew Watto: Yeah, 

Dr. Linda Bluestein: I like to end every episode with what I call a hypermobility hack Um, do you have a hypermobility hack that you can share with us?

Dr. Matthew Watto: uh, I I would say I would say that I I don't have a hypermobility [01:06:00] hack, but I would say um, if you have Uh, hypermobility spectrum disorder, Ehlers Danlos syndrome, and you're, you know, you're seeing your physician, I would maybe offer them a resource, uh, you know, tell them to listen to bendy bodies, uh, ask them, you know, to please, like, please work with you on the condition, um, because like, we, we need to spread awareness about this and for, in order for your physician to help you, you know, some, some of us are hardheaded, we need like, You know, we need things that bang us over the head a couple of times before we, it gets our attention and we start to change behavior.

So that would be the closest I can. I don't have like a specific hack other than, than that, how to get your physician's attention, maybe. 

Dr. Linda Bluestein: No, I think that's great. I love that. I love that hack, especially since you mentioned share the podcast with them. So yeah, and that's the whole idea. You know, if you're busy, um, the Ehlers Danlos Society has a fantastic program called the echo program.

Most doctors can't [01:07:00] take the time, take that much time to listen to learn about, you know, people. A set of conditions, even if it affects, you know, realistically, it actually may affect a significant portion of their population, but they have to learn about so many things. So that's where I try to make the podcast accessible.

So you can listen to it when you're driving to work and, you know, you can pick out episodes that seem most pertinent to you. So. Dr. Watto. Thank you so much. I was so great to chat with you. Before we go, would you be able to share with me where people can learn more about you and if you are doing anything research wise, if you have any projects on the horizon that you want us to know about?

Dr. Matthew Watto: I would just say, uh, the curbsiders. com is, is where our, our podcasts, like our podcast show notes are. We have a pediatric medicine podcast called the crib ciders. We have an addiction medicine podcast. We have a medical teaching podcast. And, um, they're, they're all on there. You can type curbsiders into any podcasting app and you can find our [01:08:00] show.

So subscribe to the show. And we're just constantly, our goal is to some patients listen, but largely we're just trying to make people better clinicians. Uh, if you're working in primary care, hospital medicine, just kind of make your day easier by. Giving you a lot of knowledge on a topic. So next time you see the condition, you know what to do, you feel confident and ultimately down the line.

Patients are benefiting because everyone's taking the best care of their patients. 

Dr. Linda Bluestein: It's a great show and I love how practical it is. And I, I, every episode I've listened to, I've, I've loved if that was really, really helpful. So. 

Dr. Matthew Watto: Well, thanks so much for having me on. This was a lot of fun and I, I really look forward to learning more on this topic.

And I'm not just saying that it's a. Like this, this is a, this is something I've now identified a new area, so full speed ahead on this. Uh, so thank you. 

Dr. Linda Bluestein: I love it. That's awesome. That's fantastic. Well, thank you again. It was so great to chat with you and I know that the listeners are really [01:09:00] gonna love hearing from you and they will have really learned a lot.

Dr. Matthew Watto: All right. My pleasure.

Dr. Linda Bluestein: I absolutely loved that conversation with Dr. Watto. He is so well spoken and obviously a really caring and empathetic doctor and I love the fact that he is training other doctors. I hope that you feel inspired by this conversation because I feel myself super inspired and more hopeful for the future. I think more internists being aware of these conditions will be so, so important and hopefully you learned some tips for how to work with your patients.

Or internist to get better care. Thank you so much for listening to this week's episode of the Bendy Bodies with the Hypermobility MD podcast. You can help us spread the word about joint hypermobility and related disorders by leaving a review and sharing the podcast. Please tell your friends, family, and healthcare professionals to listen to the podcast.

If you'd like to dig deeper, you can meet with me one on one. You can visit the services [01:10:00] page of my website at hypermobilitymd. com to learn more. You can also find me, Dr. Linda Blustein, on Instagram, Facebook, and Twitter. Facebook, TikTok, Twitter, or LinkedIn at HypermobilityMD. You can find human content by producing team at Human Content Pods on TikTok and Instagram.

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