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The 4 "P's" Many Doctors Get Wrong

Updated: Jun 8, 2023

What do PTSD, pregnancy, postpartum, and prostates have in common, besides starting with P? Many doctors get them wrong.


In this case, it’s not generally the doctors who get it wrong, though some might. It’s that the official criteria for diagnosing it look like something out of the 1970s, when it was thought to be largely a condition of soldiers returned from Vietnam. There are eight criteria and you have to meet all of them to get the diagnosis. Otherwise, it’s quite possible that insurance won’t pay for treatment.

Here is just one – “Criterion A”:

You must have been exposed to or threatened with death. Or, you must have had an actual or serious injury, or actual or threatened sexual violence. You must have experienced at least one of these things in the following ways:

  • First-hand experience

  • Witnessing the event

  • Learning that a close friend or relative experienced it or was threatened

  • You’re regularly exposed to other people’s trauma, maybe for your job

Among other things, you must wait a month to confirm the diagnosis, in case your PTSD goes away on its own (yes, that would be Criterion F). And yet that first month may be the most traumatic. Or, it may be 6 months or more before the trigger causes symptoms.

To which I ask the American Psychiatric Association: "Seriously?"

What about teachers in Nashville? Many would be affected by last month’s shootings. And that’s just for starters. You don’t have to be in proximity or even know anyone, in order to be affected by school shootings. Many teachers would be at risk of PTSD, even hundreds of miles from Nashville.

Further, Criterion C says that to qualify, “you avoid things that remind you of the trauma.” If you go back to school to teach, does that disqualify you? And what about the schoolkids? 352,000 have experienced gun violence at school since Columbine.

Finally, childhood trauma, which can manifest itself in adults, is extremely common. But it’s not remotely addressed by the APA criteria.

A much more comprehensive, albeit "unofficial," description of PTSD causes, symptoms and treatments can be found here.

Our advice: provide access to/cover mental health services and/or an EAP that don’t require meeting strict criteria to qualify. Provide coverage based on that "unofficial" list instead.



In the immortal words of the great philosopher Yogi Berra, it’s tough to make predictions, especially about the future.

Not so when it comes to predicting the likelihood of early delivery. It is now quite easy to accurately predict (and hence get a major leg up on preventing) premature delivery. The PreTRM test from Sera Prognostics. The odds of a premature delivery are about 1 in 11 for singleton pregnancies, and PreTRM can predict that with 75% certainty, and it is remediable. Whereas doctors (often at patient request) are testing for absurdly low-probability abnormalities that aren’t remediable in any event, with low-accuracy tests:

Kudos go out to Elevance (Anthem) on this one, as being the only national insurer to cover PreTRM. Thanks to Elevance’s coverage, my daughter got this test because the conventional old-school wisdom would have put her in the high-risk category. PreTRM showed that in fact she was low risk – and, as predicted, went to term.

As to the other carriers and doctors, I would ask: “What’s the holdup here?” Quizzify teaches employees to ask for PreTRM, and the benefit is quite clear both in fairly immediate savings and, of course, in maternal health.


Postpartum Risk

The United States has the highest postpartum death rate in the developed world…and it has been rising. And yet while babies are, well, babied, little attention is paid to the moms. As one expert put it:

“Our approach to birth has been that the baby is the candy and the mom’s the wrapper, and once the baby is out of the wrapper we cast it aside,” said Dr. Alison Stuebe, a professor of obstetrics and gynecology at the University of North Carolina School of Medicine. “We need to recognize that the wrapper is a person — moms are getting really sick and dying.”

The standard protocol calls for one final exam for the mom several weeks postpartum, but evidence suggests this appointment often isn’t kept or maybe not even made. Further and most importantly, more recent research shows that the high-risk period extends for one year postpartum.

This is particularly the case for women who are over 35 or have a chronic condition to begin with. It is also a health equity issues, as socioeconomic status and race are also predictors. (Whatever your commitment is to health equity, we would once again suspect that this “fourth trimester” risk is not on your health equity radar screen. We would add fourth trimester risk management to our unique list of health equity initiatives that pay for themselves.)

No vendor specifically addresses this fourth trimester risk. And as this is likely the first time you are hearing of it, neither have your employees’ obstetricians, in many cases.

Do you cover doulas? Coverage for doulas, though still rare, is becoming more common. It doesn't even have to be 100% coverage. Just make them affordable.

Further, you might want to do something as basic as checking your benefits design to see if in fact this fourth trimester OB follow-up visit is 100% covered as prevention. This is not an ACA requirement, as other 100%-covered preventive care is. It’s just a question of acting in your own financial best interest, not to mention the best interests of the employee.


Swollen Prostates

One would suspect that here in Boston, the medical mecca of the US where quite a number of doctors are both male and over 50, they would be up to date on prostates. And certainly many are, especially in prostate cancer management, where “watchful waiting” has clearly overtaken aggressive intervention.

But apparently when it comes to a few basics about the almost-inevitable swelling of this gland in the >50 crowd (benign prostatic hyperplasia, or BPH), they are missing three things about managing BPH, or they aren’t getting the word out to their patients.

First, men with swollen prostates should not routinely take over-the-counter decongestants, antihistamines or sleep meds which contain the latter – which is to say all of them not based on melatonin or valerian. Those drugs relax your bladder muscles, which makes it harder to pee if your prostate is already swelling. These drugs create “urgency” in many people, but for those without swelling prostates it’s just a minor inconvenience. But if you’re having trouble peeing already, the inconvenience can become a real problem.

This side effect should be better known, but it isn’t. Even gets it somewhat wrong too. These drugs don’t “affect your prostate” per se. They relax your bladder muscles.

Second, unless almost every reviewer on Drugs.Com is lying (um, for obvious reasons), Cialis (tadalafil) works better for BPH than the much more widely prescribed Flomax (tamsulosin). Read the reviews and decide for yourself. Here are the ratings. Note that the generic and brand name are rated separately:



Third, if Cialis doesn't work (and the patient is willing to admit it...), there is a new minimally invasive surgical technique where an application of steam shrinks your prostate. It is far safer and more comfortable than the traditional resection of the prostate. And yet, while catching on, it does yet not appear to be the standard of care. It allegedly takes 17 years for new research to make it into practice, but this treatment should be the exception. (Of course, dentists are still filling cavities.)


Bonus Fifth “P”: Dental prophylaxis

That’s teeth-cleaning. We covered this in a previous blog post.

You’re likely covering 2 visits for everyone…but that’s overkill for many people and of little help to employees who need more, and who will be spending much more of your healthcare money if they don’t get them. Those employees are by and large the socioeconomically disfavored ones, making the 2-visits-fits-all dental model a classic health disparity. Covering a third or even fourth visit at 100% will easily pay for itself. And, unlike other things covered at 100%, additional coverage will not encourage overuse. Who amongst us wants to visit the dentist any more than necessary?


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