Do a good physical examination and listen to the patient.
You know the old expression…”Trust me….I’m a patient.”
That may not sound correct, but in so many cases, this applies. Take this next example:
Roger Kasendorf, DO, recalls a 72-year-old male referred by his office to address chronic foot pain and to consider an epidural steroid injection. The patient brought in a CD containing an MRI of his low back which showed herniated discs at L4/5 and L5/S1 bilaterally. The patient reports, “My feet hurt all of the time.”
Over the course of my career, I’ve found that most of the time, the patients know what they have and have a good idea about what to do about it. Unfortunately, physicians often rely on their education and experience before hearing the patient through.
The patient told us that he thought he had a circulation problem. His pain worsened at night, causing him to get up and move around to get relief a few times per night. On examination, his feet appeared erythematic (red) swollen
In the abovementioned case, the orthopedic referred this man to my office to address perceived neuropathic pain from a herniated disc. It was clear that this man’s previous physician was looking at the MRI and NOT the patient. Although herniated discs may be part of the differential diagnosis, listening to the patient and doing a full examination brought us to a correct diagnosis.
As a matter of fact, I’ve found that MOST of the time, the PATIENT is right. There is no way for a clinician to know that the patient is feeling better than the patient. It is crucial that as physicians, we listen to what they have to say.
There are few greater joys to a doctor than coming up with a definitive diagnosis for someone who has been in severe pain for a long time and doesn’t know why. An additional example comes to mind.
A 27-year-old female comes into my office with severe chronic pain for 15 years. The history that I received from the previous physician was that she had undergone an extensive rheumatologic workup that was negative (Lupus, Rheumatoid arthritis, etc.). Prior treatment included extensive physical therapy, acupuncture, and massage. She has been prescribed just about every medication you could think of, including Gabapentin, anti-inflammatories, muscle relaxers, and even opioids. She had a diagnosis listed of fibromyalgia.
This presentation seemed odd because of her age and longevity of symptoms without any benefit from any treatment. Fibromyalgia, as many in the medical world refer to fibromyalgia as a wastebasket diagnosis, meaning it’s the diagnosis you use when all other attempts at finding a true diagnosis come up short. In my opinion, fibromyalgia does exist; however, it is likely misdiagnosed. However, there was nothing specific in my history taking that tipped me to anything specific in this case. That was until a slight side comment she made while my head was drawn into my computer typing.
She simply said, “yeah, its kinda a family thing”.
My head snapped around. “Huh?!” It was just like when I say the word “treat” to my dog, and his right ear perks straight up. In this case, I quickly twirled my chair around.
“What do you mean by this?”
I next learned that the girl’s mom has the same issues, and her dad was once worked up for Marfan’s Syndrome due to his elastic skin. And then the floodgates opened. “Oh yeah, my joints are loose, but my muscles are tight. Could that mean anything?”
After not gaining any additional knowledge in the first 30 minutes of my initial consultation, the last five became essential. I asked if she had ever had joint dislocation. “Yes, but isn’t that normal?”. I asked if she got fluctuations in blood pressure. “All of the time!” I asked if she was flexible (I used the term double jointed for my patient). I am, and so is my mom.
Over the next few minutes, I had a new definitive diagnosis of Ehlers-Danlos Syndrome. I said to my patient, “Congratulations, you do not have fibromyalgia, but you likely have a hereditary connective tissue disorder. I explained my reasoning and went over the treatment.
You’d normally think that someone who was just told that she has a significant medical condition would be upset; however, it was just the opposite. She was elated that someone listened to her, and she had a diagnosis. She felt vindicated after being told she was depressed, crazy, or making it up.
Another skill to master is to be able to dose fires. I don’t mean using a fire extinguisher, although I actually had this occurrence once in my office (this story is being saved for my second book). Every so often, there is what people call the “difficult patient”.
Although most of my patients are pleasant and calm, there are always exceptions. These people come in with a scowl. They will immediately ask if I’m running late. They will complain about their co-pays being too high. They will refuse to fill out intake information (“because I do the same damn papers every time”).
These are the patients that make me the most nervous of all. If not contained quickly, the negativity will spread not only to other patients but also to the staff. The staff will get antsy and frustrated that you, as the doctor, wondering why you are not doing enough to contain these people and not show disrespect. This will lead to quiet uncomfortable tension as you wonder, “what the heck is going on out there?!”
Does this sound familiar?
It’s so important to find the correct balance between appeasing difficult patients and sticking up for your staff. Being a natural pleaser, my intuition says to try to do both. Having a plan ahead of time to handle a difficult patient is essential. I find it important for an irate patient not to have this loud “discussion” between herself and the receptionist through a small glass window. First of all, the front ‘line of defense’ to you is also usually the lowest paid and least qualified to answer many of the issues. An office manager should be ready to swoop in right away, possibly move the patient to a side room to cool off and discuss the issue calmly.