I recently fielded a case that made me wonder how well we deal with potentially serious medical cases. Neurologic diseases with ocular involvement, for example, get lots of attention but simply are not commonplace for those of us who practice at the primary care level.
My approach has been to develop phrases, or scripts, that can put the patient at ease despite a potentially serious outcome.
Let’s get into the case, and I’ll suggest how I might have handled it as the primary examining doctor. A 15-year-old white male presented for a second opinion after being told that “something was pressing on the optic nerve.” Mom was greatly concerned, as she did not recall if any differential diagnosis options were presented for this asymptomatic patient. A battery of tests had been scheduled, with possible “referral to neurology.”
We all have situations where we are unsure. Finding the comfort level when findings are uncertain can be a lifelong challenge.
But, our holiest of obligations is to put patients at ease unless there is a compelling reason to do otherwise.
Based on Mom’s understanding, there was surely a reason to present disc drusen, or normal anatomical variation, as “most likely” diagnoses. Of course, I wasn’t THERE in the exam room when this all transpired, so it’s possible that the doctor did a great job, and Mom was hearing none of it. As I’ve known the Mom for many years, I am thinking otherwise.
I pursued the examination and found a resentful 15-year-old with no symptoms or obvious signs. Headache and other neurological symptoms were not in the picture. Acuity, color vision, confrontation fields, pupils, EOMs, and dilated funduscopy were all normal. As I grasped for a reason for the concern and special testing, I noted that there was the SLIGHTEST non-edematous nasal disc elevation o.u. Symmetry from o.d. to o.s. was as perfect as one could imagine. Drusen were certainly well-buried, if present, but the bilateral symmetry made even this unlikely.
It’s also an easy argument to say that, “we all have to practice within our comfort zone, and we should refer the patient out when parameters are not within that zone.”
This truism may apply, but at a certain level, the patient is unnecessarily frightened by discussion of findings that are well within the limits of normal. This begs more questions than answers, i.e., did training not provide the skill set and confidence to provide a better patient “outcome” in this case?
The other question is, do we rely so much on our “specialized testing” that we’ve stepped down from the responsibility of physical diagnosis based on history and findings?
Would the findings not have reminded the doctor of similar photos reviewed in training, even if cases of this nature were not seen? My classmates and I saw relatively few cases of papilledema and other disc elevations, yet we reviewed and discussed hundreds of photos and scenarios on the same. Yes, it’s an extremely difficult issue.
Here are some suggestions for confronting the unknown and potentially serious cases:
*Take a deep breath, turn to face the patient directly, and fold your hands in your lap. Awful body language and getting your computer-face on are helpful to no one.
*VERBALIZE the findings in question, and compare them to accepted standards for referral to emergent, secondary, or tertiary care. Symmetric, non-edematous, sharp disc margins, positive venous pulsation, normal visual acuity, normal color vision, full confrontation fields………. Most importantly, know these standards.
*Develop differential diagnoses and present them to the patient, with an appropriate level of concern. You are not going to nail every case, every time.
*Demonstrate findings via the computer in your exam room. Even if you don’t have ready access to a camera, OCT, etc., it’s an easy Google to find comparable photos and use them to elaborate on your concerns.
*Remember the conditions that tend to be symptomatic. Papilledema, papillitis, and other serious pathologies will most often cause complaints with vision and comfort. Have I ever sent an asymptomatic patient to the emergency room? You bet, but this is far from common. Surely, idiopathic intracranial hypertension and systemic hypertension can seem to present asymptomatically, but careful historical questioning usually tells a different tale.
*Allow ample opportunity for patient and family questions. Allowing the perception of unaddressed concerns is a surefire formula for having the patient seek a second opinion.
The end result in this case is that lots of concern were generated for findings that were barely worth recording. Hopefully, I’ve not conveyed too much frustration regarding our 15-year-old, but we’ve got to do better.