Primary care physicians often have to see patients with a litany of issues — often within a span of a 15-minute office visit.
This places the doctor in the middle of a tension: Spend more time with the patient to address all of the concerns, but risk the wrath of patients scheduled afterwards, who are then forced to wait. And in some cases, it’s simply impossible to adequately address every patient question during a given visit.
It’s a situation that internist Danielle Ofri wrote recently about in the New York Times. In her essay, she describes a patient, who she initially classified as the “worried well” type:
… a thin, 50-year-old educated woman with a long litany of nonspecific, unrelated complaints and tight worry lines carved into her face. She unfolded a sheet of paper on that Thursday morning in my office with a brisk snap, and my heart sank as I saw 30 lines of hand-printed concerns.
Ms. W. told me that she had recently started smoking again, after her elderly mother became ill, and she was up to a pack a day now. She had headaches, eye pain, pounding in her ears, shortness of breath and dizziness. Her throat felt dry when she swallowed, and she had needling sensations in her chest and tightness in her gut. She couldn’t fall asleep at night. And she really, really wanted a cigarette, she told me, nervously eying the door.
This is the kind of patient who makes me feel as though I’m drowning.
Dr. Ofri did as many doctors do: She listened appropriately, went over the patient’s history and physical, reviewed prior tests, and concluded that many of her symptoms were due to anxiety. Except, in this case, they weren’t. The patient eventually had a pulmonary embolus, and hospitalized.
In Dr. Ofri’s poignant words:
The truth was, any of her symptoms might have masked a life-threatening illness. Headaches could have been a cerebral aneurysm. Needling sensations in the chest could have been angina. Pounding in her ears could have been a brain tumor. But I had to rely on my clinical judgement that it was extremely unlikely for her to have all of these serious conditions simultaneously, so I chalked it all up to stress. And I was wrong.
She did the right thing, apologized to the patient and told her what happened. But therein lies the conundrum that doctors face.
Should every patient’s symptom be tested for the unlikely risk of something dangerous? In the current practice environment, where doctors have decreasing amounts of time to see patients, and mistakes are dealt with in an adversarial malpractice system, the incentives all point to the affirmative. The subjectiveness of clinical decision-making is poorly tolerated in the United States.
I like Dr. Ofri’s suggestion of prioritizing complaints, and explaining to patients that only so much can be done within the constraints of a 15-minute office visit. In fact, that’s exactly what I do. But I’d be willing to bet that she’d be more prone to order that D-dimer or CT-pulmonary angiogram the next time she’s faced with a similar patient.
*This blog post was originally published at KevinMD.com*