True Detectives: Problem Solving in Endocrinology

From dealing with difficult patients to time constraints and those perplexing cases, all endocrinologists become adept at problem solving one way or another.

Every clinician will have at least one: the patient whose name on the chart instills a feeling of anxiety or even dread, the patient whose presence in the waiting room sets off loud sighs and rolling eyes among the staff…the “difficult” patient.

About 15% of doctor-patient relationships rate as “difficult” by the physicians themselves, and that can be for any number of reasons. The patient can be defensive or distrustful, or there could simply be a breakdown in communication between physician and patient.

Another issue is that the patient can present with a highly unusual case and the doctor is only allotted a short time to figure out the best course of action, which can call for different approaches, creative maneuvering, and a bit of luck.

Indeed, maintaining a healthy doctor-patient relationship is of the utmost importance, even in the face of whatever challenges may arise. Here we’ll look at some problems that may present in your practice and ways to tackle them, and maintain a relationship that is beneficial to both physician and patient.

The Difficult Patient

Some patients come to the clinic ready to spar with their doctors. They’re sick or in pain, nervous about what diagnosis they may receive, or misinformed about treatment options. They can be non-compliant and distrustful, and that can certainly damage the doctor-patient relationship.

For Richard J. Santen, MD, a professor of medicine at the University of Virginia, a practicing endocrinologist in Charlottesville, and former president of the Endocrine Society, it’s a matter of being patient with the patient. He admits that obtaining a patient’s trust is not usually a problem, since he’s a specialist that the patient has been referred to. “When this does occur,” he says, “time usually solves the problem. On repeat follow up, the patient realizes that the physician is knowledgeable. However, I have had instances when that trust did not develop for six months to one year of taking care of the patient. In these instances, the interpersonal relationship with the patient over time is key.”

But sometimes the patients are so distrustful or defensive; it’s just that they don’t know how to communicate what’s wrong with them. They have unfocused methods of expressing and characterizing their symptoms, which is understandable, since they have no medical training.

In medical school, it’s often taught that non-directed questions work best, but Santen says that strategy often does not work, and clinicians need to ask specifically about how, when, why, how severe, how often, and so on in a directed fashion. “If I have a patent with hyperthyroidism and ask the non-directed question ‘How are you feeling?’ I might get one of several answers,” he says.

“On repeat follow up, the patient realizes that the physician is knowledgeable. However, I have had instances when that trust did not develop for six months to one year of taking care of the patient. In these instances, the interpersonal relationship with the patient over time is key.”

— Richard J. Santen, MD, professor of medicine at the University of Virginia, practicing endocrinologist, Charlottesville, Va.

Santen says it’s better to ask questions related to what he knows can be experienced by hyperthyroid patients: Do you have palpitations? Have you lost weight and specifically how many pounds over the last six months? Do you have muscle weakness and cannot get up from a chair without difficulty? These are direct questions that can draw more meaningful and substantive answers.

Time Constraints

And of course, substantive, knowledgeable answers are what you’re looking for from your patients. So what happens when you only have 20 minutes allocated by your healthcare system to discuss complex issues with them?

The first thing to do is explain briefly to the patient that you have a limited timeframe, especially if your patients are used to seeing you for longer. “For years I was allowed 30 minutes to see a follow-up patient and 60 minutes for a new patient,” Santen says. “The hospital and department dictated that all faculty members must see follow-up patients in 20 minutes and new patients in 40. My patients in general are quite complex. I also felt that if a patient had an internal medicine problem that was not related to endocrinology, for example a urinary tract infection, I would take care of that on the visit. My patients were used to this approach. When the 20-minute rule came in, I explained to them how I would have to change my practice. When carefully explained, the patients understood and in general were willing to see another physician for the non-endocrine problems.”

Written materials – handouts, pamphlets, etc. – are excellent resources to give to these patients. It’s also a good idea to refer them to patient education resources like the Hormone Health Network. The patients can then read and study the materials so they can be armed with more knowledge and you can have a more meaningful discussion at the next visit.

Make use of newer technologies as well. Put up a general discussion on YouTube that the patient can access. This can be an effective way for patients to get the information on issues that physicians have to explain repeatedly – menopausal hormone therapy, how to take thyroid hormone levels and measure their effects, and so on.

You can also use phone time to discuss issues with your patients, although the drawback to that is that it’s not reimbursable. Santen says he calls patients to report abnormal lab results or follow up if clinic time is insufficient. “The electronic medical record makes it easy to document time spent on the phone,” he says. “If physicians are able to bill for phone time, I believe that this use of the phone will become common. This approach is more personal and patients feel that the physician is personally concerned if he or she calls the patient. Some of our other older physicians use the phone commonly also but as mentioned, this is a generational thing.”

The Unusual Case

It’s bound to happen in your practice, especially as an endocrinologist. A patient will present with a highly unusual case – a rare disease or an odd array of symptoms or a patient who does not respond to first-line therapies. The first course of action is to know where to look in the literature to find an answer. It also never hurts to walk down the hall and consult a colleague or send an email to an expert for a little assistance.

Santen describes the case of a woman with Riedel’s thyroiditis, a rare disease that causes thyroid enlargement that is like scar tissue. If left untreated, the thyroid can grow and cut off the wind pipe. Santen treated this patient for three years, and in that time her windpipe became progressively smaller, and her shortness of breath increased. The medical literature suggested using high doses of corticosteroids to treat her. But she didn’t respond, and worse, she developed all of the side effects of this type of therapy — weight gain, frequent bruising of the skin without trauma, high blood sugar, weakness of her legs, and high blood pressure. Santen tried several other drugs, but none were successful.

So Santen looked for outside help. “I consulted several of the world’s experts to see if there were any new therapies that might work and tried them all – five in total,” he says. He found that the only way to benefit her was to perform a tracheotomy, even though it would interfere with speaking and require a tube in her throat for the rest of her life. The patient agreed to the procedure when her shortness of breath became unbearable.

“In the medical literature,” Santen says, “it is stated that the scar tissue characteristics of Riedel’s thyroiditis are so great that surgical removal of the thyroid is not possible. The patient understood this but was willing to go ahead with the surgery. Because she had been on so many medications to try to shrink the thyroid in the months prior to surgery, we thought that there might be a chance that the surgeon could remove some thyroid tissue.” Santen and his team asked the surgeon to try and remove the thyroid tissue if he could. The surgeon spent five hours meticulously dissecting out one side of the thyroid, which freed up the patient’s windpipe and eliminated the need for tracheotomy.

“When she woke up after the surgery,” Santen says, “she thought that a miracle had been performed. She could breathe normally and did not have a tracheotomy. What a wonderful feeling as a physician that this took place.” He says that they speculated that all the anti-inflammatory and anti-immune drugs used allowed the surgeon to cut around the thyroid to allow removal.

“Over the last six months, the patient has continued to breathe relatively normally, and for the first time in many years to be able to sleep lying flat at night,” Santen says. “One experience like this for a physician trumps all of the difficulties encountered otherwise in a practice.”

—Bagley is the associate editor of Endocrine News. He wrote about stem cell tourism in the June issue.

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