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Fatigue
Key Feature 4: Avoid early, routine investigations in patients with fatigue unless specific indications for such investigations are present. Skill: Selectivity Phase: Investigation Key Feature 5: Given patients with fatigue in whom other underlying disorders have been ruled out, assist them to place, in a therapeutic sense, the role of their life circumstances in their fatigue. Skill: Patient Centered, Communication Phase: Treatment Key Feature 6: In patients whose fatigue has become chronic, manage supportively, while remaining vigilant for new diseases and illnesses. Skill: Patient Centered, Clinical Reasoning Phase: Hypothesis generation, Treatment Multiple Medical Problems Key Feature 6: In patients with multiple medical problems and recurrent visits for unchanging symptoms, set limits for consultations when appropriate (ex: limit the duration and frequency of visits). Skill: Patient Centered, Professionalism Phase: Treatment, Follow-up Today I saw two very different patients for a primary complaint of fatigue. The first was a man approaching 90 years of age who had an exhaustive list of chronic comorbidities, while the other was a middle-aged man who was fit and without any pre-existing medical issues. The differential for fatigue is massive, and requires an approach that fits the individual. For the 90 year-old gentleman, presumably with fatigue of a multifactorial nature secondary to significant advanced illness, performing an intensive search for a new cause would be much less likely to result in a cure for the fatigue than addressing his chronic disease progression. He had good reason to be experiencing what he characterized as a gradually worsening fatigue given what was already known. On the other hand, the spry 50 year-old had developed a new complaint of fatigue over the past month, without any evidence of any underlying culprit. I requested no new investigations of the 90 year-old gentleman, while I requested some basic bloodwork to screen for an underlying cause of fatigue in the 50 year-old man (given that he didn't have any localizing symptoms to tip me to look for any specific causes). This man also did not have any diagnosed psychiatric illness, and he took no medications and only occasionally drank alcohol. His sleep was pretty ordinary, and he was not experiencing any significant life stressors at home or at work. All other reasons for developing fatigue. According to the UpToDate article, "Approach to the adult patient with fatigue," "Fatigue caused by an underlying medical or psychological condition usually presents as one of several reported symptoms. A specific etiology for fatigue is found less often when it is the principal or only complaint." That being said, it may be more likely than not that the bloodwork results for the otherwise healthy man comes back positive. If he returns to clinic to follow-up, which I advised him to do, then I would plan to delve a bit deeper into the possible psychosocial circumstances that may be contributing to this common symptom of general distress. How he may react in such a circumstance is as much my best guess as yours. Some people are very open-minded when it comes to the possibility of psychosocial circumstances affecting how one physically feels, while others negate against it like their life depends on it. In these circumstances, it is important to focus on building rapport and empathising with their perspective. After all, they may be feeling so crappy that it is hard to believe there is no underlying physical cause. But that is not true either. After all, there is no diagnostic testing to prove that patients with migraines feel pain, but we know it is fact, and there can be both physical and stress-related triggers for why they precipitate. This is not unlike chronic unexplained fatigue. There are many things that medicine does not have a test or a cure for. That being said, there is always a place for a relationship that can be therapeutic, in which patients are heard, understood, and cared for if only at the very least and very most by compassionate listening. It is important to provide supportive care for patients with chronic medical symptoms affecting quality of life, while at the same time setting limits on how frequently some patients return to clinic when symptoms are no longer changing despite best medical efforts.
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Priority Topic: Depression, Priority Topic: Immigrants, & Priority Topic: Multiple Medical Problems7/6/2018 Depression
Key Feature 2: Screen for depression and diagnose it in high-risk groups (ex: certain socio-economic groups, those who suffer from substance abuse, postpartum women, people with chronic pain). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 3: In a patient presenting with multiple somatic complaints for which no organic cause is found after appropriate investigations, consider the diagnosis of depression and explore this possibility with the patient. Skill: Clinical Reasoning, Patient Centered Phase: Hypothesis generation, Treatment Immigrants Key Feature 4a: As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Screen for depression (i.e., because they are at higher risk and frequently isolated). Skill: Clinical Reasoning Phase: History Multiple Medical Problems Key Feature 3: In a patient with multiple medical complaints (and/or visits), consider underlying depression, anxiety, or abuse (ex: physical, medication, or drug abuse) as the cause of the symptoms, while continuing to search for other organic pathology. Skill: Clinical Reasoning Phase: Hypothesis generation I was tempted to tack these learning objectives into a previous blog that fit, partly due to the urge to be lazy, but also because they really do mesh with so many patient situations I encounter. In previous blog posts, I have discussed the power of the social determinants of health to influence health status, which of course includes mental health. I have also talked about the bidirectional influence of mood and chronic pain, and I have talked about the importance of screening for postpartum depression. Without being too much of a bummer, depression is really everywhere. Or, without being too heavy, and recognising that I am skewed by seeing a greater proportion of the population who may be at increased risk for mental health concerns given their history medical issues, perhaps it is better to say that it can be anywhere. Certainly not everyone is depressed, but almost every single person in their lives has risk factors for depression or anxiety. On the flip side, some people are extremely resilient, and managing to deke out this omnipresent state despite a significant number of risk factors can be truly remarkable. Nevertheless, I think it is important to recognise, as a family physician, that any of my patients may be at increased risk for poor mental health if they present with ongoing health concerns. I may be the one person in the medical field who they are in contact with to do so. I can't tell you the number of times patients have presented for bodily concerns and, once probed, reveal significant mood disturbance. After appropriate investigation for the other bodily concerns, depression, anxiety, or other psychiatric distress may in fact be the most likely etiology responsible for them. Alternatively, it could be a secondary to chronic physical discomfort, or it could be totally unrelated. In some patients, it may be all too intimately mumble-jumbled to really know. But does it matter? I would argue that it doesn't, and that whether it causes, contributes, results from, or is entirely separate from other somatic complaints, treating mental health concerns may have the possibility to alleviate or lessen the severity of other symptoms, or at the very least increase one's capacity to cope with them, and it deserves treatment as it's own disease process that decreases quality of life. It takes two seconds to ask, and patients are often so very honest. But yet clinicians often don't ask, at least when it is not their domain of care (ex: Emergency Room Physicians, Surgeons, Cardiologists, etc. etc. etc.). Partly, this makes sense. They are there to treat a specific issue and not the rest of the body. I can't imagine practicing medicine like that, although I appreciate specialists' commitment to ameliorating and improving the lives of the patients they serve in their way. As a Family Physician, screening and managing depression and anxiety, and other mental health concerns (ex: abuse, whether physical/emotional/sexual/financial etc. or self-inflicted such as via harmful use of prescribed or non-prescribed substances) is absolutely under my purview, and detecting and providing therapy for these issues could arguably be how I may have the greatest impact in my career given the prevalence of it. It is also intimately related to quality of life at least as much as any other disease process, and helping my patients achieve better quality of life is my purpose for doing what I do. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Chronic Disease Key Feature 4: In patients with chronic disease, actively inquire about:
Phase: History Difficult Patient Key Feature 3: In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times. Skill: Patient Centered, Professionalism Phase: Treatment, Follow-up Key Feature 4: With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (ex: psychiatric patients, patients with chronic pain). Skill: Selectivity Phase: Hypothesis generation, Diagnosis Disability Key Feature 3: In patients with chronic physical problems (ex: arthritis, multiple sclerosis) or mental problems (ex: depression), assess for and diagnose disability when it is present. Skill: Clinical Reasoning, Patient Centered Phase: Diagnosis, Hypothesis generation Key Feature 4: In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family). Skill: Patient Centered Phase: History Key Feature 5: For disabled patients, offer a multi-faceted approach (ex: orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration. Skill: Patient Centered, Professionalism Phase: Treatment Multiple Medical Problems Key Feature 4: Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it. Skill: Clinical Reasoning Phase: Hypothesis generation, History Key Feature 5: Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to:
Phase: Treatment, Follow-up Stress Key Feature 1: In a patient presenting with a symptom that could be attributed to stress (ex: headache, fatigue, pain) consider and ask about stress as a cause or contributing factor. Skill: Clinical Reasoning, Communication Phase: Hypothesis generation, History Key Feature 2: In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress). Skill: Patient Centered Phase: History, Diagnosis Key Feature 3: In patients not coping with stress, look for and diagnose, if present, mental illness (ex: depression, anxiety disorder). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 4a: In patients not coping with the stress in their lives: Clarify and acknowledge the factors contributing to the stress. Skill: Patient Centered, Clinical Reasoning Phase: History The first patient I saw in clinic today was the first patient I saw in clinic at the same time last week, a 47 year old female who had an extensive relationship with chronic pain. Over the years, she had trialed a significant number of medications and alternative therapies to alleviate her pain, but her pain was tenacious. During my first visit with her last week, after confirming that her pain was indeed unchanged over the last many years, and after confirming for myself there weren't any "red flags" in her presentation suggestive of more ominous disease, I reviewed her current pain management strategies, including whether or not she was using any non-prescribed substances to cope. Her approach was as chaotic as the shopping bag she brought with the countless concoctions of over-the-counter supplements and herbal remedies, including some that appeared to not be sold on Canadian pharmaceutical shelves. She was speaking very quickly, wanting to tell me so very much about everything, and I think she was probably in anxious distress and having a hard time trying to cope. At the first visit, we reviewed the past history of her chronic pain - all of the previous investigations that were done and all of the specialists she had seen - and what the conclusions were. We then proceeded to clean up her pain medications and reduce them to the ones she felt confident were making a real difference in her pain. And then our time was well up. We ended this visit with an organized regimen of pain medications and a followup appointment to reassess how things were going in one week. And now here we were. She sat down in front of me and after a polite exchange of hellos she gently asked what we should do this week to modify her pain medications. There is so much about chronic pain we have yet to understand. The pathophysiology is still highly theoretical. We are aware of its association with mood disorders and psychosocial stressors, but we do not understand at a level of utilitarian specificity as to why this is the case. Chicken, egg, or both? In any case, no matter how we arrive at chronic pain, we do know that it worsens mood and aggravates social stress, just as mood and psychosocial stress negatively modulate perception of pain. By extension, if I can do anything to improve mood and psychosocial stress, I may alleviate suffering, and the corollary argument also holds that if I alleviate pain I may improve mood and attenuate psychosocial stress, thereby enhancing quality of life. Knowing the connection between chronic pain, mood, and stress, and now that I had the medical facts straight, during this follow-up appointment I decided to explore what was going on in this patient's personal life. As for mood, although she did not think she was clinically depressed and denied active suicidal ideation, it was certainly suboptimal, compounded not only by her pain but by her debt of sleep secondary to her pain. As it turned out, she attributed her low mood to the stresses in her life: her father living overseas was currently admitted to hospital for life-threatening cardiac disease, and her husband was riddled with aneurysms from his aorta to his renal arteries and was awaiting urgent surgery to prevent sudden rupture and possible death. Wow. Suddenly her pain had context, and was only a part of what I felt was infringing on her quality of life. The focus of our conversation shifted entirely away from her pain at this point, and she opened up about her fears of living life without her most significant others as well as her concerns regarding return to work as she felt she needed to prepare for a future with less financial stability, which was already troublesome. I did not have any advice for her anymore, and instead I just sat there listening to her experience with ache in my heart. After she shared the most salient aspects of her personal life stressors and the impact they were having on her ability to function or create disability, we rerouted the conversation to some practical takeaways to manage things for now, with planned follow-up again in one week. We decided that what was best right now was probably not to make any significant changes to medications, and rather to first have follow-up counselling later this week with her psychologist whom she endorsed having a strong relationship with. At this time she was not interested in any support groups or other community supports, but she said she would consider it in the future depending on how things progressed. She had come to the clinic today asking what we should do to modify her pain medications, and she left saying she was happy we weren't making changes to her current medications and that we were instead focusing on other ways of modulating her pain (I think this must have been partly because she had so many futile experiences with inconsequential medication changes over the years and didn't have much faith that yet another medication change would be her solution). As she was getting up to leave the examining room she said, "I'm now leaving here with more hope, and it's what I really need right now." When I first encounter patients with very complicated medical histories, either because of the number or significance (ex: cancer) of the comorbidities, I find myself feeling stunned by the complexity, oftentimes not knowing where to begin or to what depth I should delve under the pressure of time constraints. Indeed, this is how I felt when I first met this patient. In vain, I have felt personally overwhelmed by patients with multiple somatic complaints, serving only to increase my stress without making any difference in quality of patient care. Instead, these feelings ought to serve as internal cues to the fact that if I am feeling overwhelmed, it almost certainly means the patient is feeling this too, and likely with greater whelm. In that midst of overwhelming complexity, taking time to move beyond exploration of the disease process to exploring the illness experience, can, as this patient taught me, be the basis for a restoration of hope, alleviation of suffering, and improved quality of life.  By the end of postgraduate training, using a patient-centered approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Key Feature 1: In all patients presenting with multiple medical concerns (ex: complaints, problems, diagnoses), take an appropriate history to determine the primary reason for the consultation. Skill: Selectivity, Clinical Reasoning Phase: History Key Feature 2: In all patients presenting with multiple medical concerns, prioritise problems appropriately to develop an agenda that both you and the patient can agree upon (i.e., determine common ground). Skill: Patient Centered Phase: Treatment If you're a physician working in any area of medicine - and I would say particularly so if you're a family physician - you frequently have patients present to an appointment for multiple medical concerns. If you're a physician on a schedule (like, who isn't?) who doesn't have an hour time-slot to comprehensively address the sometimes multiple presenting concerns, prioritising is important to address the most pressing issues. The script that I've found works for this when I start a patient encounter is as follows: 1. Wash my hands before entering the patient environment (10 points) 2. Introduce myself (Say my name name and that I am a resident working with the physician) 3. Clarify their identity (Confirm their name and how they would like me to address them [ex: If their name is Jennifer, I ask if it's okay that I call them Jennifer or if they have another preference, such as Jen] if I think it's warranted) 4. At this point I like to say something to build rapport, such as apologising if they had to wait to be seen, or complimenting them on something nice they're wearing. If they look somewhat uncomfortable I use this moment to see if there's something I can do to make them more comfortable. This is just a nice thing to do, but it also seems to promote patient agreement to have me lead the appointment (see next point) 5. State my intent (Not everyone knows what the role of a resident is, so I say something along the lines of "As a resident, I'm a doctor who has recently graduated from medical school and am training to be a family doctor. If it's alright with you I would really appreciate if I could work through what brought you in to the clinic today and see if we can come up with a plan to address it together. I would then review with my attending physician to make sure they're on board with the plan and to see if they have any further or alternative suggestions. Is this okay with you? 6. Elicit presenting concern(s) ("So what brings you in to clinic today?" They may say one concern and only have one concern, they may say one concern and have multiple concerns, or they may say multiple concerns right off the top. So I hunt further. "And is there anything else that you were wanting to address today?" I repeat, "Anything else?" until they have run out of concerns.) 7. Prioritise (Unnecessary if a patient has only one concern, but this tends to be the exception in the family physician office setting. I start off by asking them, "Out of the concerns you currently have, which of these is most important for you that we address today?" If I've elicited a concern that I feel could be a more urgent issue [ex: chest pain], then I will let them know it is of greater concern to me. This may in fact change a patient's priorities, because if the doctor is more concerned about one thing than another, then the patient sometimes also perceive it as more medically important to work up first. I ask if this is the case, "Knowing this, would you be okay if today we addressed the issue I think is more medically urgent?" If they are not, I then go on to address the patient's greatest concern, but still briefly rule out any acutely worrisome features of the concern I am most worried about and ask if they can book a followup appointment in the next day or so, assuming there is nothing identified as seriously urgent compelling action at this visit. In reality, the agenda tends to be a compromise, such that multiple concerns are in fact addressed at the visit, and that followup visits are also warranted. I explain that to do a thorough job addressing each concern, I really do need to be able to devote more time to working each one up. Patients tend to be agreeable to this.) Prioritising the appointment agenda is a great example to me of how the art and science of medicine collide. Although I've been trying to hone this part of the patient encounter for the past 4.5 years now (medical school and now halfway into my first year of residency), I am still constantly tweaking and adapting my approach. There is no one-size-fits-all-patients approach, and creating an agenda that the patient and myself can agree on, and to do so efficiently, is a work in progress. Finding the common ground between patients' value-informed concerns and my own hierarchy of most important medical concerns is one of the most frequent challenges in the family physician office visit, but without devoting the time and energy to doing this well at the start of the visit, this can lead to serious disappointment for me and the patient. The patient may otherwise only mention a potentially serious medical concern (something that cannot be ignored) at the end of a visit, requiring time to address that may make the next patient's appointment start late. Or the patient may be disappointed that the reason that was most important to them that they wanted to come in for wasn't addressed. This can happen if they mention a secondary concern first (sometimes there is some fear about discussing certain problems, perhaps related to stigma or fear that a symptom is indicative of a serious underlying medical concern) and we've taken the full appointment time already to address the less concerning issue in full. As a family physician, both the selection of appropriate medical interventions and the quality of the patient-physician encounter are important in providing high quality primary care, and establishing a mutually agreeable agenda at the start of the office visit is, in my opinion, a requisite for this. |
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