Changing the Subject

Mrs. Blouin was new to our practice. Her previous doctor, in the next town up the road, had left the area just over a year ago. Her presenting complaint was “Wants Reclast infusion”.

Reclast is a once-yearly $1,200 intravenous infusion for osteoporosis, primarily for patients who cannot tolerate the older treatment alternatives.

I have many misgivings about osteoporosis treatment, and have not yet prescribed Reclast. It has a long list of drug interactions and side effects, and it is still very new.

It didn’t take me long to realize that there were other issues afflicting Mrs. Blouin. She was fatigued, her blood pressure was very high, she had no idea what her cholesterol was, and she had a foreboding family history of cancer and heart disease.

Dr. Greyson’s notes mentioned her blood pressure being up a bit, ongoing fatigue, breathing problems and several other symptoms. Reading through them, I wasn’t sure how osteoporosis came to be the predominant concern.

“How did you and Dr. Greyson come to focus on your bones?” I asked.

“I don’t know”, she answered. “I guess he thought they were really that bad.”

“It sounds like we need to look at the whole picture right now. You couldn’t get your infusion now anyway without some fresh bloodwork. We might as well see if we can find out why you’re tired, check you for anemia and thyroid problems. We could also check your cholesterol if you’d like. And I’d like to check your blood pressure one more time, since it’s higher today than it was last year at Dr. Geyson’s.”

I had moved the focus of our visit away from what Mrs. Blouin had come to see me for. So had Dr. Greyson, but in the opposite direction.

Physicians change the subject of patient visits all the time. Sometimes we do it because we feel there is a more pressing issue than the one a patient came to see us for, like correcting a high blood pressure or screening chronically ill patients for depression, which may be a barrier to achieving better health. Other times we may be guilty of shifting the attention away from a symptom we are unfamiliar or uncomfortable with in favor of something we find easier or more satisfying to deal with. Sometimes we may avoid or postpone issues that aren’t easily solved in a fifteen-minute-visit.

I sometimes hear patients say about other doctors: “He didn’t seem concerned about my symptoms”. Some people may say that about me too; I know I don’t pay as much attention to arthritis pain and old sports injuries as some patients might expect when they come in for physicals and have unmet screening needs for cancer and cardiovascular risk that I feel a need to cover in my half-hour with them.

But where do we draw the line? When is it fair to change the agenda for a patient visit and when is it not? When are we doing the right thing by steering our patients toward issues they may not have thought of as priorities, and when are we doing the wrong thing by not making them equal partners in their own health care?

1 Response to “Changing the Subject”

  1. 1 Wren January 15, 2011 at 5:21 am

    A very good question. Like the patients you mentioned, I’ve had doctors seem less concerned about the symptom I’m there to get help for than some other issue which was new to me. It can be very frustrating.

    Why can’t the doctor address the issue the patient has come to him for AND any new issues he/she discovers during the course of the exam? And if time is the only problem, couldn’t the doctor address the patient’s request, and then have them schedule a new appointment to deal with the new issues (unless the new ones are serious and imminently dangerous, of course)?

    I have nothing but respect for physicians. I believe we’re all very lucky to be living in a time when so many of our ailments are treatable, and that our lives can be saved by an observant and caring doctor. But sometimes these same great docs minimize the patient’s complaint, and that can be deeply frustrating. I believe this happens more frequently to those of us with chronic illnesses, like rheumatoid arthritis.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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