How to Approach the Patient Who Doesn't Improve

In medicine, our goal is always primarily to heal and do no harm. Quite obviously we do our best to avoid medical errors, treatment failures, and complications, but these are natural and a part of medicine.

It is also a part of learning to practice medicine.

Today, we will look at some tips and tricks that I have developed over my career to try to mitigate the above. Specifically, I want to discuss the patients that do not get better.

In family practice, this happens frequently. It may be as simple as telling a patient to call back in a week, if they are still suffering from sinus symptoms, for a possible antibiotic.

In other cases, it can be as frustrating as following an elderly patient who continues to lose weight, and you, as the clinician, can not figure out why. 

In the first part of my career, I struggled with this significantly. In PA school, we learn about what tests are available to us, but seldom what steps to take, and how to go about continuing to work up a patient. For me, when a patient came back to the office for follow up, I was always anxiously awaiting the nursing report. Were they better?

Sometimes trying to think of the next step could present challenges moving forward as I felt a sense of nervousness about re-evaluating the patient.

As I have moved forward in my career, I have become more confident when patients call in or come back to the office without getting better. Whether this is a depression follow up, cough evaluation, or lower extremity swelling, I have added tools to help evaluate the next step and assure things flow smoothly, but believe me, it is not always that way!

Still, I occasionally find myself stumped. Sometimes this is with a patient who continues to have ongoing joint swelling, has failed multiple interventions for cough, or presents with a complaint I am not familiar with.

 

What Do We Do When We Are Stumped?

Here are some tips and approaches to help narrow down the problem/diagnosis when you feel lost...

  1. The first step that I take when a patient calls in or is put back on my schedule with a complaint (i.e. cellulitis not improved with bactrim or worsening cough), is to review and re-evaluate.

    My documentation at the time of the patient visit is key, as I see about 100 patients per week. I am unlikely to remember specifics about the visit, so I make it a clear point to read my progress note as well as my assessment and plan.

    This usually provides me with a clear picture of what I was planning to do next, such as switch antibiotics, or order an imaging test such as a chest x-ray or ultrasound.

  2. Next, I try to think about what else could be causing their concern. As clinicians, we have to be willing to accept that our diagnosis might be wrong.

    Maybe the patient with chronic cough needs a trial of a PPI next as opposed to an anti-histamine. Thinking clearly through the differential provides helpful information and allows us to weigh the likelihood of each concern based on the history and physical.

    Another pertinent question to ask is if there is something else occuring. It is the same reason why when reading an x-ray, we do not stop when we find that first fracture.

  3. The most important step in the process is to re-evaluate in person. Have the patient come back for a follow up visit in the office.

    I have found too many times that taking phone messages or looking at patient portal messages asking for updates do not serve me well.

    I can’t explain it, but seeing the patient back and re-evaluating them in person is the best option. This provides time to re-read my progress note, see if symptoms have changed, and look at the case with a fresh eye, aware that what we originally thought was not correct.

 

Examining the Patient

During the examination, it is important to see what is different and discuss that with the patient. In some cases, if a blood pressure is not at goal or if their depression is not improved, simply asking the patient if they are compliant with medication solves the puzzle.

Patients are non-compliant for many reasons, but finding out why they aren't is crucial. The patient is an important centerpiece that helps you increase and decrease the likelihood of processes on the differential diagnosis.

After a secondary H and P, I find it is helpful to call for help. In my office, I am blessed to have a very approachable, available supervising physician who I can consult if I am stumped. We typically discuss the case in person and consider what else might be going on.

We talk through labs that might be helpful or whether a referral to specialist is needed. It is also very helpful to have another person with a different thought process on the case, as they may look at things differently.

In some cases, even having another provider come in the room, to help evaluate a patient has helped nail the diagnosis.

 

What If There Is Still No Improvement?

So what do we do when we have seen the patient, re-evaluated the diagnosis, have them come back into the office, and ordered numerous tests, but still don't have a diagnosis?

A good example would be the patient who originally presented with an upper respiratory infection. We might try over the counter anti-tussives, benzonatate, or oral steroids as an initial therapy. In family practice, I tell patients their disease is likely viral and to call back in a week if still symptomatic; at which point we will consider an antibiotic.

What if that patient subsequently calls back and tells us that they completed their azithromycin, augmentin, or doxycycline, but still has complaints? We might try an inhaler for post tussive bronchospasm, but what if this does not work either?

A re-evaluation in the office may not show any hints toward the true diagnosis, but could provide us with a next step.

What if a subsequent chest x-ray is normal? Should we order an echocardiogram? Should we look for inflammatory disorders via lab work? Should we refer to the specialist?

At some point, when we have performed a lot of tests and the diagnosis is still unclear, we may need to start looking for zebras.

What are the rare things that could cause cough?

We are taught to first look for horses, but there is always the elusive zebra. As a way to build our clinical knowledge, we must always be willing to do research in consideration of the rarer conditions that might be contributing to symptoms. In this way, we learn more about arcane conditions and even if not related, we learn.

We must always be willing to keep learning.

Throughout the entire process, we must not allow for bias to come into our minds. We must be open to all diagnoses and comb over each piece of information, even if it does not seem noteworthy or important at the time.

In my experience, sometimes the smallest piece of information might be the essential piece that motivates us to order the correct test.

Lastly, it is always important to remain humble and willing to keep digging. If we become complacent or too confident because we have “seen this a thousand times”, that is when we get into trouble.

Past patients can be helpful to indicate how a condition presented previously, but all patients are different, and we must keep this in mind. In medicine, we must always be ready for the rare, the weird, or the unexplainable.

As discussed throughout the article, not being able to determine a diagnosis can be very frustrating and even frightening as a clinician. Our education is aimed at providing excellent patient care, but working through a long or complex differential can hurt our clinical confidence.

Whether this is a crashing patient in the hospital, or a nagging complaint without a diagnosis in primary care, the frustration can still mount. I am hopeful that today’s article will help you plan to attack a complicated differential with confidence!