Clinical Scenario
Have you ever heard the expression, “Patience is a virtue”? This statement has never rung truer than for elderly patients you might see in your practice. Consider this example:
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January 2023Today, you are seeing a new patient, an 82-year-old female who indicated to your medical assistant that she wishes to be referred to as “Miss Lydia.” Miss Lydia is accompanied to her appointment by a caregiver who is not a designated surrogate. The actual designated surrogate is Miss Lydia’s daughter, who lives and works in a nearby town.
During her visit, she tells you that her chief concern is that of worsening imbalance and light-headedness, with an increased risk for falling. (This was also related in the referral that came to you from her primary care physician.)
As you begin your conversation with Miss Lydia and proceed into learning more about her symptoms and associated medical conditions, you begin to understand that Miss Lydia is prone to some mind-wandering and task-irrelevant thoughts. Some of the questions you ask her regarding her symptoms seem easily answered, while other responses are hesitant or, you suspect, may even be inaccurate.
Her caregiver, unfortunately, isn’t much help. She indicates that she is new to the job of caring for Miss Lydia and has only limited historical knowledge of Miss Lydia’s physical and mental condition, including the condition Miss Lydia has visited you for. While Miss Lydia is quite friendly and genuinely pleasant, you understand that this could become a difficult interview, given the complexity of determining a likely set of differential diagnoses. Additionally, your clinic is overbooked today, and your daughter has a soccer game in the late afternoon, which she begged you to attend. Miss Lydia may need more of your time than you can afford to give her.
Discussion
Did that sound like a familiar scenario? As the U.S. population ages and the birth rate declines (by 20% over the past 15 years, by some estimates), otolaryngology–head and neck surgery practices are increasingly treating older patients on a regular basis. Additionally, while the share of elderly persons with dementia or other cognitive dysfunctions appears to be decreasing, the baby boomer population is experiencing a rise in dementia. Indeed, physician experience dealing with patients who have dementia is also increasing—but how will this affect clinical efficiency in busy practices?
It’s well known to otolaryngologists that patient concerns involving balance disorders—vertigo, dizziness, light-headedness, and disequilibrium—require considerable sleuthing efforts to consider potential and probable etiologies for any given patient. Patients with balance disorders often have their first stop with us in the form of a referral from their primary care office to otolaryngology to sort out the complex symptoms. Even with a patient who is a good historian and communicator, the road to diagnosing balance disorders is a time-consuming journey. What is the ethical obligation of an otolaryngologist to provide the necessary time for the encounter, especially when the patient is having some cognitive hesitance in his or her ability to provide clear and concise responses?