COMMENTARY

Listen Up! Forging Therapeutic Alliances With Your Patients

Andrew N. Wilner, MD

Disclosures

December 16, 2016

The Most Powerful Tools

I work in a neurology clinic in one of the best technologically equipped hospitals in the world. My patients have access to sophisticated MRI machines, PET scanners, autonomic testing, and exotic blood tests. A recent patient interaction reminded me, however, that the most powerful tools of the trade are always at my fingertips: a good pen and blank sheets of paper.

Clinical Case

A 36-year-old woman* presented with multiple symptoms, including heaviness in her arms and legs, tingling in both arms, pain in the knees and shoulders, daily abdominal and pelvic pain, and episodes of shortness of breath. She reported increased anxiety, restlessness, a mild tremor, and an occasional uncontrollable bouncing in her left leg. She had weekly migraines with occasional visual aura that began when she was a teenager. Apart from the migraines, all other symptoms had begun in the previous year. The rest of her medical history was unremarkable. She took ibuprofen for the migraines but no other medications.

As she talked, I wrote down her strange jumble of complaints. The patient had seen another neurologist, but she found that visit unsatisfactory. "He just tapped on my reflexes and said I had fibromyalgia," she lamented. "He gave me a prescription for Cymbalta, but I didn't take it. He didn't seem very interested in my problems."

When I examined her, she demonstrated her leg bouncing and pointed out her tremor, but both disappeared with distraction. Otherwise, her neurologic exam was normal. Toward the end of the exam, she started crying. Her aunt, for whom she had served as primary caregiver, had died a year ago after a difficult battle with ovarian cancer.

As she finished wiping the tears from her eyes, I dictated her history of the present illness (HPI), exam, impression, and plan. I suggested a few tests and consultation with a psychiatrist.

At our follow-up visit a few weeks later, all of her tests were normal. The psychiatrist had diagnosed generalized anxiety disorder and prescribed Cymbalta, the same drug the previous neurologist had recommended after his 10-minute consultation!

What was the difference this time? The patient felt satisfied that her complaints had been heard and appropriately investigated. The patient and I had formed a therapeutic alliance. She was willing to accept the diagnosis and take the medication.

*Details changed to protect patient privacy.

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