Note: The name and some details of these patient cases have been changed to protect their identity. The essence of each story, however, remains intact.
She was a 42-year-old healthy woman. She had the misfortune of being born into a family whose vasculature was genetically intolerant of tobacco smoke, but she didn't smoke. Many of her older cousins were riddled with coronary artery disease at a young age. She had buried relatives and attended to others who were suffering from their addiction. She had too much responsibility and too little joy in her life. Despite the fact no women or nonsmokers in the family had had a heart attack, stent, or bypass surgery, she continued to complain of chest pain even after two normal stress exams some years apart.
She was never in any apparent distress when I examined her, and after ruling out other potential causes of her pain, I performed a coronary angiogram at her insistence. It was predictably normal. She came back months later with the same complaints. I declined to cath her at that time but 3 years later, I took her back to the cath lab against my better judgment. Afterward, I gave her two glossy black and white copies of her large pristine coronaries.
During her last office visit I suggested she seek psychiatric treatment for anxiety. "Millie, you are demanding too many tests and seeing too many physicians," I warned. Months later she died in a tertiary center from complications of another cardiac test, I assume from dissection or catheter-induced spasm. I never knew for sure.
Frequent Flier vs Bounce Back
This is an extreme and unfortunate example of a "frequent flier." Perhaps a good working definition of the term might be: "A patient who despite stable testing returns frequently to the medical setting when no change in therapy or additional testing is objectively indicated."
The frequent flier is not to be confused with the "bounce back," who returns because they were discharged prematurely and have an acute exacerbation of an illness requiring readmission within 30 days of discharge. The frequent flier's return often invokes eye rolling, sighs, disgust, and feelings of exasperation on behalf of family members as well as healthcare workers.
Despite this pervasive problem, no one really knows how to stop the revolving door from turning for these patients. Perhaps if we consider the different categories of frequent fliers we can understand what might work best to reassure them.
The worried-well patients have extreme cardiovascular anxiety without pathology. They may have family members who have heart disease. Often, they point to a "terrible family history of heart trouble" that occurred in a much older relative. Occasionally it's someone who was forced to confront his or her own mortality when a good friend or acquaintance met with an untimely illness or death. It also includes the patient who was misdiagnosed with CVD for whom technology has now proven the diagnosis inaccurate but left the patient insecure.
With generous reassurance, a good listening ear, and a lot of patience, most of these patients learn to cope and enjoy longer and longer periods outside of the medical system. If they cannot achieve any measure of reassurance, they should seek a second opinion and then consider mental-health counseling.
Stable but Worried
The stable but worried have abnormal test findings but are appropriately managed with meds and lifestyle. There is pathology but it's not acutely life threatening. A promise of close surveillance and a change in workup or therapy when warranted can help reassure these patients. Often, they just need more than the typical 20-minute office visit. If possible, book these patients at the end of the day so that other patients aren't made to wait.
I find that most of these stable-but-worried patients find peace of mind after I extensively explain their test results complete with the use of illustrations, drawings, or models. Discussing the COURAGE trial data, which showed no additional benefit for stents over medical therapy in stable coronary disease, is also helpful. Some patients in this category have turned out to be my most loyal and compliant patients.
The at-Risk vs Secondary Gains
The "at-risk" or sick person who does not participate in prevention or therapy: It includes those who don't take their meds but continue to seek attention (often for reassurance). My frequently-positive-for-cocaine population comes to mind as well as those who continue to smoke, lead a sedentary lifestyle, and remain overweight. They book an appointment to tell you their symptoms but are unwilling to change their behaviors from visit to visit. I fully expect to read about these patients in the obituaries. There is nothing left to do but be honest, offer tests periodically, offer medications, and document well.
Finally, there is the frequent flier who is healthy but with secondary gain for their visit. A jailer once informed me in the cath lab that my prisoner patient, a self-professed methamphetamine "chef," told his fellow inmates that once in the cath lab he "would make a run for it." He was a smoker with mild creatine phosphokinase elevation and a nonspecifically abnormal ECG (this was before the availability of high-sensitivity troponins).
After I had gowned and gloved, I explained the angiogram in detail again, but this time made the special point of emphasizing that if he tried to get up during the procedure he could tear a large hole in his femoral artery. I assured him that it would be difficult to make it to the front door of the hospital if that occurred. The jailer handcuffed him to the table and a seemingly definitive test resolved the issue. This Walter White wannabe never returned to the hospital for chest pain during his incarceration. Playing hardball, respectfully and competently, can be best in a situation like that.
I've practiced medicine for nearly 30 years and have worked in a hospital setting since my teenage days—this is about as comfortable as I will ever be with the frequent-flier population. I've advised my students that these patients represent a clear and present danger to themselves because of their interface with a system whose only answer to a symptom is often another test.
At the same time, labeling a patient as a frequent flier must be balanced with an open mind and an open eye because the little boy who cried wolf eventually lost his sheep to one.
My best advice to deal with frequently returning patients with no new objective indicators of need is to approach them as if one were wading into a cold pool of water. Despite dread and initial discomfort, within minutes we acclimatize. That stance often affords an opportunity to provide acute reassurance by discussing the implication of a normal test (be it a stress test, troponin, or LV function). There is little else to do beyond suggesting they get a second opinion to make certain we haven't missed anything (most often, we haven't).
When providers learn to accept that frequent fliers are unlikely to feel secure for long, we can begin to find satisfaction in the short-term success of the next discharge or reassurance provided at the next phone call. In order to remain a durable and effective provider, at the end of the day we must remember it is the patient who has the problem. We should resist the urge to make it ours.
How do you deal with frequent fliers in your office or hospital practice?
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Strategies for Managing Frequent-Flier Patients - Medscape - Dec 06, 2017.