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Back to the basics

Kolmetz, Melodie Joy, MPAS, PA-C, EMT-P

Journal of the American Academy of PAs: November 2018 - Volume 31 - Issue 11 - p 1–2
doi: 10.1097/01.JAA.0000546483.87312.f9
Mindful Practice

Melodie Joy Kolmetz was a member of the first graduating class of the Rochester Institute of Technology PA program in Rochester, N.Y., and is now an assistant professor with the program. In her 22-year career as a PA, she has practiced in family medicine, emergency medicine, urgent care, occupational medicine, hospital medicine, and gastroenterology. You may find her on the sidelines of her boys' sports endeavors, on the ambulance volunteering as a paramedic, or driving the fire truck in her community.

Tanya Gregory, PhD, department editor

My medical assistant leaned over and said, “It's another anxious one.” The next patient was 30 minutes early for her appointment and couldn't wait to hand over her patient registration information. Her speech was so fast that the medical assistant had trouble obtaining any information. The patient came to the desk multiple times asking, “Is it my turn yet?”

In gastroenterology, anxious patients are a frequent occurrence. So often, they are the worried well who have had multiple laboratory tests and imaging procedures before their specialist appointment. I am sometimes surprised that the primary treatment they require is education: about the tests that have been done, about the differential diagnosis associated with the chief complaint, and about treatment options. Education establishes a relationship built on trust, which is essential for the prescribed treatment to have the desired effect.

I could immediately tell that this case was different. This 72-year-old woman had been referred for a “screening” colonoscopy. She was obviously anxious, wringing her hands frequently. Her speech was rapid, and she repeatedly asked, “Is there something wrong with me? Is it bad?” She had never undergone a screening colonoscopy but was complaining of constipation and centralized abdominal pain for the past 2 months. Guiding her through a review of systems was difficult but she revealed that she had suffered from chronic constipation since she was a child, averaging two stools per week. When asked about changes in her bowel habits, she reported that she was now going only once every 10 days. She also mentioned a recent ED visit for abdominal pain.

Upon viewing the reports from the hospital electronic medical record, I found that she had been to the ED four times and urgent care three times in the past 8 weeks. Each time she complained of abdominal pain and constipation. There were no laboratory results or imaging results and no rectal examination documented. The diagnoses were anxiety and chronic constipation. She received a prescription for a laxative and was referred back to her primary care provider, who scheduled the appointment with us.

Her physical examination, including a rectal examination, was unremarkable. Not surprisingly, the stool fecal immunochemical test (FIT) was positive. She repeatedly asked “Is it bad?” and I struggled with how to proceed. I was concerned that my usual patient education process would aggravate her underlying anxiety. I was afraid that once we reviewed my differential diagnosis, she would refuse to have a colonoscopy.

Taking a deep breath, I showed her the positive stool FIT results. I was shocked when she grabbed my hand and said, “I was right. There is something wrong. Thank you for listening to me and for doing a rectal examination. When can I have that colonoscopy? How about tomorrow?” We discussed the difference between a screening examination and a diagnostic examination. Thankfully, there was a cancellation, so her colonoscopy was scheduled for 2 days later.

I reflected on this case later that evening. I had never met her before, so I had no understanding of her baseline mental health. Was she always anxious? I thought about the number of visits it took for her to be taken seriously. Did her anxiety stem from a subconscious understanding that something was really wrong? I eventually concluded that it didn't matter, because anxious patients have diseases, too.

It would have been very easy to let others set the tone for this patient encounter. I could have taken a dangerous ride down the slippery slope of early closure. Anchoring bias and the bandwagon effect can be tough to avoid, especially with patients who have seen other medical providers. Hassle bias is also tempting when working in the ED or a busy medical practice.

The lack of information in her chart forced me to go back to the basics and listen to her story. Taking a good history and performing a thorough physical examination let me formulate a thoughtful differential diagnosis. This was perhaps even easier without the distraction of a plethora of previous laboratory test results and imaging studies. It was a good reminder to follow that algorithm with every patient. Listen first, then look at all of the information provided.

Not surprisingly, this patient was found to have a colonic mass lesion in the area of her splenic flexure. CT of the abdomen and pelvis was arranged for the same day, right after her colonoscopy. Thankfully, it showed a solitary colonic lesion, with no evidence of lymphadenopathy or metastatic disease. An appointment for consultation with the colorectal surgeon was immediately arranged.

She insisted on seeing me before she went home. I walked over to radiology where I found her sitting in the waiting area with her daughter. They both stood to give me a hug and she thanked me for taking care of her. She was just told that she has colon cancer, I thought. Why does she want to thank me? I watched her as we reviewed her results and discussed the next steps. Her speech was normal and her questions were very appropriate. I recalled my earlier reflection and realized that the answer was right in front of me. She wasn't anxious anymore.

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