Looking Beyond The Patient’s Chief Complaint
- Russell Volpe DPM
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One of the things I learned early on in my career from my teachers and mentors in podiatric medicine is the importance of looking beyond the chief complaint when evaluating a patient’s feet.
It is easy to simply address a symptom promptly and consider the care finished. This is especially true as we all are busier and busier, and as we are working against the inane restrictions of health insurance forcing us to see more and more patients to make the business model work. The patient will be happy to have received short-term relief of a nagging symptom, one that has often become worse before the patient finally visits the doctor.
However, if we say goodbye at that point and move on to the next patient, we miss an invaluable opportunity to uncover faulty biomechanics aggravating a hallux valgus, residual metatarsus adductus inflaming a styloid process or poor shoe shape and design causing toes and nails to become cramped, curved and callused.
In my experience, the patient is usually unaware that structural, mechanical, systemic medical or environmental factors may be contributing significantly to his or her foot problem. Only in taking time to perform a thorough exam to identify these co-causative factors do we open the door to offering patients real, lasting solutions to their problems and not merely quick fixes for inflammation and pain. After all, it is not very difficult to prescribe a series of nonsteroidal anti-inflammatory drugs (NSAIDs) until you find one that offers relief or dose a stronger and stronger analgesic until it dulls the pain.
That may look like success but what happens when one removes these medications, after potentially causing side effects, and the same patterns of repetitive microtrauma, inappropriate shoe gear and exacerbation of symptoms return? Does the patient go back on the meds? For how long?
Expanding a consultation visit to include evaluation for co-contributing and aggravating factors allows you to expand the recommendations you make to the patient beyond simple symptom relief. You now have the opportunity to recommend position altering foot orthoses or braces, appropriate shoe choices, stretching and strengthening, surgical realignments and a host of other outcome enhancing suggestions.
In doing this, you are now offering your patient so much more than just pain relief. This comprehensive, etiology-based approach to management sets the patient on a path to long-lasting changes that will alter the big picture as opposed to simply making acute pain go away for the short term. With long-lasting changes, the likelihood of recurrence of symptoms and progression of pathology is significantly reduced. You have to explain and teach at these moments, ensuring that the patient understands how this expanded approach to care will offer value-added, sustained benefits.
Needless to say, my campaign for comprehensive evaluation of patients, one that goes beyond targeting relief of symptoms as the only goal, benefits from a practice environment in which the economic model can support generous scheduling of appointment time. Insurance-based practices do not lend themselves easily to this model with their insatiable thirst for volume.
However, even in an insurance-based practice, the thorough evaluation that identifies a potential patient benefit offered by custom foot orthoses not covered by the insurer, for example, offers a golden opportunity for enhanced care and enhanced revenue.