The Need To Frame The Right Questions When Working With Complex Patients:
Complex cases without a known cause require a unique approach. The approach includes the essential skills of active listening, patient engagement and deep thinking together with collaborative or shared decision making.
What does not work with complex cases is the spot diagnosis. The expectation of an instant diagnosis and treatment plan is flawed. The inability to provide a quick answer is felt by some doctors to be a personal failure or personal lack of competence. This is not correct. The struggle to define the root cause of the problem and develop an actionable solution is challenging and takes time.
Resolving complex cases also requires a creative process starting with an openness during discovery and then allowing the solution to emerge. The solution building phase is emergent. It arises from a somewhat chaotic collection of facts driven by asking the right questions and being curious.
Dee Dee was about 42 years of age. She was from Vancouver. Dee Dee had been sick for about 2 years with a number of symptoms. She had a number of symptoms that were associated with auto-immune diseases. She had joint swelling and pain similar to Lupus. She had back pain similar to Ankylosing Spondylitis. She had dry eyes or iritis. She had large blisters which was similar to Pemphigus. She had the muscle aches of polymyositis. She had skin stiffening and skin thickening of Scleroderma.
The problem with confirming her diagnosis was that all her lab tests were negative or normal. This lead to “pass the buck” medicine. Dee Dee had seen 16 specialists over the course of 2 years. None of the specialists had collaborated. None of the specialists had engaged with Dee Dee or taken the time to think deeply about this case.
RCM Is Engaged By The Family:
The family retained Rupert Case Management to assist. Our team of case managers and nurses accessed all of Dee Dee’s medical records. We spent considerable time framing the right questions. We know that in these complex cases, the question is the answer. The key to this case was to be curious, ask the right questions and follow through.
A hunch lead to a simple google search with the key words: silicone breast implants and auto-immune diseases. Out popped the autoimmune/inflammatory syndrome induced by adjuvants (ASIA) and the location of the world authority who worked in Edmonton.
Dee Dee went to Edmonton. Dee Dee saw the expert who confirmed this to be ASIA plus acquired reactive perforating dermatosis (ARPD). It was a great step forward in defining the problem and organizing the solution which involved explanting the silicone breast implants which had triggered a granulomatous inflammatory response and the various auto-immune diseases.
The Lessons Learned:
Dee Dee’s case confirmed that Rupert Case Management’s approach is appropriate for very complex clients.
Complex cases require active listening, patient engagement, curiosity, deep thinking and the ability to ask the right questions.
All the facts have to be considered in formulating the right questions and allowing the answer to emerge.