The obvious exception to the logic of my argument in a post several weeks ago is the patient with BPPV or acute vertigo. Li, Li, Epley and Weinberg{{1}}[[1]].Li, J. C., Li, J.C., Epley, J., & Weinberg, L. (2000). Cost-effective management of benign positional vertigo using canalith repositioning. Otolaryngol Head Neck Surg, 122(3), 334–33)[[1]] report that in their study of patients with confirmed BPPV, nearly all were given Meclizine as the treatment, and that each patient saw (on average) 4 doctors about their dizziness before they got a correct diagnosis. Of course, this is horrifying when you know how prevalent and easy to treat BPPV really is.
I read an article in a Family Practice journal a few years ago (don’t remember exactly which journal) that recommended that PCPs treat BPPV with meclizine and observe for 30 days. If the symptoms persist, then send the patient to a specialist for repositioning. That started me thinking about how patients think.
“What would the patient want if you presented the facts (as we know them)?”
The Facts:
- BPPV is a benign inner ear condition.
- It will likely improve on its own with no treatment.
- The average duration of untreated BPPV is over one month (some studies say 2-3 months).
- A trained specialist can probably resolve it immediately.
“What do you want to do?”
We went back to the last 50 CRP (Canalith Repositioning Procedure) patients and asked them, “Knowing what you know now–the cause of your dizziness, the testing, the treatment, the cost, the time involved–would you return immediately for treatment or wait it out if your symptoms returned?” Only one patient said they would wait it out. The other 49 said they “would definitely return immediately.” Clearly, patients with BPPV would prefer immediate referral as opposed to the AAFP recommendation. You can bet I share this information with PCPs.
We also see any patient referred for acute vertigo on an emergency basis. When we get a referral for acute vertigo, we ask the referring physician how long the patient has had acute vertigo. If the answer is “less than a week”, we have the patient sent right over. If someone has acute vertigo for more than a week, the likelihood is that the cause is not peripheral vestibular, or the referring physican has a different understanding of “acute” than we do.
Bottom line, devote your practice building efforts to educating the local PCPs, produce good results, and you will have no trouble staying busy.
