The importance of asking the right questions (and getting those questions answered)
Today’s blog is inspired by a comment by Bruce Piner, AuD. We are all trying to be productive during this quarantine, so I have asked readers for suggestions. See Dr. Piner’s comments at the end of this blog.
Having a clear understanding of the complaint is crucial to accurate diagnosis and management in a patient complaining of dizziness and vertigo. Even with the most comprehensive test battery, a diagnosis is rarely definitive, but rather a “most likely” scenario based on history, symptoms and test results. Of all vestibular pathologies, only BPPV can be diagnosed with certainty without also knowing the patient’s symptoms.
While there is no medical complaint with more possible causes than dizziness and imbalance, the vast majority are related to only a handful of disorders.
Multiple reports, as well as our own clinic data, find that the conditions of BPPV, Orthostatic Hypotension, Vestibular Migraine, Meniere’s disease, Vestibular Neuritis/Labyrinthitis, and Peripheral Neuropathy account for over 80% of patients seen.
Our approach has been to identify these conditions quickly and efficiently, with the goal of having adequate time for frequently exhaustive interviews with patients with more unusual, complex, or multi-factorial issues.
Several years ago, I developed what I call the “Short Form Questionnaire.” It is the first thing I look at before I take a patient back to the test suite. The patient is asked to pick the description that BEST fits their symptoms. When I was in private practice in a more typical community ENT/Audiology setting, this form was about 70% predictive of final diagnosis. In the university medical center setting, with a schedule heavy with patients with unclear symptoms or atypical findings, it is about 60% predictive.
For example, the first item on the list reads “1. The room spins for less than one minute when, I lie down, roll over, or tilt my head back.” If the patient chooses this, I can focus on my questions on BPPV history and symptoms, rather than sit through the often-irrelevant responses you get when you ask the patient to “Tell me what brings you here today?” This is not a criticism of the patient. They do not know what information is diagnostically relevant. Their story will eventually reveal useful information, but it requires time and patience (both often in short supply) on the part of the examiner.
We are not the only people using these types of questionnaires to predict likely diagnosis. In 2015, a multi-site study was published describing a 32 question survey with a 78% predictive rate. In a specialty setting such as ENT/Audiology/Neurology, I would suggest using this survey. Our short form was intended for primary care settings where time of exam is more critical.
When a patient chooses “8. None of these describes my symptoms.”, we revert back to “Tell me what brings you here today.” I can definitely relate to Dr. Piner’s comment about demanding an answer to a direct question versus letting the patient meander. This is our cross to bear as vestibular specialists, but with experience, you can mange those meandering patients more effectively (usually). If the patient does not answer the question, I will wait for them to pause and interject, “The question I asked was …. and I did not hear an answer to that.” If that doesn’t work, I will say “I can’t really move forward until I get an answer to …. Can you focus your answer strictly to ….. ? Occasionally, you will run into a patient that just does not have the communication skills to provide helpful information, and you must rely on your tests to paint a diagnostic picture.
Here is an excerpt from a blog I did a few years ago tiled Guidelines for being a good patient:
Don’t try and self-diagnose. Simply describe your symptoms without being tempted to say, “I think this is what’s wrong.” If you trust your HCP, they will use their training to determine the problem. If you don’t trust them, find a new HCP. Ignore what you neighbor tells you.
Listen to the question your HCP is asking, and restrict your response to specifically answering the question asked. If he/ she asks “When did you first notice this?” Don’t answer, “A long time ago” or “as long as I can remember.” Be specific, and answer in a period of time such as 3 days, or 2 weeks, or 6 months.
We have the patient fill out not just the “Short Form Questionnaire”, but also a fall risk questionnaire, and a standard dizziness questionnaire. There is redundancy in several of the questions (worded differently), but we look for consistency across the three items.
Dr. Piner asks how much time we dedicate to the history. I would say as long as it takes, or until we determine the history interview is not going to be very helpful.
Comments by Bruce Piner, AuD
I’d like for you to blab a bit about the relative importance of taking the time to obtain an accurate and thorough history. If you have 1hr.&15 min. for a VNG (including head-thrust &/or V-hit (&c.) if needed ), how much time do you devote to the Hx? Sometimes I find it difficult to find a happy medium between 1. demanding an answer to my direct questions, and 2. allowing the patient to meander- which sometimes reveals crucial information. Do you always winnow the time a bit by requiring a prior questionnaire to be filled out?
50 to 60% of my VNG referrals these days have already been seen and questioned (and often Dix-Hallpiked) by an MD, so I often find key information from a very close and detailed history…which can be time consuming.
ALSO! The referring MD and the patient often appreciate my input re: a potential dx of Personal postural perceptual dizziness, vs. Mal de Debarquement, vs. SEE sick syndrome, vs. blah blah, etc., etc… and in order to tease out the differences of each of these, I find that a really good history is paramount!