11 February, 2015
Here’s a story about how being honest about not knowing can lead to better patient care.
Medicine has a long past of thinking it knows best. Looking at medical history and changes in care guidelines you can look back and laugh. Yet over and over I see providers negate the worries of the parent and scoff at home care remedies. When will we start being honest with our patients about the fact that we don’t know everything?
I saw a 15 month old for her well child check at a community health center where I am currently doing my NP residency. Her mother reported that since birth one of her eyes was different than the other. Recently she noticed that when the child opens her mouth wide or is chewing, one of her eyelids moves synchronously with her jaw. There were no other asymmetries noticed in her face with cry or with smiling. She was developing normally and she had no concerns about her vision. Her mom just wanted to know why that happened and make sure it wasn’t anything dangerous. On exam she had very subtle ptosis of one eye that I wouldn’t have noticed otherwise. The rest of her exam was normal.
We get plenty of strange complaints in primary care. Sometimes it’s about funny noises the child makes, the posture when they walk, small anatomical differences the parent notices. Mostly we reassure the parent letting them know it is likely a normal variant and to let us know if it is interrupting any part of their daily activities. While that answer is absolutely valid, what would happen if we said, “huh, I don’t know why that is. Let me look into it and see if I can find any information in the medical literature.”
There was nothing leading us to think that there was anything pathological going on with this patient. I knew that the trigeminal nerve innervates both areas of the face and theoretically and issue with that nerve could have something to do with it. I looked in some books quickly, found nothing and my preceptor reassured her that it was likely a normal variant and that it would only be concerning if it was acute, affecting her vision, or if she noticed asymmetry of the face. I told the mom I would consult with my other residency preceptor in Neurology and let her know if I find anything.
The best part about taking this approach with your patient is that you get to learn new things too! After consulting with my NP preceptor in Neurology, she recommended we refer to ophthalmology in case there was an issue with the patient’s vision that was causing her to wink as a compensatory measure. I doubted that cause and told my preceptor back in Primary Care. She also doubted this was compensatory, but said we could offer the referral. Before making the call to the patient I did a thorough search of the Internet using a combination of different key words related to her case. BINGO! Marcus Gunn Jaw Winking Syndrome!!
Even if there was no identifiable diagnosis, I think that taking your patient’s concerns seriously and investigating them as you would your own, can lead to better care. Maybe there’s something out there that you’ve never heard about before.
That patient is definitely going to Ophthalmology now, and we all learned something new!