You are asked to consult on a 55-year-old male referred by his primary care physician for a greater than six-month history of bilateral tinnitus. The primary care physician requested this consultation by personal phone call, indicating to you that the patient has become increasingly anxious about the tinnitus and has been pressuring the physician for a prompt resolution. You feel comfortable evaluating patients with tinnitus and accept the request for consultation.
Explore this issue:May 2015
On the day of his appointment, the patient presents himself to your office two hours before his appointment time and informs the front desk that he would like to be seen as soon as possible. Your staff reassure him that he will be seen as close to his appointed time as possible but that other patients have earlier scheduled appointments. He returns to the front desk several times with the same request. Finally, he is brought back to the intermediate waiting room for the initial screening and to have his vital signs checked. He complains about having his blood pressure and weight taken, because, he tells the staff, his trouble is with his ears, not his blood pressure or weight. The staff member is courteous and patient, reassuring him that this is important information for you to consider.
When you enter the examining room to introduce yourself and greet the patient, he jumps up from his seat, shakes your hand, and tells you, “You have to stop this ringing in my ears!” You realize that this will not be an easy consultation, so you take a seat and begin to elicit a pertinent history and review of systems from the patient. The patient indicates that the onset of the tinnitus occurred gradually months ago but without any known inciting event. You learn that the patient is an automobile insurance salesman, which he claims is a very stressful job, subject to onerous oversight and unrealistic sales target expectations. He has been divorced for three years and has no children. The patient also relates a long history of insomnia, vague muscle aches, and a neurodermatitis being treated by a dermatologist with a topical preparation. He takes only a multiple vitamin and the occasional medication for sleep. He denies any head trauma, recurrent ear infections, exposure to loud noises, or Eustachian tube blockage. His last physical examination, according to the primary physician’s medical records, was essentially normal.
You perform a complete head and neck examination, including nasopharyngeal endoscopy and a basic neurological examination. You find no evidence of any contributing pathology in your examination. Having re-reviewed the American Academy of Otolaryngology-Head and Neck Surgery’s clinical practice guidelines for tinnitus the day before seeing the patient, you begin to formulate a diagnostic plan (Otolaryngol Head Neck Surg. 2014;151(2 suppl):S1-S40). You tell the patient that the next step should be a prompt audiologic examination, conducted right away in your office. He agrees to this, and your audiologist personally escorts him to the sound booth.
Thirty minutes later, the audiologist steps into your office, closes the door, and tells you that there were no pathologies found on the complete audiologic examination, including special studies. But, as an experienced audiologist, she found the patient’s demeanor and behavior unusual. You discuss this with her for a short time, then return to the examination room to review the negative findings with the patient. You explain to the patient that at this point in time you would characterize his tinnitus as primary (idiopathic and not apparently associated with a sensorineural hearing loss), persistent (because it has lasted longer than six months), and bothersome (because it distresses the patient).
The patient requests a magnetic resonance (MR) imaging study, which he says was recommended for tinnitus by “experts” on the Internet. You try to explain to him that in the absence of any localizing neurological signs or symptoms, pulsatile tinnitus, or asymmetric hearing loss, an MR scan is not recommended by clinical guidelines. He further requests that “some medication be placed in my inner ear through the eardrum,” which he also gleaned from Internet searches. Again, you cite the recommendation of the guidelines against intra-tympanic medications in patients with persistent, bothersome tinnitus. The patient, obviously distressed and anxious, accuses you of “writing him off.”
Realizing that this patient’s reaction to his tinnitus is more exaggerated than the primary care physician presented to you, you begin to educate him, in a calm and empathetic manner, on the latest information regarding persistent, bothersome tinnitus and some management strategies that you would like to suggest to him. You also inform him about cognitive behavioral therapy for tinnitus and a possible trial of sound therapy. This extended discussion seems to calm him, and you send him home with some pamphlets regarding these potential therapies, asking him to return in one week for a second discussion. As he is making the return appointment, your billing clerk requests his insurance co-payment, and he refuses, stating, “He did nothing for me, so I am not going to pay until he does.”
The Return Appointment
The patient calls the office the very next morning, urgently requesting an appointment. You happen to be in the operating room that day, not in the office, and your receptionist offers him a 1:00 p.m. appointment for the next day you are seeing patients in the office; however, the patient presents himself to your office at 8:00 a.m. on your surgical day and demands that you see him in between surgical procedures. When the staff inform him that will not be possible, he becomes belligerent and verbally abuses the staff, who politely attempt to help him. He remains in the office waiting room for an additional two hours, grousing about your office to the other patients and repeatedly bothering the staff. Finally, he leaves.
He does show up for the next day’s appointment, but he is late and states he needs to be seen immediately. Before accommodating his request, the staff again ask him to provide the co-pay for the previous visit, which he refuses to do. He continues to verbally abuse the staff in front of other patients and rather loudly before he is escorted into an examination room. When you enter to greet him, he refuses to shake your hand and confronts you with the statement that you are not a competent physician and that he should report you to the state medical board for not further evaluating his tinnitus and for trying to make him pay for no treatment. While you are calmly listening to his tirade, he is pacing the floor in the examination room, all the while shouting intermittent profanities as you attempt to better understand the underlying issues that are so bothersome to him. Finally, he rushes out of the room, informing you that “he will be back tomorrow and he expects his problem to be taken care of completely.”