Managing unsuccessful cases

I wanted to share an example of managing an unsuccessful case since no one is successful with every patient:

 A 74 year old female diagnosed with chronic spinal nerve degeneration – a condition similar in some ways to ALS. I told this patient during the initial intake that since her symptoms of marked muscle weakness was so consistent and had been steadily worsening, the chance of her having noticeable improvement was less than 50/50 but we may be able to slow the rate of degeneration. This is what I advise to do in these cases in my chapter on estimating the odds of success.  We tried 10 treatments over 6 weeks in which I tried two different treatment techniques with no noticeable improvement (but little if any worsening).

I asked her to return for one more treatment and we would discuss where we go from there. She came-in today and I explained that I wanted to do this last treatment, a variation off my first treatment approach, and see what happens. If she was to notice any improvement over the next few days, that means it finally began to take-hold and she should come back for more treatment – otherwise we could stop now. I let her know that sometimes when the treatment did not cause any noticeable improvement and I stop a treatment process, I will hear back from the patient some weeks later telling me that they noticed their symptoms were getting worse at a faster rate so they realized the treatments were slowing the rate of degeneration quite a bit and they want to return for more treatment. This is always uncomfortable for me because it means I was helping the patient but I don’t ever want to see them do worse to find that out.

I told this patient that I did not want to charge her for this last (11^th) treatment but she insisted that she wanted to pay and was quite grateful for how I tried to help her and explained every step of the process. I am pretty sure she will refer others too me if the opportunity for this should arise.

 I don’t report all this to you as a way of saying how great I am at managing difficult cases because failures like this bother the heck out of me and I will have some trouble sleeping tonight. This is just the about the best you can do to manage your inevitable failures.

One little bright spot – my very next patient today was one that had not been responding so well (chronic neck pain with years of congestion in the ears) after 6 treatments. I had switched the treatment approach (went to plan “B”) after the 4^th treatment and she reported that the last treatment started to unclog her ears and they were staying that way. This is a very good sign and shows how you win some and lose some (but I will still lose some sleep tonight).

Matthew Bauer