Why isn't this discussed more? Why isn't there an entire AAN journal dedicated to this? Many days I see more functional patients/consults than "normal" patients. I'm becoming more and more cynical, I almost assume each patient is functional before meeting them.
These patients are ticking time bombs for the clinician. It's drilled into us about appropriate use of testing/imaging but where do you even begin with their ridiculous amount of symptoms? Of course the correct answer is to order as little testing as possible but all it takes is one of these crazy patients with 100 poorly localizable symptoms with one real underlying symptom/finding which can easily be missed to sue you and jeopardize your career.
And the idea that you should be "open" with these patients and have a frank discussion almost NEVER goes over well. 95% of the functional patients automatically become defensive and get upset no matter the amount of reasoning.
Just need to vent.
It is AWESOME that the conversation doesn’t go well. This is because you are being honest. If you’re honest, then most will hate you. It is the marker of a good doctor.
At the same time, however, you’ll get better at this. My last few actually thanked me because I showed them that they could move their weak arm the less they concentrate on it. They considered themselves healed by me just doing some nonsense distraction.
Couple of other pearls:
1. Never assume functional disorder. I know, it’s hard, but this is a sign of your burnout and you can’t project that on the patients. You fail to treat someone clearly having conversion with tPA, then they have + MRI for stroke, Better Call Saul. DItto with pseudoseizures. I’d also advise that you keep the door open to neurologic disease. You’re going to be right in 90% of cases, so that leaves 1 in 10 where you’re wrong. I’ve given tPA to at least half dozen to a dozen conversion cases and many where I honestly couldn’t tell. Even in retrospect would do the same with each case. That said, it is always right to consider FND when appropriate and the sooner you disclose this in the diagnostic process the better. That way you can say, “as we discussed last time, when I told you the brain sometimes gets in it’s own way, that appears to be the case.” Get your own style and use it.
2. Check yourself. If you are getting frustrated, then there’s a good reason for it. You’re burned out, upset, angry. All these things are normal, but they aren’t helpful. Just be open and caring and nice. Many patients are actually looking at you to be dismissive. The line between FND with ZERO insight and some malingering with a bit of insight is impossible to see, but their anger and their close observation for any signs that the doctor is dismissing their symptoms offers some hints. Don’t give them that thread to pull on.
3. As has been said, there is something wrong with these people. Consider them as volitional disorders that get at the illusion of “normal” volition, along with Torette’s and alien limb. THe brain is a big place, and something is getting in the way of their conscious volitional motor/sensory functions. So we don’t know what’s wrong with these folks and as such, treating them like they have a fake disease is not a good solution. This is hard, because as we all know, these cases have horrible overlap with all sorts of personality disorders and psychiatric problems. Real hornet’s nest. If they respond poorly, that’s on them, and as
@DrSatan mentioned above, fire them for any behavior that’s threatening or upsetting to you.
4. I firmly believe that the only way to get better from FND is for the patient to accept it and move from there into some sort of therpeutic relationship with PT and counseling. By offering them a clear and crisp diagnosis, you’re literally offering them lifesaving therapy and steering them away from absolutely horrific garbage: from the worst sorts of quackery to surgeries. Be proud of that.
