The Need for Balance Centers

The first chapter and the first topic we will cover is the current state of vestibular management available to most patients. We have the ability to diagnose and effectively treat most causes of dizziness. It is not a matter of “Can we help?”, but more a matter of getting the right patients to the right specialists. The vast majority of dizzy patients never make it as far as a vestibular clinic, even though epidemiologic studies have shown that more than half of dizzy complaints are the result of a vestibular disorder. The most important thing we, as Audiologists, can do to help dizzy patients is to educate primary care doctors about our abilities.

It is important to understand the primary care approach. Most Primary Care Physicians (PCP) will admit that they are, to a degree, educated gamblers. Most PCPs do not have the facilities and/or training to accurately diagnose everything that walks into their office. When a patient complains of something, the PCP thinks, “Well, usually that symptom is a result of this, so we will treat you for this.” Since a good PCP, well trained in epidemiology and symptomology, is usually right, the patient improves and no further evaluation is needed. So what about the patient that has something unusual, or doesn’t wish to “wait it out”? For the dizzy patient, that is where we come in.

I have found that the best way to build my practice has been to actively educate the local PCPs. That is how the “Short Course” booklet came to be. When I first started this, there was no one in the region doing rotary testing, posturography, or canalith repositioning. There was a lot of skepticism by the PCPs, not to mention outright hostility and disparagement from some local ENT docs. Imagine this scenario: Most PCPs were unfamiliar with BPPV, none had even   heard of Canalith Repositioning. They have seen these patients for years complaining of positional vertigo, treating them with Antivert, and seeing that most took several weeks to recover. Here I am, telling them that I can perform the Dix-Hallpike test, perform Canalith repositioning when appropriate, and that over 90% will be better by the next day. What they are hearing is this young (at the time) former Yankee, with a funny Boston accent, telling them that I will put their patient in a headlock, slam them down on a table, twist their head around, sit them up, and they will cured. No surprise, it took a few years to convince them that they could trust me with their patients.

In order to deal with and overcome this skepticism, you must fully understand the historical approach to the dizzy patient at the primary care level. I have included an abstract of an article by Dr. Phillip Sloane. He is a PCP at UNC Chapel Hill. He has written extensively on the PCP approach to dizziness. I have to say, I don’t agree with some of the primary care practices. I would recommend you read the original article, and get a feel for his perspective. Here is the abstract and identifying information:
J Am Board Fam Pract. 1994 Jan-Feb;7(1):1-8.
Related Articles.
 Management of dizziness in primary care.
Sloane PD, Dallara J, Roach C, Bailey KE, Mitchell M, McNutt R.
Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill 27514-7595.

BACKGROUND: We sought to determine the types of dizziness problems that are commonly seen in primary care practices, and to bring to light clinical and demographic factors that predict management decisions. METHODS: We undertook a prospective cohort study with a 6-month follow-up using data gathered in nine primary care practices in two North Carolina counties. Subjects were 144 dizziness patients examined by primary care physicians. Data collected included demographic characteristics, a standardized dizziness history, physician estimation of symptom severity and diagnostic certainty, and physician “worry” about arrhythmia, transient ischemic attack, and brain tumor. Physicians reported their management decisions and diagnosis (or differential diagnosis) by responding to a questionnaire after completing the patient encounter. A 6-month follow-up chart review and physician interview were completed on 140 patients (97.2 percent); information obtained included changes in diagnosis and patient mortality. RESULTS: The most common diagnoses were labyrinthitis, otitis media, benign positional vertigo, unspecified presyncope, sinusitis, and transient ischemic attack. The initial diagnosis changed during the 6-month follow-up period in 34 (24.3 percent) of patients. The overall course of these patients was benign, however, with only one death occurring during the 6-month follow-up period. Patients’ dizziness tended to be managed using a combination of strategies, including office laboratory testing (33.6 percent), advanced testing (11.4 percent), referral to a specialist (9.3 percent), medication (61.3 percent), observation (71.8 percent), reassurance (41.6 percent), and behavioral recommendations (15.0 percent). Office laboratory testing was associated with younger patient age, a suspected metabolic or endocrine disorder, and physician worry about a cardiac arrhythmia; advanced laboratory testing was associated with suspected cardiovascular or neurologic disorders. Medication tended to be prescribed for vertigo and severe symptoms and avoided when physicians were worried about a cardiac arrhythmia. Referral to a specialist was associated with suspected neurologic disease. Observation, behavior change, and reassurance were avoided in patients with poorly defined dizziness and tended to be used in older patients. The management approaches employed by the 4 physicians who referred the most subjects to the study varied considerably. CONCLUSIONS: Dizziness in primary care represents an extremely broad spectrum of diagnoses. The generally conservative management approach of primary care physicians in this study is consistent with basic clinical and epidemiologic principles, and patient mortality with this approach is low.

PMID: 8135132 [PubMed - indexed for MEDLINE]