Tinnitus highlights poor doctor patient communication

I’m both interested in and disturbed by what some doctors have said to patients at the first consultation for tinnitus,  an annoying perception of sound that comes from somewhere within their heads.  Not many of these patients are referred to me – most come of their own accord for a second opinion.  What they tell me their doctor said is a lesson in how not to communicate with patients, and I think worth repeating here.

The most common doctor diagnosis, treatment and reassurance is a curt, “You’ve got tinnitus, and there’s nothing you or we can do.  Learn to live with it.”

Few patients can be more anxious.  For most, tinnitus is a minor annoyance, no cause for concern, not due to any serious illness, and simple reassurance is all that is needed.  The unfortunate other end of the scale is the tinnitus sufferer tormented by the incessant buzzing in his or her head, and whose life becomes consumed by efforts to escape the distraction.  Helping these patients is a real challenge, some driven as far as suicide.

At first glance certainly the first and last parts of the doctor’s statement are true. The middle is a common and mistaken assumption by many doctors, perhaps a bit of medical ignorance, but hardly negligent.  Or is it?  Overall, I’m disturbed by the callousness of this dismissal, for the following reasons.

Tinnitus is a symptom, not a disease.  The original statement is analogous to saying “You’ve got a backache.” Putting only a name to a symptom is a start, but not very helpful in the long term.

The possibility that tinnitus is due to a disease process is ignored.  Tinnitus may be pulsatile or continuous.  If in time with a patient’s heartbeat, (i.e. pulsatile), there is a reasonable possibility of some disturbance in vascular flow in the neck, skull or brain, varying from as minor a problem as a small and insignificant kink in the normal internal carotid artery due to minor arteriosclerosis, to major challenges like vascular tumors filling large areas of the head and brain. Pulsatile tinnitus should be investigated, by careful clinical examination and usually an MRI angiogram.

Continuous tinnitus is often described as “buzzing, like the sea, or crickets” may be due to an abnormality anywhere in the hearing system.  It can be something as minor as wax in the ear canal.  Or as major as a tumor of the vestibulocochlear nerve – an acoustic neuroma. The commonest cause is going to be a degree of nerve deafness due to common everyday wear and tear.  But a diagnosis still needs to be made.  The statement closes the door on the possibility of diagnosing and removing the cause, and risks missing serious pathology.

“There’s nothing you or we can do.”  I guess what the doctor means is, “There’s no medication shown to reduce tinnitus,” which at this point in time is generally true.  Intravenous lidocaine has been shown to be effective in the very short term, but is very toxic and impractical in any form for tinnitus sufferers. There are other medications thought to have some benefit, but results of studies are variable.  Unfortunately for tinnitus there is no magic bullet. But “we cannot write a prescription” should be very distinct from “there’s nothing you can do.”

There is a lot a doctor can do for a sufferer, given a basic understanding of tinnitus, and a diagnosis is a good place to start.

First, for idiopathic or sensorineural hearing loss-related tinnitus, the exclusion of serious pathology is very helpful for the anxious patient – an MRI scan of the brain has a good therapeutic effect in offering reassurance.  In my opinion, the worst sufferers have little chance of overcoming tinnitus until an MRI scan convinces them there is no tumor inside their heads.  Second, an explanation as to why tinnitus is there in the first place is essential, i.e. “sound perception due to nerve activity within the brain, which is usually not heard by the conscious brain, but which becomes heard due to other abnormalities” or, in other words, a “raising of sensitivity to natural brain ‘sound’, which is not usually heard.”

The majority of patients are happy with just an explanation, especially when they realize that if they focus attention on the tinnitus, it will naturally become louder.  Advice to “learn to ignore tinnitus” is very different to “learn to live with it.”

The latter advice is impossible to follow without a basic understanding of why the tinnitus is there, and why distraction techniques are so important in learning to ignore it.  The patients have to be given the tools to “learn to live with it” – on its own that advice is as meaningless as is “learn to read” to someone who is illiterate.

Those seriously affected by tinnitus may find wearing hearing aids or tinnitus maskers – hearing-aid like fittings that mask the tinnitus sound with another – very useful.  Some may need antidepressants to deal with the associated comorbidities.

And there are conditioning and behavior modification therapies specifically designed to treat tinnitus – tinnitus can and should be cured by, among others, audiologists and other professionals who are specially trained to deal with difficult cases.

The majority of my patients need little more than a history, quick physical examination, a hearing test, an MRI scan in selected cases, and then twenty minutes of detailed explanation and communication.  But omit the explanation, and all the rest is money and effort wasted, with little chance of cure.

I was taught to make my goal in medicine application of the three important principles – to do no harm, sometimes heal, and comfort always.

Saying, “You’ve got tinnitus, and there’s nothing you or we can do.  Learn to live with it,” is a poor five second substitute for a thirty minute communication.

Martin Young is an otolaryngologist and founder and CEO of ConsentCare.

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  • justin

    I agree. Let’s get an MRI for everyone with tinnitus. I’ll take two.

    • http://thedocsquawk.com thedocsquawk

      One for the left and one for the right?

    • MarylandMD

      If we screen everyone with a brain MRI before they get tinnitus, would that be primary prevention?

      • r watkins

        Only if done three times per year.

  • jsmithfan

    This is ridiculous. A perfect example of what is wrong with American health care. I agree that better communication and empathy is needed in these situations. But to suggest that most tinnitus sufferers need an MRI/MRA is akin to suggesting every person with a headache needs a CT/MRI or every person with chest pain warrants a CT coronary angiogram.

  • MarylandMD

    Therapeutic MRI. Interesting new concept developed by ENTs. I guess that’s the route you go if you don’t have the ability to explain clearly that the symptoms and clinical exam do not suggest any kind of brain tumor and an MRI isn’t warranted. But it’s kind of ironic that the author is bemoaning “poor doctor patient communication” then punts and orders an MRI/MRA when the going gets tough. Or perhaps ENTs need a spine transplant to accompany their excellent doctor patient communication skills?

  • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

    jsmithfan,
    There is nothing wrong with MRI’s. In certain cases, they can make both the doctor and the patient feel that nothing has been missed. If third party payers were not so involved with outpatient care, it also wouldn’t be an issue – because it would be the patient paying for it. THAT is what’s actually wrong with modern American health care – not doctor’s decision-making.

  • http://www.drmartinyoung.com Martin Young

    Dear MarylandMD

    I’m certainly not advocating an MRI for everyone with tinnitus, but I am saying that it is very useful for those who find tinnitus interfering with their quality of life, and who need further intervention like tinnitus retraining therapy, because it gives the assurance that there is no other pathology and allows the patient and therapist to move on. And some of those patients scanned will have an acoustic neuroma..

    I’ve seen acoustic neuromas present in all kinds of ways, and I can say with confidence that a normal clinical examination does not exclude the diagnosis – except for the massive ones, clinical examination often is normal. Neither does a normal audiogram mean there is no acoustic neuroma. So clinical suspicion is enough – I order MRI’s on about 10% of people who present with tinnitus, and they either have a unilateral nerve deafness or are very anxious and find their quality of life is hampered by the tinnitus.

    I also don’t think it is the primary care physician’s responsibility to investigate tinnitus, but it is to refer the patient to someone who knows enough about it – usually an ENT, audiologist or a neurologist.

    Donald Rumsfeld suggested that the most dangerous things are “what we don’t know we don’t know” and you seem to fall into that category. And if you are not a specialist I can’t find fault with that, but I think doctors should be open to reexamining their own assumptions that may be wrong.

    Your last statements suggest a doctor is ‘brave’ when he/she holds back on ordering investigations. Where is the ‘bravery’ in being cavalier with other peoples’ health and lives? That’s just bizarre.

    • MarylandMD

      What’s bizarre is you creating a false choice: Either you do an MRI even when there is no suggestion of an acoustic neuroma, or you are “being cavalier with other peoples’ heath and lives”. That type of logic applied liberally in health care creates a slippery slope which will quickly get you into overtesting, which can truly cause harm. If you don’t think the MRI is indicated, don’t do it and explain to the patient clearly why the test isn’t indicated and stick to your guns. If you think it is indicated, then do it.

      And if you say you can’t rule out acoustic neuroma with your exam, history, and other testing, then you are, in fact, advocating MRI for everyone with tinnitus. Do only your “worried” patients get the MRIs? Are you being “cavalier with the health and lives” of those who do not worry or have severe symptoms and thus do not get the MRIs?

  • http://www.whooshers.com WhooshEr

    On behalf of pulsatile tinnitus sufferers, thank you so much for writing this article, especially for distinguishing between non-pulsatile and pulsatile tinnitus. All tinnitus sufferers deserve compassionate care, but when pulsatile tinnitus sufferers don’t receive it, it could very well lead to dangerous consequences. And to make things more complicated, the list of possible underlying causes of pulsatile tinnitus is quite long and crosses medical specialties. Each of us is different, so we need very specialized care. To pulsatile tinnitus sufferers looking for support through this journey, please see http://www.whooshers.com. You’re not alone. Thanks

  • Patrick MD

    @ Martin Young, MBChB, FCS(SA)
    You are quoting in your article, ““There’s nothing you or we can do.” I guess what the doctor means is, “There’s no medication shown to reduce tinnitus,””…and…, “”Saying, “You’ve got tinnitus, and there’s nothing you or we can do. Learn to live with it,” is a poor five second substitute for a thirty minute communication.”"

    My question is, did you hear the doctor say this or is this what the patient told you the doctor said (i.e. hearsay)? As a physician, you do realize that what a physician says to a patient is not necessarily what they hear and then relay to others later, right?

    Then you go on to say, “I’m both interested in and disturbed by what some doctors have said to patients at the first consultation for tinnitus…”

    I am disturbed by the assumptions you make about us on the primary care front. I certainly don’t talk to patients in the manner you have portrayed.

    • Stephanie

      I am sure all doctors are different, as they are people, but my husband returned from Iraq with tinnitus and was told just that by his doctor. “Sounds like tinnitus. It’s not serious and there is nothing that can be done.” In his case, he does have hearing loss and there probably isn’t anything that can be done about it.

  • http://www.drmartinyoung.com Martin Young

    Dear Patrick MD

    Please note I said ‘some’ doctors, and that clearly means ‘not all.’ It does not say ‘most’ – I could argue that ‘some’ refers to a very small fraction. I trust MD readers will recognize which group with regard to tinnitus they fall into.

    I agree patients understand and relay only a small amount of what doctors say, but this tinnitus ‘advice’ has been a recurring theme both in my practice (not in the USA, BTW) – and when I have worked in other countries, and I assume one of two possibilities – either the doctor(s) does not know, and is passing on the popular but incorrect belief, or does not have either the time or energy to pass on the information properly.

    If you read the tinnitus support websites, you will see a very similar message – and I found that out after I had written and submitted this post.

    Few other conditions depend so strongly on good communication for treatment, and tinnitus is therefore a great example to use.

    As a former PCP for 10 years I understand the issues and difficulties – they are global, common to all healthcare systems. But I welcome moves to correct misinformation, or to draw attention to dangerous or unsound practices, and try to do the same, as in this example. This is a great forum to make a contribution.

    When someone says something like “doctors are more interested in money” or “doctors overservice patients” you can be sure they have their own valid reasons for saying it, based on their own experiences. And there are some doctors like that. Not the rule, but the exception fortunately.

    I really think we should be able to look at our profession objectively, point out the problems and pitfalls, and try to address them as a collective internal effort. The alternative is that someone else outside medicine does that for us – they are already trying. And we don’t like it one little bit.

    Do we try to change things internally, or rely on external pressure? Those are the only alternatives we are given.

  • Michael Eliastam

    Your article brought back painful memories that never reaally go away.Before her suicide, my mother suffered from debilitating tinnitus, in Johannesburg, and got little to no empathy never mind real help from her many doctors there. Medical Schools in the western world (I have little knowledge about the effectiveness in these cases of non-western medical care) seem to not be able to train doctors to support such patients when the diagnostic and therapeutic options are limited.
    BTW, it is nice to see a Witsie advocating for this kind of patient.
    Be well
    Wits Class of 66.

    • http://www.drmartinyoung.com Martin Young

      Thanks, Michael!

      UCT actually, but no offence taken :)

  • Bill Tucker

    A lot of hand wringing about ordering an MRI. How many of us in Primary Care and Neurology have ordered needless brain MRI’s and MRA’s on HA Pt’s…when we know full well it’s truly not indicated. Or CXR’s for that matter. Truth is we, health care providers and patients, have a hard time living with uncertainty…simple as that.

  • Kim

    I found this very interesting, as I have tinnitus, a side effect of my Meniere’s disease. I’ve been to a few ENTs who have thankfully taken the time to really investigate and confirm my Meniere’s diagnosis; I’ve grown accustomed to a hearing test and an MRI (I was diagnosed very young, so my case is an outlier worth investigating).

    That said, I value the time that my first ENT spent suggesting things that could potentially aggravate my Meniere’s and/or tinnitus (his theory was that the more fluid my body retained, the more severe my symptoms would be, but that was 10 years ago, so excuse me if the consensus in medical literature has evolved). A simple change in my diet, to restrict sodium and caffeine, has done wonders. It’s been years since my last Meniere’s attack, and my tinnitus is only occasionally bothersome.

    My current ENT keeps me in mind for trials, which is all I can ask for if there’s no current treatment out there. Right?

    Both ENTs have done their due diligence, as there’s limited uncertainty with my diagnosis and prognosis, and I’m a content patient.

  • T.Guido

    I have had tinnitus for over 25 yrs.I have noticed that over the years the tinnitus gets louder and louder.It’s also more constant. I was told the same as most,Yes you have it and no we can’t help you.Mine comes from working construction all my life and loud music, loud machinery.Most day’s of the week, I have a headache from the buzzing in my ear’s.

  • Fran

    In a similar vein, my Mother has auditory (musical) halucinations in which she hears songs in her head, to the point that it becomes annoying.. It wakes her from a sound sleep at times. She mentions it to her docs & some have no clue as to what she is talking about. Others are aware but don’t know what or who to recommend for her. Anyone have any suggestions?

    • http://www.drmartinyoung.com Martin Young

      Fran, this is something completely different from tinnitus. What you describe would seem to be either a hallucination or persistent thought of some sort. The causes thereof range from psychiatric illness, medications, through to temporal lobe epilepsy. And in some cases there is no pathology. Some songs get stuck in my head for weeks at a time as well….

      It;’s worth investigating if not already done so by your PCP, but she may be told she is completely healthy at the end of it!

      Good luck!