Practice dilemma - When consultant opinions conflict

The Dilemma - You see a 39-year-old woman with migraine that does not settle on conventional treatment.

Explain that the link between PFO and migraine is not clear (Photograph: SPL)
Explain that the link between PFO and migraine is not clear (Photograph: SPL)

She happens to have private medical insurance. On full examination, you notice that she has a subtle heart murmur and wonder whether she has a patent foramen ovale (PFO), thought to be associated with migraine. You arrange a neurological referral and organise for her to see a cardiologist. The cardiologist feels she should undergo PFO closure, whereas her neurologist is vehemently opposed, saying that neurologists do not believe such a procedure will resolve her migraines. The patient comes to you angry with the situation and confused about whether she should have the procedure. What should you do?

A GP's response
Dr Zara Aziz is a GP in Bristol

The dilemma here is that the patient has been given conflicting advice for the same problem but from two different perspectives. I would like her to know that PFO is present in about 25 per cent of the general population and is asymptomatic in most cases. The physiological mechanism of how the condition may be linked to migraine is not understood.

PFO can be closed using an endovascular procedure, as suggested by the cardiologist, but the evidence for this in the prevention of migraine remains inconclusive. The patient should be made aware of the uncertain efficacy of the procedure and the possibility of any complications that could arise from it.

There is a small incidence of serious adverse events caused by closure of PFO. I would like the patient to have access to written information about what the procedure would entail. NICE has recommended that patient selection for PFO closure to relieve migraine should be carried out jointly by a neurologist and a cardiologist. The procedure should only be carried out in specialist units and the results should be audited.

I would be interested to hear the neurologist's advice on managing her migraines through other means. The two specialists are not in agreement so it may be that a second opinion has to be sought from both specialties. The patient's best interests should be paramount and information should be presented to her clearly so that she can make an informed decision.

It is very likely she will need time to think and a follow-up consultation should be arranged to discuss any unresolved issues.

A medico-legal view
Jim Rodger is head of professional services with the UK-wide Medical and Dental Defence Union of Scotland (MDDUS)

You have a difficult situation with an irate patient and no wonder. The patient has a problem, for which she seeks help, and there may be an effective treatment. The matter here is one of informed consent.

The patient has been offered a surgical intervention and to consent to go ahead with that, she needs clear and understandable information on which to base her decision. You might try to find more information about the condition and its relationship to the migraine, an area which may be unfamiliar to most GPs.

At the same time, you might share this increased knowledge with the patient or point her in the direction of helpful reading material. She should be in a position to understand the difference in the consultants' opinions and why they might hold these views.

You could also agree to seek other opinions; because her private insurance will not agree to multiple opinions, this could be done at modest cost to her.

She might also be able to secure another opinion from within the NHS. The condition does not indicate great urgency and there would be time for you to gather more views.

You might write to each of the consultants to indicate that their disagreement has affected the patient's trust and seek some form of compromise, so that the patient can come to an informed decision about her treatment.

A patient's opinion
Jacqui Storer is an expert patient

The patient is, in part, the architect of the situation, in that she is seeking an alternative route to the conventional approach. The referrals sought have resulted in conflicting advice.

The patient must be assured that every possible avenue is being explored, with her well-being and opinions given full consideration. Her anger is justifiable because she feels vulnerable and not in control of her situation because she is receiving conflicting opinions, in addition to being unwell.

Dialogue with, and explanations from, both consultants about why their views conflict are needed. The patient also needs reassurance in the form of accepted facts and the reasoning behind the respective opinions. This may help to alleviate her anxiety, confusion and anger.

The patient is searching for a resolution of her condition in an unconventional way, so she must be made aware that this cannot be achieved without first considering the positives and negatives of the procedure. She needs to feel that she is in charge of her own health. Her dilemma must be resolved in a balanced and sensitive manner, and she should be given the opportunity for meaningful discussion.

The options need to be evaluated by all parties with evidence-based explanations, from which the patient will be able to come to a rational decision. Time must be allocated to enable her to feel involved in any judgments made on her behalf.

What is now needed is the provision of complete reassurance for the patient and the demonstration of respect for her opinions. Meaningful dialogue will help guide her to an acceptable outcome with compassion and dignity.

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