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December 10, 2020

Consultative Medicine Clinic — The front door for adult patients with complex & serious illnesses

By Advancing the Science contributor

Every day the door to the Division of General Internal Medicine’s Consultative Medicine Clinic at Mayo Clinic in Rochester opens, and patients from around the country with complex and serious illnesses enter. More than 8,000 of them per year are seen for unexplained masses and weight loss, undiagnosed rheumatologic and neurologic disorders, and medical mysteries that have been unsatisfactorily explored at other medical centers. Comparable clinics at Mayo Clinic in Arizona and Florida see 1,780 and 3,100 patients annually, respectively.

Disease detectives are on the case: Physicians in the Mayo Clinic Consultative Medicine Clinic share a recent medical mystery and the results of their investigation. Nancy Binder of Macon, Missouri, had myriad unexplained symptoms that had confounded her local physicians for several years. Before she went to Mayo Clinic, she felt like she was losing control of things. Now she has diagnoses and treatment recommendations.

Considerable work is done in advance of these visits by a team of internists — disease detectives. Nerissa Collins, M.D., Division of General Internal Medicine and director of the Consultative Medicine Clinic at Mayo Clinic in Rochester, is one of these detectives.

“Most internists at academic medical institutions have strong investigative skills,” says Dr. Collins.
“Our patients typically have more than three medical issues and have had numerous tests and consultations elsewhere. We review the information they provide before their visit and determine the tests they need and specialists they should see, with a goal of providing patients with the most efficient use of their time at the clinic.”

Upon arrival, patients see an internist in the clinic for a medical history, review of records and physical examination. They’re provided with an itinerary of specialist consultations, laboratory tests, imaging and procedures. On average, patients are at Mayo Clinic for five to seven days. Their time at Mayo Clinic concludes with another meeting with the internist and discussion of the conclusions about their condition — a diagnosis and treatment recommendation. When appropriate, patients are referred back to their local physicians for treatment and ongoing management of their care.

Dr. Nerissa Collins

How does the Consultative Medicine Clinic succeed in this effort when other institutions have not? Dr. Collins says time is a big factor. “At Mayo Clinic we’re given adequate time to spend with each patient to acquire their history of illness, perform a thorough examination and determine the elements we think are essential to arrive at a conclusive diagnosis. It helps to have specialists under the same roof and trained in the Mayo culture of picking up the phone and talking to each other about cases. Patients spend their valuable time and money to come to Mayo Clinic for our expertise. We want to provide them with answers as efficiently and thoroughly as we can so they can return home and to their families with answers to their medical mysteries.

“Patients tell us they’ve never had physicians spend so much time with them or experienced this degree of collegiality across an institution. They say they feel truly cared for, which affirms to us that we’re doing the right things.”

“Above all things, let me urge upon you the absolute necessity of careful examinations for the purpose of diagnosis. … Say to yourselves that you will not jump to a conclusion, but in each instance will make a thorough and painstaking physical examination, free from prejudice, and your success is assured. Do this in every case. The mental effect on the patient is good, the practical knowledge to yourself is better, and if you avail yourselves of all the means of physical diagnosis and repeated examinations, the number of unsolved cases will be surprisingly small.”

— William J. Mayo, M.D., 1895

Show-me state patient gets long sought diagnosis

For several years Nancy Binder of Macon, Missouri, had a plethora of unexplained symptoms: swelling and tingling of her feet and lower legs, skin blistering, facial puffiness, hair loss, weight gain of 40 pounds, an increase in abdominal girth, belly hardening, sensitivity to touch, and purpura. Her local physicians detected a mass on an adrenal gland but determined it wasn’t cancerous and didn’t pursue further testing.

Binder had been active in country line dancing but had to give it up when the swelling in her lower extremities proved too painful and affected her balance. “It was upsetting not to do what I enjoyed so much,” says Binder. “I had to sit on the sidelines and watch my friends dance. By not being active anymore, I became weaker. I fell a couple of times and couldn’t get up. I felt like I was losing control of things.”

Various people in her community mentioned to Binder that she needed to go to Mayo Clinic. When those voices got louder and included local physicians, Binder and her daughter, Loree Jefferson, made the six-hour trip to Rochester, Minnesota.

Binder saw Susan Romanski, M.D., in Mayo’s Consultative Medicine
Clinic. In reviewing the information Binder provided before her visit, Dr. Romanski suspected Cushing’s syndrome, which occurs when an adrenal gland tumor produces excess cortisol. The in-person medical history and physical exam were consistent with the suspected diagnosis. Dr. Romanski had scheduled Binder for a consultation with an endocrinologist and biochemical testing to check her cortisol level, in addition to a handful of other specialists.

Binder had other concerns, including her memory. She didn’t think it was as sharp as it had been. Dr. Romanski scheduled more tests, including a head MRI and neuropsychometric testing. By the time Binder circled back with the Consultative Medicine Clinic three days later, Dr. Romanski had reviewed test results and specialist notes and confirmed the Cushing’s syndrome diagnosis. Endocrinologist Caroline Davidge-Pitts, M.B., B.Ch., and Dr. Romanski recommended Binder have a laparoscopic adrenalectomy to remove the affected gland.

“I like that all the doctors talk to each other and have access to my medical records. They were very interested in my problem and cared about helping me.”

— Nancy Binder

The recommended course of action for Binder was complicated because the MRI revealed an indeterminate mass in her brain that required further consultation. Binder met with neurologist I. Darin Carabenciov, M.D., and neurosurgeon Giuseppe Lanzino, M.D., to discuss options for diagnosis and treatment. Together, the physicians, Jefferson and Binder decided to treat the Cushing’s syndrome first, allow Binder time to recover and then re-evaluate the brain lesion.

“The collaboration between teams in Nancy’s case is an excellent example of what Dr. William J. Mayo described in 1910 as necessary cooperation in practice: ‘The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary,’” says Dr. Romanski.

Binder had the adrenal surgery at Mayo Clinic two weeks later. “I could have had the surgery locally, but I felt comfortable at Mayo Clinic and wanted to get my care there,” she says. “I like that all the doctors talk to each other and have access to my medical records. They were very interested in my problem and cared about helping me.”

Dr. Romanski told Binder it will take about a year for her to feel normal as her body adjusts to steroid withdrawal and begins to produce hormones naturally. Binder says she feels better already — just months after surgery. She’s eager to get back to dancing.

Binder decided to have all of her treatment at Mayo Clinic, including treatment for the brain lesion. “I know they’ll take good care of me,” she says.

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This article was originally published in Mayo Clinic Alumni magazine.

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Tags: Caroline Davidge-Pitts, collaboration, diagnostic odyssey, Elizabeth Windgassen, endocrinology, Giuseppe Lanzino, hereditary diseases, I. Darin Carabenciov, Nancy Dawson, Nerissa Collins, neurology, News, Opportunities, People, research, research education, Susan Romanski, team science

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