CASE
A recently immigrated Chinese man, aged 36 years, presented with a six-week history of worsening right facial swelling with diplopia and episodic unilateral right-sided headaches. There was no dysphagia, dysarthria or constitutional symptoms. He had a 10-pack year smoking history. Medical and family history was unremarkable.
As a recent immigrant with no regular general practitioner (GP), he had seen two GPs for initial symptoms of toothache and scalp pain. Upon developing diplopia, a third GP recommended presenting to the emergency department (ED). The patient declined and instead agreed to a brain magnetic resonance imaging (MRI), which showed a right Meckel’s cave mass with maxillary nerve involvement (Figure 1).
Due to unavailability of the third GP, a fourth GP explained the results; however, the patient, with his sister, consulted a final GP for a second opinion regarding the MRI and necessity to present to the ED. On this examination performed by the final GP, there was right mandibular swelling with medial deviation of the right eye at rest (Figure 2), along with two semi-firm lymph nodes (LN). Through shared decision making with his sister, the patient presented to the ED for inpatient management where an LN biopsy demonstrated nasopharyngeal carcinoma (NPC).
In hospital, neurosurgery and otorhinolaryngology specialist teams in the hospital discussed biopsy of the MRI lesion. However, the patient self-discharged from hospital and initial attempts to follow-up from the hospital were unsuccessful. The final GP was able to reach the patient, where he revealed his fear of undergoing a biopsy and Western treatment and preferred seeing a traditional Chinese medicine (TCM) practitioner instead. The final GP maintained the therapeutic relationship with the patient by sharing his health information with the TCM practitioner and including them in the multidisciplinary team (MDT). The patient re-presented later to the final GP with worsened diplopia and eventually agreed to hospital admission. He currently is being followed up at a cancer care centre, and both he and his family still see the final GP and TCM practitioner for continuity of care, having regained baseline function.
Figure 1. Axial T1 magnetic resonance imaging with intravenous contrast demonstrating a lesion in the right Meckel’s cave indicated by the white arrow.
Figure 2. A picture of the patient at presentation to the final general practitioner demonstrating right-sided medial gaze palsy. This was associated with diplopia.
Question 1
How does NPC present?
Question 2
What factors contributed to the patient’s lack of continuity of care?
Question 3
What is whole-person integrative medicine and how can it be applied in Australian primary care?
Answer 1
NPC often presents late with non-specific sinus symptoms, headaches and neck lumps (Table 1). In non-endemic populations, NPC is rare and commonly mistaken for upper respiratory tract infections.1 Asian ethnicity is a major non-modifiable risk with modifiable risks including smoking, Epstein–Barr virus infection and nitrosamines in preserved foods.2
| Table 1. Presenting symptoms of nasopharyngeal carcinoma2 |
| Type |
Symptom |
| Nasopharyngeal |
Epistaxis |
| Nasal congestion |
| Rhinorrhea |
| Rhinolalia |
| Ear symptoms |
Hearing loss |
| Tinnitus |
| Otitis media |
| Neurological |
Facial numbness |
| Diplopia |
| Facial pain |
| Blurred vision |
| Facial droop |
| Other |
Headache |
| Neck lumps |
| Dysphagia |
Answer 2
As a recent immigrant, his lack of a regular GP and sociocultural background likely contributed to his initial fractured care. Ultimately, his decision to see the final GP regularly might be because of the therapeutic relationship built by committing time to explore his concerns and active support for his TCM treatment. Figure 3 depicts the factors influencing the patient’s care.
Continuity of care has a significant protective effect on patient outcomes, including all-cause mortality.3 In Australia, patients are increasingly seeing multiple GPs.4 Fractured care can detract from physician–patient rapport and minimises opportunities to assess patients holistically.
Figure 3. Factors in this case presentation that either contributed to, or detrimentally impacted, the patient’s continuity of care. Factors that improved continuity of care are outlined in green and factors that acted as barriers are outlined in orange.
GP, general practitioner.
Answer 3
Whole-person integrative medicine is a multidimensional assessment of patients that emphasises the therapeutic alliance and individualises patient management through a range of treatment modalities including complementary medicine.5 In this case, whole-person care included involving the patient’s family in decision making given his Chinese background, eliciting his concerns with Western medicine and integrating his TCM practitioner into the MDT.
In practice, integrative medicine is difficult because of time constraints and lack of proper remuneration and formal training,6 with only 30% of Australian GPs self-reporting being integrative medicine practitioners,7 and just 12% of surveyed GPs in integrative medicine interest groups are TCM educated.8 This is despite increasing TCM use9 and a diverse Australian patient population. Introducing professional development-accredited courses on TCM and holistic medicine, along with the inclusion of TCM practitioners in Enhanced Primary Care referrals, might reduce barriers for primary care physicians to practice integrative care, which has been shown to improve physician–patient satisfaction and patient health.10
Key points
- Always consider NPC in high-risk patients with recurrent nasopharyngeal symptoms involving the face and neck.
- Establishing the therapeutic alliance by considering the patient and family’s sociocultural context is critical to maintaining continuity of care, which is an important metric of quality of care.
- As complementary medicine becomes increasingly more common, undergraduate or postgraduate exposure to complementary medicine and healthcare policies would better support primary care physicians practising whole-person integrative medicine.