Can you relate to this? You'd be surprised how many perfectly healthy patients believe they're ill
Doctors aren't supposed to do unnecessary procedures, but it's hard when healthy people won't stop worrying.
It was an impossible situation. A young man had come to my clinic complaining of a headache and was concerned that he had a clot in his brain. He wanted a CT scan, but there was nothing on his physical examination or history suggestive of anything more than a simple tension headache. I tried to reassure him and hoped to have him try some ibuprofen. Yet I could see that he felt almost cheated.
I thus faced a choice: I could get a scan that not only raised his exposure to radiation, but also ran the risk of uncovering incidental findings requiring further tests, raising further stress; or I could reassure him and stick to what I thought was the right course for him.
Ordering the CT scan constituted no more than a click of a button for me. But would a normal CT scan be able to relieve his fears? I tried to comfort him and convince him that it was unnecessary. The visit ended with him firing me as his primary care physician, leaving me in my room with only the whirring computer for company. Should I have just pressed the button and gotten the scan?
All physicians treat anxiety, whether it is an obstetrician squeezing a first-time mother's hand in clinic or whether it is a surgeon in the intensive care unit having a conversation about end-of-life care with a 37-year-old.
Disease breeds dread and despair – and hospitals don't help. Neither do the scalpels and catheters bundled with the experience of sickness. But there's a difference between a genuine anxiety about being sick and the people who believe they are ill even when they aren't.
Not all people who are anxious or worried about their health have an underlying medical condition. One study categorized patients into four groups: the truly healthy (I am healthy and I know it!), the health evaders (I am dying and I know it...), the health illusionists (I am dying and I deny it...) and of course, the worried well – constituting a fifth of patients – who are well, yet incongruently worried.
Anxiety, like most human responses, likely lies in a bell-shaped distribution with most individuals expected to fall at the "right" level, which is conventionally supposed to be the middle. When physicians interact with patients, their expectation, flawed as it may be, is to deal with someone who would be as close to the mean as possible – a normal test would elicit a normal result with the patient being reassured; an abnormal test would alarm the patient into either seeking medical care or reshaping their lifestyle.
But studies show that not everyone is reassured by even a normal test result. A study published in the British Medical Journal showed that most patient who had normal ultrasounds of their hearts were not reassured even after their results were communicated. The lack of reassurance had real consequences – one patient left his job worried about heart disease, several sought care from other providers and some even had the scan repeated. While ultrasounds do not use radiation, most radiological scans utilize radiation that in cumulative doses can have serious ill effects.
Physicians have to balance their responsibility to both alleviate anxiety and also avoid unnecessary testing, procedures and hospital visits that will only multiply concerns that patients may have. But that can be a difficult argument to make, especially when someone is feeling aggravated and desperately seeking answers. In fact, there is evidence that up to a third of physicians would yield to ordering expensive unwarranted MRIs based on patient expectation and pressure.
Interestingly, data shows that patients who end up being most satisfied with their care are on more medications, stay in the hospital longer, incur higher costs and ultimately die more often. While medicine as a whole is becoming increasingly patient-centric, the medical consumer is unlike any other.
As the Affordable Care Act comes into effect, policy makers are increasingly trying to identify opportunities to cut healthcare costs. The influx of millions of the erstwhile uninsured has to be counterbalanced by adequate cost cutting in areas where waste is accumulating. The key to managing the worried well is increased patient engagement and increased patient education. Not only does improved patient communication very reliably increase patient satisfaction, it also increases compliance and adherence to treatment.
Putting patients first means that, when necessary, physicians need to protect them from their own misguided expectations and desire for non-beneficial treatments. Ordering that CT scan will always be tempting, but fighting that impulse and having an honest conversation with patients is about more than just saving them from a huge medical bill, an incidental finding, a treatment-induced injury, or an adverse outcome. It is about saving them from themselves.