They're not sick; they need a doctor; you can cope

You became a doctor to take care of sick people. So what are all these healthy folks doing in your waiting room?

By Gail Garfinkel Weiss
Senior Editor

You've done the appropriate tests and told the patient not to worry. But here he is again, WebMD printouts in hand, taking up your time with yet another vague symptom that he's sure indicates an ulcer at best, stomach cancer at worst.

These aren't Munchausen or even somatization syndrome patients, and they're not faking illness to collect disability payments or defraud an insurance company. Rather, they're the vast army of the worried well.

"The worried well are challenging from a time-management standpoint, and they tap into our anxiety that we might miss a 'real' illness," says Houston internist Gary Glober.

That's the problem in a nutshell: Anxious patients make physicians anxious. But there are several ways to defuse their anxiety—and yours.

If they're well, why are they so worried?

It's important to find out what patients are really saying when they insist that they're sick. "You need to ask them why they're so convinced, and what they're afraid of," says family physician Birgit Houston of Nashua, NH. "Unless you get to the root cause of the belief, you can't address it properly. Often I'll find out that the patient has a relative, friend, or co-worker who was diagnosed with some dreadful disease—after presenting with symptoms the patient is complaining of now. If I can get these details, I can explain to the patient how his condition is different from the other person's."

Many patients who refuse to take "You're not sick" for an answer are depressed—but aren't eager to accept that diagnosis. "If they're having a lot of pain, they think I'm telling them it's all in their head," explains Houston. "I tell them studies show that depressed patients often have higher physical pain scores than patients with serious orthopedic issues like chronic disc disease."

Indeed, sometimes an antidepressant is the cure for what ails anxious patients. Family practitioner Paul J. Molinaro of Chino Hills, CA, treated a 40-year-old who complained of headaches, insomnia, and a rapid heartbeat. "He'd already had an angioplasty for a blocked vessel, plus back surgery for a pinched thoracic nerve," Molinaro recalls. "We talked for over half an hour while I did a complete exam with ECG and chest X-ray.

"Then I carefully brought up the idea that his current symptoms were due to anxiety. He was only marginally open to my diagnosis, but I promised a full workup with a cardiologist and a neurologist if he tried Paxil during the interim. The plan worked well. Both specialists gave him a clean bill of health, his tests were normal, and once the Paxil kicked in he told me he felt better than he had in years."

Robert S. Maurer, an FP in Edison, NJ, doesn't rule out referring a chronically anxious patient to a psychiatrist, but not before trying other means of easing the patient off the "I know I'm sick" treadmill. "I do a specific exam regarding the area of complaint as well as a generalized full-body physical," Maurer says. "I also do a few benign tests to rule out the most serious of possible diagnoses. That way I can reassure the patient by telling him that, as far as I can tell, he does not have a specific disease."

What else can you do to reassure these patients? No doubt, you already have a few tricks of your own. You might consider adding one or more of the following tactics to your repertoire:

Get the patient to work with you. "I turn the patient into an ally," says Denver internist Judy Paley, "by acknowledging that she is extremely tuned into her body, sensitive to changes in her environment, and so forth. I always conclude that the condition in question, while not serious, is seriously annoying to her.

"Sometimes, for the sake of time and sanity, I ask these patients to prioritize their troubles so we can turn our attention to whatever worries them the most. And I try to keep in mind that if they could act otherwise, they would."

Maureen Mondor, vice president of risk management with ProMutual Group, based in Boston, recommends a similar approach. "Tell the patient, 'Right now, I don't think there's anything wrong with you, but that can change. So we will continue to monitor this together.' That way, the patient walks away with the perception that you're empathizing with him and taking his concerns seriously."

FP David L. Sharp of Houghton Lake, MI, also likes the patient-as-ally method. He asks patients to pull a chair around so they can view normal test results with him, or he gives them a copy of the results.

Give the patient regular appointments. "People who call all the time with problems that have no medical basis get on my nerves less if I give them regular appointments," says Baltimore FP Jeffrey Schultz. "Some I'll see weekly or every other week for reassurance. After a while, I'll try to spread out the visits, telling them I think they can make it every three weeks—then once a month. It eases their anxiety if they know I will see them at some set interval."

Use active listening skills. "It's important to make these patients feel heard and understood because the worried well aren't going to believe what you say next if they think you've written them off as hypochondriacs," says internist Barry E. Egener, medical director of the Northwest Center for Physician-Patient Communication in Portland, OR. An example of active listening: "I understand you've been having headaches and you think that represents a brain tumor. You must be pretty upset."

The next step is to share expertise: "You're concerned that this headache indicates a brain tumor. I've done a physical exam. I'm convinced that this is a tension headache, for the following reasons."

Facing the big "what if . . . "

One of the chief dangers for the worried well is that, after a time, physicians are inclined to dismiss their complaints. Kokomo, IN, internist Robert J. Steele, who has served as an expert witness in hundreds of malpractice cases, says, "I've seen countless physicians fall into the trap of assuming a patient is a crock, often with tragic if not fatal consequences.

"The most important thing with such patients is to be sure there hasn't been a subtle modification from their habitual complaints that might indicate something else is going on," he says. Steele remembers a case involving a woman who'd had gastroesophageal reflux disease for years. In reading the physician's notes, it became obvious that her symptoms had begun to mutate about a year before she was diagnosed with unresectable gastric carcinoma. She died, and the physician lost a mega-buck malpractice case.

Steele doesn't recommend filling up the chart with a laundry list of tests, but he stresses the importance of ordering studies appropriate to the patient's complaints. Judicious use of some basic screening tests is also prudent. "In addition to the obvious, such as exploring and documenting any weight changes, most patients with a serious underlying problem will have at least a slight change in their hemoglobin and/or MCV, and often an increased sed rate. A frequently overlooked warning sign is monocytosis, which can often signal an occult malignancy, as can a falling serum albumin."

And don't neglect a reasonably detailed and thoroughly documented physical exam. As Steele puts it, "In many malpractice cases, a patient's first and angriest complaint is, 'The doctor never even touched me.' When the notes don't say otherwise, the physician has little to prove that he examined the patient."

To be sure, one of the challenges that the worried well offer is the delicate problem of how to document their many visits. "I wouldn't document that there's nothing wrong," Maureen Mondor says, "and I wouldn't document that the patient's a nuisance. We actually had a case where the record said, 'Patient is always complaining about pains here and pains there. This patient is a pain to me.' "

A more prudent strategy is to indicate what tests and exams were done, what they showed, and what you instructed the patient to do if his symptoms change. "That puts the onus on the patient to keep track," Mondor notes.

As tempting as it might be to view the worried well as pests—or to refer them to a specialist to get them out of your hair—Melinda Lantz, director of psychiatry at the Jewish Home & Hospital in New York City, stresses that "the approach to care should focus on health promotion and disease prevention."

Lantz sees a positive side: "These people are coming to you because they want the advice, support, and reassurance that seeing a physician provides. They go to the doctor because seeing a physician is comforting."

 

Gail Weiss. They're not sick; they need a doctor; you can cope. Medical Economics 2002;21:41.