Thursday, January 20, 2005

"Worried Sick"

"There's no medical explanation for your symptoms. I recommend that you see a psychiatrist." What patient isn't shocked and angered by those words? No matter how well-intentioned or tactfully conveyed, these referrals can be devastating for patients. "I'm sick, and they don't know what's wrong with me...They think I'm crazy!"

When I first meet these patients, I tread carefully. Most are embarassed, tearful, suspicious, discouraged, helpless. They're completely overwhelmed by their unexplained symptoms. I ask, "Can you help me understand what you've been going through?" and "How has this affected your life?" I encourage them to speak openly about their suffering. Often, the history comes out in torrents, unstoppable. I write down everything they say. Many feel that no one has yet listened, or understood them. Most are unable to talk about anything except their unexplained symptoms. Many feel that their doctors have given up on them, and that their families are burning out. (Sometimes they're correct on both counts.)

In "Worried Sick," Susan J. Landers at American Medical News asks, "What can doctors do about hypochondria?"
"Every physician has a thousand examples," said Robert D. Gillette, MD, a family physician, now semiretired, who works outside of Youngstown, Ohio. "The only question is whether you recognize it and know what to do about it or do you just kind of blow it off."

Ignoring such patients is a technique that has been employed by many. But Dr. Gillette and others have come to understand that dismissing such patients can lead to more trouble down the road for themselves, their patients and the other physicians to whom the patients will inevitably turn. In fact, he decided years ago that a sign he saw on a plumbing shop wall applied to their care: If you can't find the time to do it right, how will you find time to do it over?

"If you have a patient like this and you don't deal with it adequately, you are going to keep seeing the patient over and over again until they go somewhere else. Whereas if you can deal with it effectively, it takes a little longer up front, but it saves time in the long run," he said.
Ms. Landers reports that as many as one in 20 patients suffers from hypo- chondriasis. Most never see psychiatrists, as the referral makes no sense to them. She describes a general approach to assessing and managing these patients (hint: frequent appointments help, reassurance doesn't).

Note the impact of Internet-acquired health information:
...the problem is far from going away. Ready access to the Internet and its vast supply of good and bad medical information has provided additional fuel. Hypochondriacal patients often surf the Web with the hope they are going to find something reassuring, Dr. Barsky said.
'But almost all of them will tell you that by the time they finally get off the computer, they are more frightened than they were initially. They learn about all kinds of other diseases they never even knew about and now they can worry about them. I think it's not very helpful for these people at all.'"
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