The doctor’s concern is the patient’s fear

River Bed
Katherine River
How often have you listened to a patient’s story and thought, “OMG! This person has a brain tumour.” After a few more minutes listening (if you are into that sort of thing) your concern might have developed into a mere brain abscess or perhaps a cerebral vascular abnormality. Reacting directly to such gut responses is one reason that doctors now do so many CT Scans of peoples’ brains. I am ashamed to admit that we now cause more brain tumours than we detect. That is clearly not good for our patients and the public purse. In fact, it is a disgrace.

So what should we do with this concern that patients so easily generate in our viscera? We ignore it at our peril for we do not know if it is based on reality, searching google and incorporating the symptoms, a grief reaction to the death of a loved one or even just chance. Whatever turns out to be the case, if the patient was not fearful before telling us their story, they will be after they witness our response. 

What I am saying is – the doctor’s concern and the patient’s fear is the same thing. Singular. One. 

 There is a solution. To respond as a professional rather than as a social being. The neighbour, friend or chat room acquaintance will stay with the patient’s fear – “You need a CT Scan my friend”. As a doctor you can feel and acknowledge the concern, either internally or openly with the patient, and recognising that it is probable that the patient is afraid of whatever you have become concerned about. Now park that concern and go about your professional business.  You can continue gently with the history gathering information that might confirm or refute the possible calamity and examine the person carefully. I cannot stress enough the need to examine people carefully if you are going to refute their fear and explain the symptoms another way. The laying on of hands shows care and attention to detail and justifies our professional opinion.

There is still work to do but investigation is not usually helpful if you do not think it will change the management. Investigation may mean an easy life for you and the patient might attend less in the short term. But the patient has proven that they were right to be afraid and shown that the doctor needed to do a test in order to discover that the feared condition was not present. What is that patient to do when the symptom recurs? How long is a reasonable gap before the test is required again as the doctor is unable to allay the fear without the result? It is a bit like the acceptable period before a widow or widower takes a new partner: there is a wide variety of opinion and a lot of gossip.

 Once in a while, the fear may be so out of touch with reality that it is best to refute this in theory and avoid getting dragged into a clinical black hole. I met a patient who was repeatedly terrified that she had melanoma and would only trust a biopsy result; the doctors were concerned. When I refused to do this on the grounds that she had no added risk and normal skin, she became a very frequent attender for a skin check. It was only when we began to focus on the rest of her life that this fear resolved. 

So use your fear barometer, your concern dial, but be aware who is pushing it.

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