Two weeks ago I wrote about the demise of the traditional annual physical for healthy adults who have no symptoms.
The First Step: Identifying a Symptom
People who do have symptoms should see a doctor. They should have appropriate evaluations that may or may not include a partial or complete physical exam. One problem is that people may not be able to decide what qualifies as a significant symptom. Could the heartburn actually be a heart attack? Is the fatigue a normal result of exertion, or could it be a sign of something serious? Could my headache be a sign of brain tumor, or should I just take an aspirin? My spouse says I’ve been snoring more: could that be a sign of sleep apnea? What if I just “don’t feel right”?
This is a real dilemma, because minor transient symptoms are a normal part of life. Some of them are due to trivial conditions that spontaneously resolve; some are sensations due to the normal functioning of the body. Some people are more aware of these sensations than others. Paying attention to them tends to make them worse. Some people barely let these minor sensations intrude on conscious thought; others fixate on them and obsess about them. There is a spectrum of human reactions ranging from the stoic denier to the hypochondriac.
One of my classmates in medical school did a research project where he had healthy volunteers keep a detailed diary of every annoying bodily sensation. When you pay close attention and write them all down, it’s amazing how much you can notice. Today my ankles were a bit sore for about 5 minutes after I exercised, my nose itched, my eyes felt dry, I had a brief twinge of lower back pain, I felt a bit lightheaded when I stood up suddenly, I woke up twice during the night, my weight was up a pound from yesterday, just now my left knee felt like it was going to give way, my shoulders ached a bit after I sat too long at the computer, I noticed a new red bump over a knuckle, and now that I think of it I have a bit of a mild headache… you get the idea. If I were depressed, anxious, or under stress, it might be tempting to fixate on some of these symptoms and magnify them in a search for a physical scapegoat to explain my psychological distress. As it happens, I’m not at all worried about these trivial symptoms and I’m not going to waste any time thinking about them. As a doctor, I have a knowledge base that gives me reasonably good judgment about when to worry; but I could hardly expect the average layperson to have as good judgment.
We don’t want patients to bother doctors every time they have a loose stool or a pimple. Useful criteria are to see if a symptom persists or becomes more severe or frequent over time. But how much is too much? And should you go to the emergency room or can it wait for a routine appointment?
There are lots of “When should you see a doctor?” and “What are signs of cancer?” and “Are you having a heart attack?” guidelines on the Internet and in books. Many health care institutions have hotlines patients can call to talk with a nurse for guidance. These are useful but not foolproof.
The Second Step: Dealing Appropriately with the Symptom
Once a symptom is reported to a doctor, another problem arises: the doctor may not respond appropriately. Sometimes instead of improving health outcomes, both CAM and mainstream providers only create more suffering. If a provider spends a great deal of time with a patient asking detailed questions, it may just raise more alarms in the patient’s mind. It may make them more observant of all those normal bodily sensations. The doctor asked if I ever get short of breath; now that I know to watch for that, I’ve been paying more attention and I’ve noticed that I do get a little short of breath sometimes. The homeopath asked me about my dreams and said dreaming about robbers is one of the things listed in his book that helped him choose the remedy he prescribed for me; should I start keeping a dream diary to help monitor my health? The chiropractor asked if my baby nursed more from the left or the right breast; should I have kept better track? Did I inadvertently cause a subluxation in my baby’s spine? The naturopath asked me about every detail of my diet; today I ate a piece of fried chicken and now I feel really tired; was it because of the chicken? The integrative medicine specialist asked about a lot of things unrelated to my chief complaint, things that I hadn’t even known I should be concerned about, and then recommended a whole list of diet supplements; I couldn’t afford to buy them all and now I’m worried that I may develop cancer without them; my bowel movement today was an unusual color: could that be a sign of cancer?
A minor symptom can escalate into the perception of a serious problem with the collusion of a provider. An overzealous doctor may embark on a cascade of unnecessary tests that not only worry the patient but can lead to physical harm from biopsies or exploratory surgery. A more judicious provider can minimize the concern, reassure the patient that the symptom is not a sign of anything serious, encourage the patient’s coping skills, and get him thinking about his strengths and the ways in which his health is good.
CAM providers even invent new pseudo-diseases to worry about and treat: an example is the solanine toxicity syndrome I wrote about three weeks ago. Or they frighten patients by diagnosing real and serious diseases on the basis of unvalidated tests, as Dr. Gorski described in his post yesterday.
To Comfort Always
The motto of good medicine is “To cure sometimes, to relieve often, to comfort always.” The motto of CAM might be “To cure never, to relieve sometimes, to comfort always.” CAM specializes in the comfort; science-based medicine specializes in the cure. There are a lot of things science can’t cure and doesn’t promise to cure; CAM can’t cure anything but promises to cure everything, and even to make you healthier than healthy. As practiced in our high-technology, hectic, demanding modern medical settings, science-based medicine brings trauma patients back from the brink of death and transplants organs, but sometimes skimps on the comfort. In the patient’s perception, comfort may be more important than cure. We can do better.
Recently a friend called me about something that had him really worried. He had been exposed to an immigrant with TB and AIDS, and the health department wanted to test him and all his family members for TB. He thought he was contagious, confined himself to the house for fear of infecting others, and dreaded the results of the test, thinking the disease was devastating and possibly fatal. I was able to reassure him that his exposure was probably not close enough or long enough to be a significant risk, that he wasn’t contagious, that TB was curable, and that if the test was positive it wouldn’t mean he had active TB but only that he was at risk of developing it and would need to take isoniazid pills for a few months as prophylaxis, as I did when my skin test converted in 1975. I can’t cite any randomized controlled trials to prove the benefit of our conversation, but I doubt if anyone would question the fact that I gave him comfort based on my knowledge of medical science.
I can’t help but wonder what the average chiropractor or naturopath would have said to him. I have encountered chiropractors and natural hygiene advocates who would have told him to refuse the TB test and not to worry, because TB germs don’t cause disease. Others might have started him on a regimen of diet, supplements, maintenance adjustments, or other treatments to protect his health.
When should you see a doctor?
In my opinion, if you are concerned about anything or even have any questions about your health, you should never hesitate to consult a science-based health professional. This doesn’t necessarily mean a formal appointment with a doctor: a telephone or Internet contact with a physician assistant, nurse, or other member of the health care team might suffice. Even minor worries take their toll. For me, the most rewarding thing about practicing family medicine was being able to reassure the worried well and those with overblown worries about minor illnesses. No questions are silly questions: it’s only silly not to ask.