In all cases — but especially when taking care of a worried-well patient who is analyzing or questioning everything you do or don't do — use your best judgment, common sense, and a consistent practice pattern. Base your decision-making on the most up-to-date information, be as thorough as you feel you need to be, and document carefully so that if questions ever arise you can explain your thought process and action plan — years after the fact, if needed.

Special care should be taken with follow-up when caring for the worried well, particularly when employing the watch-and-wait approach. If you tell a patient to return in five days for a recheck and they don't show up, every effort should be made to contact the patient, and this should be recorded in the chart. 

Once you've determined, based on a good history and physical, your experience, and good old-fashioned intuition, that whatever the patient is in for does not warrant a work-up or complex medical intervention, managing the worried well might include the following tactics: 

• expressing genuine concern and acknowledging that the patient does indeed have a physical symptom;
• offering a reasonable, nonaccusatory explanation for the symptom ("That back pain is probably from a muscle strain. take some Tylenol and take it easy for a few days.");
• instructing the patient to follow up if symptoms persist, worsen, or recur;
• trying to uncover why the patient might be so worried;
• suggesting healthy lifestyle choices if there are reasonable changes that could be made; and
• if you think depression is an issue, beginning discussion or treatment.

"I find that in order to have credibility with a patient in terms of telling [them] that there is nothing wrong that it's important to have done a good physical exam first — even if I can tell from just listening to them that their symptoms aren't serious," says Ewing. "If I'm kind and nonjudgmental with my approach, then they will usually accept my opinion." This course of action can help establish rapport with the worried-well patient, making caring for them not only less time consuming, but also more rewarding for the physician. 

According to Taylor, things to avoid when managing the worried well include ordering unnecessary studies, a repeated pat assurance that there is "nothing wrong," telling a patient that it's all in her mind, prescribing a placebo, or becoming argumentative or confrontational. Smith adds, "It's not a good idea for the doctor to be painfully honest and tell the patient that "there is a 2 percent chance it's cancer" or something like that. If the patient already has health anxiety, this just encourages them to keep exploring the issue unnecessarily."

What about the possibility of underlying depression among worried-well patients? Patients who do not respond to a treatment plan offered by their primary-care physician may then need to be referred for a psychological or psychiatric evaluation. Be prepared for some resistance, however. "These patients are sometimes insulted if their doctor wants to refer them for counseling, but if they are clearly depressed or become dysfunctional at home or at work, then that would warrant a psych referral," says Smith.

The time factor

For the busy physician with a full patient load every day, it may seem more efficient to get a worried-well patient in and out of the office as quickly as possible. But if the patient returns to the office again and again with minor complaints, managing him ultimately ends up taking more time — not less. Spending a few minutes educating patients about their symptoms and explaining what kinds of things tend to be resolved on their own (e.g., cold without a fever, headache with a one-day duration, occasional mild nausea) can help unclog a schedule that is overloaded with patients who could probably come in less frequently.

"Demanding patients take more time and effort to treat," says Ewing. "One reason medical care is getting more expensive is because the easy thing to do is order tests, as opposed to spending more time with the patient getting to the bottom of the issue. If you can take a few minutes and say to the patient, 'It seems that something is really worrying you. Can you tell me more about that?', you can sometimes get on their wavelength and uncover what they're really concerned about."

Practices that employ physician assistants or nurse practitioners can have front-desk staff schedule chronically worried-well patients with these midlevel providers who often have more time to listen and educate patients. Individuals with health anxiety sometimes need only to 'talk it out' and get reassurance in order to feel better about their situation. If a patient insists on seeing the physician, have them scheduled in the last time slot before lunch or at the end of the day.

Taking care of the worried well is a fact of life for most physicians. Keep in mind that the vast majority of these patients are average people who have health concerns along with a little anxiety. Everyone needs a little peace of mind, warmth, and caring from time to time. Sometimes that's the best medicine you can offer.  

Karen Childress, BA, is a certified coach, freelance writer, and healthcare consultant based in Scottsdale, Ariz., with more than 20 years of experience in the healthcare industry. She is the writer and publisher of "Intentions: The Newsletter for Successful Physicians," an e-newsletter for physicians and other professionals. She can be reached at editor@physicianspractice.com.

This article originally appeared in the July/August 2004 issue of Physicians Practice.

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