How to identify and manage the worried well
If you've been practicing medicine for more than a week, you've experienced it. You enter an exam room to find an apparently healthy middle-aged woman who woke up this morning with a headache. She wonders what should be done. After all, her co-worker was having headaches and had a CT scan to find the cause. Or you're seeing a young man who has a cold for the second time this season. He heard somewhere that frequent colds can be caused by a suppressed immune system. Could that be his problem? Then there is the patient who dashes into your office with every ache, pain, spasm, twinge, twitch, or itch -- just to be sure. Welcome to the world of the "worried well."
While some worried-well patients in fact have hypochondria --defined as "a morbid concern about one's own health ... a delusion that one is suffering from some disease for which no physical basis is evident" -- many have less severe, more intermittent worries about their health. Emotional distress or depression may play a role as well.
Family physician Joseph Ewing, MD, who practices in Las Cruces, N.M., sees his share of the worried well. "These are basically normal people with many of the same fears we all have," he says. "They run across all socioeconomic levels but, interestingly, I find it to be more common in people who have time to worry. Someone who is working very hard to make a living and support a family gets a bellyache, but may not have the luxury of running to the doctor."
Patients with health anxiety often present with symptoms of pain or discomfort -- sometimes vague, other times quite specific in nature. Also common is concern about cancer, heart disease, or symptoms related to a condition that a friend or family member has suffered through or died from recently.
"A key distinction in these patients is that they don't recognize that symptoms are normal. They assume that every complaint means something is wrong and needs a test. If these patients have any anxiety or depression, then it gets magnified," says Robert C. Smith, MD, professor of medicine and psychiatry at Michigan State University. "Aches and pains are normal -- it's when [patients] start to become high utilizers that it becomes a problem. That's a time to perhaps look for some underlying depression."
According to Steven Taylor, PhD, and Gordon Asmundson, PhD, co-authors of Treating Health Anxiety: A Cognitive-Behavioral Approach, the worried well may be individuals who suffered from childhood diseases or who had family members with serious illnesses. A history of sexual abuse may also contribute, as it can cause feelings of helplessness and vulnerability. Exposure to and excessive reliance on disease-related information can also add to the anxiety level.
"Modern medicine has been making such impressive advances that some people have come to believe that they can prolong their lives virtually indefinitely if they continue to worry, check, and seek medical advice about their health," says Taylor.
"Perhaps as a result of technology and today's advanced medical knowledge, many of the worried well expect absolute certainty in diagnoses given to them by their doctors. This need for certainty is, of course, unrealistic. Nothing in life is certain," adds Asmundson.
While there is an abundance of valuable health-related information available online, for the worried well patient it may be too much of a good thing. It's very easy to look up a common symptom and find some rare or serious disease to match it. If a patient shows up in the office with a ream of printouts from obscure Web sites, physicians need not feel obliged to sort through every piece of information. But don't discount the fact that your patient has taken the time to do some Internet sleuthing. Instead, explain that there is a certain amount of unreliable information in cyberspace. Be sure to note in the chart that you explained your position to the patient and that you are not factoring their Internet research into the treatment plan -- unless, of course, they've stumbled upon something helpful that you do use.
Consider maintaining a short list of reputable Web sites to recommend to patients who are inclined to do their own research. If your practice has a Web site you can provide links there. You might also post information about symptoms common to your patient panel that can usually be treated at home versus conditions for which a patient should seek medical attention, including a timeline (e.g., if symptoms persist for 48 hours, if there is fever, etc.).
Lacking a Web site, a patient education brochure with this information would be handy. Either way, include the standard disclaimer that the information is not a substitute for direct medical care and that, when in doubt, a patient should indeed seek professional attention.
Ways to respond
"Physicians face a challenging task in managing people with excessive health anxiety," says Taylor. "The doctor's first obligation is to make sure that the person truly does not have some undiagnosed disease. The risk, however, is that this can lead to excessive medical testing, which can then fuel the person's health anxiety."
Most physicians are familiar with the "tincture of time," or the watch-and-wait approach. However, reassuring a patient with health anxiety that he doesn't need a diagnostic workup for every symptom can prove challenging and time consuming. Spending a few minutes educating patients about when and why it's OK to "wait-and-see" in certain situations rather than immediately undergoing a battery of expensive tests will be effective with some individuals. However, patients often come in requesting specific diagnostic tests, medications, treatments, and referrals. Couple that with physicians' concerns about being accused of malpractice if they don't thoroughly evaluate every symptom and you have the perfect formula for driving up healthcare costs for everyone -- not to mention making a shambles of the practice's schedule.
Smith notes that medical-legal issues frequently come into play when treating the worried well. "A key distinction for physicians is to consider whether they're patient-centered or legal-centered. If you are patient-centered, once you've determined that there is nothing serious going on, you reassure the patient and follow them carefully. The legal-centered physician is the one who tells the patient, 'Well, it could be cancer -- and then proceeds to order a carload of tests.'"
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:
"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 firstname.lastname@example.org.
This article originally appeared in the July/August 2004 issue of Physicians Practice.