The Patient Was…

The patient was a 38-year-old male with an extraordinary level of hypochondria, or illness anxiety, related to his heart.

He first consulted me for evaluation of chest pain, a symptom that I always regard seriously. Despite his relatively young age, absence of known risk factors for heart disease, and the vague and changeable description of the pain itself, I was very thorough in my examination, because failing to diagnosis significant cardiovascular disease could have serious consequences.

After assuring myself that his chest pains did not represent heart trouble, I conveyed that conclusion to the patient. He seemed satisfied for the moment, but did express, almost as an afterthought as he was leaving my office, the idea that probably nothing related to medicine was absolutely certain.

The next day, he called me to report new chest pain, and said that maybe we had missed something on my initial examination of him. I told him to come to the office right away and, after another thorough evaluation, I assured him again that he was free of heart problems.

Thereafter, he made frequent telephone calls to the office, each time describing chest pain and the fear that he was having some sort of heart attack. On each occasion, I had him come to the office for Immediate evaluation. My expectation was that with repeated reassurance, his fears would be allayed and he would get past both the need to call and the feeling that he had to come right to the office. I believed that showing my concern for him would indicate that I took his complaints seriously, and that my thorough evaluations were therefore reliable.

The opposite was true! It was as if Newton’s Third Law of Motion and the Doctrine of Unintended consequences were rampant.

Newton’s Law states that for every action there is an equal and opposite reaction,  The intensity of my belief that showing interest in his symptoms and concern for his well-being were reassuring, was matched by his belief that it meant his complaints were valid and indicated potential danger.

And the consequences of my actions were exactly opposite to what I intended. Instead of being reassured, his fears and concerns were heightened each time I gave credence to them by urging him to come right to the office for evaluation.

A new strategy was needed, a radically different one. A strategy that would turn down the heat, so to speak, and lessen if not eliminate the patient’s investment in the idea of the potentially ominous implications of his chest pains.

I didn’t alert the patient to my new plan. But the next time he called with chest pain and, anticipating my instructions, said he would come to the office, I said, “No.”

He was startled. “No?” he said. “But I’m having chest pain.”

“I understand,” I replied. “But it doesn’t sound serious. Stay where you are and I’ll  call you back in a few minutes.”

“Are you sure,” he asked, a quaver in his voice.

“Yes. Stay where you are and I’ll call you in five minutes.”

I called him in five minutes, then again in five more minutes, and yet again five minutes after that. Following the third call, I promised to call him in ten minutes, but to my relief he said he thought he was feeling better and would remain at his desk.

The next day, I called him at work: “Just checking in to see how you are,” I said.

I had debated the wisdom of doing this, fearing it might suggest that I really thought he could be in trouble. But I concluded that it would more likely show  that I was still interested in his welfare and indicate that if he were in difficulty I would be available.

The end result was salutary. His calls to the office were greatly reduced, and a few minutes of conversation would resolve the concerns of the moment. He came to the office for regular appointments and, fortunately, I continued to find him in good health.

The laws of physics may be immutable. Those governing human behavior are a lot less so. Different patients require different approaches, ones that recognize their individual foibles. Getting it wrong can be a problem for patient and doctor. Getting it right can be rewarding for both.