The worried well

Lenny, Adam

One of my least favourite types of patient is the worried well. Treating them seems to me like a bottomless pit of meaningless medicine, with little progress or reward. They convince themselves they’re acutely moribund, and it’s our job to prove that they’re perfectly healthy. It’s a Sisyphean task and it’s excruciatingly frustrating. Recently, though, one of my worried well patients taught me a good lesson.

Janine Boswell is the worst worried well patient I have ever encountered. In the short time she’s been at our clinic (approximately six years, predating me by five), Mrs. B. has proven herself to be a perpetual fountain, a reliable wellspring, of woeful wellbeing. Presenting complaints have included dizziness, nausea, chest tightness, tinnitus, headaches, disordered stool patterns, shoulder clicking, rib misalignment, etc. At the end of every tale of unbearable misery, whatsoever it entails, she will plead, “Doctor, I’m in a terrible state. It’s just awful. Doctor, you have to do something for me.” Translation: “Here’s a big rock. Roll it up that hill a few dozen times and watch it roll down. Repeat ad infinitum.”

Areas of her anatomy that have been examined for specific diseases include her cerebrum, cerebellum, eyes, salivary glands, carotids, cervical spine, thyroid, parathyroid, shoulder, lungs, coronary arteries, aorta, oesophagus, thoracic spine, stomach, liver, pancreas, kidneys, umbilicus, lumbar spine, colon, rectum, pelvis, hips, knees, and left foot.

Apart from the screening studies to which she more than readily submitted, the investigations she has undergone included twenty-three x-rays, seven CT scans, two MRIs, seventeen ultrasounds, one electroencephalogram, two echocardiograms, a cardiac catheterization, referrals to twenty different doctors, eight hospitalizations, biopsies from no less than four different parts of her body, and litres upon litres of blood tests.

These tests, and their universally negative findings, have allowed us to exclude most of the known and unknown medical ailments. Aortic dissection and unstable angina have been crossed off the list, as have stroke and expanding brain mass. Myocardial infarction was ruled out on a dozen different occasions, and despite a thorough workup that showed she had coronaries of a thirty-year-old, she still managed to trick people into ruling it out several more times. She has completely normal pulmonary function tests, but somehow convinced a competent respirologist that she nevertheless had asthma. Lupus and most of Kelley’s Rheumatology have been entertained, investigated, and rigorously dismissed. The other bodily systems are similarly constituted in their wellness.

Like any other septuagenarian, she does have a certain burden of illness. Although mostly benign and largely due to overdiagnoses, the list includes atrophic rhinitis, nasal polyps, gallstones, osteopenia, asthma, hypercholesterolaemia, chronic eosinophilia, and cataracts. She has carried these around like Best Effort trophies from grade school tournaments as constant reminders of her invalidism.

The crown jewel in this collection, kept lovingly on her mind’s mantelpiece, has been her temporal arteritis. She worked hard for that one. She loved to regale new residents like me on her first meeting with us of her struggle with the adversity of a terrible, unrelenting two-week headache, how she was the underdog when no one paid her heed, and how her elevated ESR had come from behind in the end to win the day. It made for a good story.

Symptomatic treatment of her many complaints generally only lead to more symptoms. Treatment of her neurosis had the same outcome. “Doctor, I simply can’t take that mirtazepine you gave me. It made me all dizzy and sick to my stomach.” She did like the lorazepam, though. I guess I can say we’ve done something for her, because she keeps coming back for that.

Despite all the crying wolf of hyperbolic symptomatology that earned her all these negative tests and ruled-out diagnoses, she made us, the gullible village people, come running once again.

It was my preceptor’s idea. I was against it.

“Yes, she had a workup for similar complaints a few years ago, but things can change. Why don’t you order another ultrasound?”

So I ordered the ultrasound. When I came back into the room to tell her that we were going to do it, her overwhelming anxiety turned to overwhelming joy. She was very gracious - “Oh, thank you! Thank you, doctor! Thank you so much.” - but I hated her for tricking us once again. I had an overwhelming sense of being duped, and I think the unspoken message was clear. “Yeah, I’m so glad we made you ‘so happy’. Now get the hell out of my office. I have real patients to see.”

I was surprised when the results came back. “There is a suspicious mass in liver segment IV, measuring 5cm in maximal diameter. Follow up CT is recommended.”

So I ordered the CT. Then she had an ultrasound-guided biopsy. Then she had perihepatic bleeding and another admission to hospital, accompanied by several dozen more sets of vitals, urinalyses, blood tests, ultrasounds. Then, upon discharge, she came in to discuss the results.

Finally, she had what she had suspected she had had her entire life. This was the moment she had been living for. The moment she was dying for. The moment she found out she was really and truly dying.

She’d really outdone herself this time. Cholangiocarcinoma. Ninety percent non-resectable, and fatal in a median of six months from detection. She sat in stunned silence.

As I was sitting across from her, as she was taking it all in, grasping the significance of the news, I was thinking, I can’t imagine how she must feel right now. How anyone feels, for that matter, when they know they’re going to die. God, it must feel like hell.

I’m still thinking about her, a month or so later. What’s she thinking right now? It’s ten-forty-five at night. She’s probably in bed, trying to get off to sleep. I wonder how she even manages to sleep. Probably with all that lorazepam we keep giving her. She probably needs more. At this point, she probably deserves more.

It’s strange how a sudden change of fortunes can entirely reverse your opinion of someone. Why do I suddenly pity this woman, for whom, at one time, I would have given a month’s worth of my hard-earned resident’s salary never to have seen in clinic again?

I think my change of heart comes from the inevitable realisation that when you hand someone a death sentence, as I did to her, the person on the receiving end instantly becomes a vulnerable human being again, irrespective of your history. With that perspective, I saw everything - her anxiety, my aggravation, our relationship - differently.

In fact, it was difficult to see why I had ever been irritated with her at all. She had complained so often not because she wanted to torture us but because she herself felt tortured. The anxiety she had was just as much a disease as any of the ones we ruled out with all our tests, and much more difficult to treat. If she had diabetes, I would have seen her just as often for equally intractable and exasperating complaints. The practice-changing conclusion is that my frustration arose from my own inability to treat her, rather than the natural course and presentation of her disease.

Theme: Death and Dying | Décès et le mourir
Theme: Patients | Patients
Theme: Physicians | Médecins
Theme: Relationships | Relations

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.




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