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When To See a Doctor

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.

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30 thoughts on “When To See a Doctor

  1. Janet Camp says:

    This is excellent general advice, but is bound to bring a slew of personal anecdotes from either extreme. Recently, for instance, I casually mentioned tingling in my hands while at the doctor for something else entirely and she quickly diagnosed carpal tunnel. I have since had the surgery to relive it and am very pleased. On the other hand, ten years ago I repeatedly complained of chest pain on exertion and was told just as repeatedly that it was “just the asthma”. After intense nagging (having passed an EEG and a stress test), I was sent for an echo that immediately showed an almost completely blocked major artery. I got a stent two days later and have been fine since (with meds and lifestyle modification).

    However, both these examples are within standard medical experience. As you point out, when one dabbles in the woo, the outcome can be even less certain. At age 40 I had high bp (runs in the family) and was prescribed meds. Being somewhat under the influence of “drugs are evil” at the time, and also in denial that I could have this problem at that age, I refused to take the meds and experimented for five years with all sorts of nostrums. Luckily I came across some books by Shermer, Ernst, et al (pre internet) that brought me to my senses. There IS harm in woo and now I find myself worrying at times about the years I ignored significantly elevated bp–should I call the doc? :-)

  2. David Gorski says:

    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.

    Hence the reason that “homeopathic provings” always find something. After all, what are “homeopathic provings” but doing exactly what you describe?

  3. BobbyG says:

    Apropos? See Gilbert Welch’s “Overdiagnosed.” ‘eh?

    10. Get the facts
    “A lot of messages about health screening are simply variations on the same theme—in one form or another, they all push the idea that the best way to stay healthy is to look hard for things that might be wrong. Sometimes the messages reflect the best of intentions: disease advocacy groups and some doctors advise people to be screened because they believe it is right thing to do. Others times they reflect more self-serving motives: health-care companies, hospitals, and some doctors advise people to be screened because they are in the business of selling the service. But regardless of the underlying motivation, what you really need to know is whether these messages are supported by good hard facts.

    I should start by telling you the unfortunate reality: all too often, there won’t be any good hard facts to find. There is a reason for this. Most healthy people will not soon (or ever) develop the particular disease we are trying to diagnose early. So getting reliable information about the value of early detection for the few who will get the disease requires studying a lot of healthy people for a long time. And a big, long study is a very expensive study. The numbers are impressive: a typical randomized trial of mammography, for example, enrolled around fifty thousand women, followed them over a decade, and cost tens of millions of dollars. Not surprisingly, there are not a lot of these studies, although there should be. The millions we would pay to study the value of early detection pales in light of the billions we spend putting it into practice without knowing if it helps.

    But since there aren’t a lot of good hard facts out there, it is important to recognize when you are being led to believe that people know more than they do. Many messages about early detection—advertisements, public service announcements, health Web sites, and even news reports—are plainly misleading. They typically exaggerate the risks you face as a way to scare you into taking action.”

  4. DugganSC says:

    I can’t help that notice that although you start start out stating “Sometimes instead of improving health outcomes, both CAM and mainstream providers only create more suffering,” you then segue to exactly one issue involving conventional medicine and several involving CAM. I recognize that it’s easier to indicate the varieties of CAM modalities, and there is a significant (and probably justified) bias against CAM here, it kind of feels like someone saying that “black and white people commit crimes” and then following up by listing one white person as an example and five black people. :) I suspect it was unconscious, but thought you might want to be aware of it.

    As regards when to see a doctor, I’m horrible about that. I’ve had people blame it on my gender (ostensibly, males are less likely to go to a doctor based on symptoms), my background (my parents brought me up fairly old-fashioned and frugal, with the idea that you don’t go to the doctor unless something’s really wrong because most colds and sprains resolve themselves), and general laziness (setting up a doctor’s appointment around here generally requires either waiting several weeks for an appointment to open up, or calling multiple doctors to find one with an open space). It probably doesn’t help that out of the last five or so times I’ve gone, four involved the symptoms not actually adding up to anything (the fifth was a plumbing issue that I’d been blaming on pinworms based on prior experience with such), leaving me feeling silly for spending $20 to have someone tell me nothing’s wrong with me.

    Incidentally, my insurance provider does have one of those nurse hotlines and it does come in handy for those little things like when you get a sudden pain in your stomach doubling you over, or extreme stiffness in your neck. Rather than rush to the emergency room for fear of appendicitis or meningitis, they can guide you through checking for the other symptoms. Like you said, sometimes just having someone tell you that you’re alright (and telling the truth on that count!) is all you need, and the lack of the bars of setting up an appointment and arranging a co-pay makes it that much more accessible.

  5. cervantes says:

    My mentor Irving Kenneth Zola wrote a famous paper called “From person to patient: pathways to the doctor.” For the most part, what drives people to the doctor (or, in many cases, the ED at 2:00 am) isn’t really the presence of symptoms that indicate a need for medical attention. As you say, we can always decide we have symptoms but — on the other hand, people often ignore symptoms that they probably should tell a doc (or NP or whatever) about. Whether they do or not often has to do with changes in their life or mood that make the symptoms matter, e.g. I’ve put up with the sore knees for years but now I have to take care of my mother and it’s too painful to lift her out of the bathtub. Sometimes people just try to deny as long as they can, until somebody finally talks them into going to the doc, or they hear about somebody else who turned out to have cancer or died of a heart attack, or they get anxious about something else and displace it onto the symptom.

    In any event, it’s often hard to get an appointment for urgent care. The health center I used to go to had nurses to take calls and triage them, but they never answered the phone, you had to leave a message, and then they’d call you back, presumably at an inconvenient time if you were at work or whatever. If you missed the call, forget about it, you’d just have to call again and get another call back at a time when you couldn’t take it. It was easy to get tired of playing telephone tag and give up. Trying to get my doctor on the phone was just about hopeless. So we really need to make health care providers much more accessible.

  6. LMAO says:

    @Harriet said…

    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.”[emphasis mine]

    Had to laugh at this one. My 90-year-old father-in-law (whom I adore) and his 91-year-old “girlfriend” are pretty wooey due to their upbringing and their lack of education: they were raised in the days when “healthcare” was far more often comprised of Mama’s or Granny’s Indian and folk remedies than a rare (and extremely costly) MD visit, and 8th grade was all the schooling that was required (and the Depression made high school instead of work a luxury few could afford). I’m glad that it’s mostly it’s common sense type stuff (stay active, eat lots of homegrown vegetables, don’t watch TV, go to bed early, etc.), but they also believe in “natural” herbs (much safer and more effective than those “dangerous” prescription drugs) and old wives remedies (a shot of blackberry brandy every night has “cured” the girlfriend’s diverticulitis).

    They insist that doctors MAKE people sick and exist for the sole purpose of FINDING a problem. Doctors don’t really know anything about how to cure people, and their apparent mission in life is to get rich by having you in their office every week (collecting a fee) and put you on 38 different meds (all of which will kill you, yet somehow also benefits the doc).

    I think they may actually believe, at least in the backs of their minds, that it’s the DIAGNOSIS that kills people. I.e., if you don’t get diagnosed with (cancer, CAD, infection, etc.), then you won’t die of (cancer, CAD, infection, etc.).

    It’s incredibly frustrating, and worries me to no end, but I do understand why they feel this way — they’ve got the cause/effect thing all twisted up, which is common even among the most educated, much less people who quit school at 13 years old. Add in the sadness and fear of the overwhelming majority of their contemporaries being dead or dying, many of whom were/are under physician care for poor health (diagnosed by a doctor), and taking a great many (unnatural) meds (prescribed by a doctor), and you’ve got a recipe for disaster:

    In their eyes, their friends and loved ones were “doing fine” until they went to the doctor, so it must be the doctor who wreaked all this havoc.

    Further reinforcing and “proving” them right is the fact that my FIL can literally count on his fingers all the times he’s been seen by a doctor in his entire life (I’m not exaggerating). He relies almost exclusively on natural remedies, can seriously run circles around me (at about half his age), and enjoys the most amazing perfect health (and not just “for his age”), so he must be right. Right? ;)

    Of course, his younger sister avoided doctors, too, but she still dropped dead of a ruptured brain aneurysm when she was “only” 82 years old. Of course, those cases don’t seem to enter the equation, as they’re just due to “bad luck” or “her time” coming.

    Sigh.

  7. LMAO says:

    P.S., did double-ought troll (or should I say double-aught?) finally get banned? her abusive potty mouth has been so blissfully absent for the past week…

  8. TsuDhoNimh says:

    A minor symptom can escalate into the perception of a serious problem with the collusion of a provider.

    Or worried family members.

  9. DW says:

    ‘In their eyes, their friends and loved ones were “doing fine” until they went to the doctor, so it must be the doctor who wreaked all this havoc. ‘

    Seems like the same psychology with the parents who tell you that their baby was fine until he got that shot, then the next day he turned red and cried a lot, so it must have been the vaccine. It’s partly mixing up correlation and causality but also, I think, a component of fear makes people paradoxically assign the blame to the person trying to help them. We want doctors to be all-powerful, because being sick is scary; on some primitive level it feels like if they can cure us maybe it’s their fault if we’re sick in the first place.

  10. Jan Willem Nienhuys says:

    Gorski wrote:

    After all, what are “homeopathic provings” but doing exactly what you describe?

    That was my first thought too. Moreover the homeopathic provings are almost always with the highly diluted stuff (C30). I conjecture that the belief in the biological activity of diluted stuff hails not from any kind of theoretical consideration about ‘memory of water’, but from the fact but from the fact that these provings (which were never truly blinded) were done with the diluted stuff.

    Why did Hahnemann go to dilutions at all? I think that if one does tests with nasty stuff like mercury chloride, arsenic and poisonous plants, one naturally wouldn’t use large doses. So when he found out people have also ‘symptoms’ with stuff that was diluted 1:100,000 he went on diluting, and of course getting frequently other symptoms at higher dilutions, reinforcing the idea that dilution beings out new properties. Table salt, i.e. Natrum Muriaticum C30 is supposedly one of the most potent homeopathic remedies.

    Few people realise that most provings were done with highly diluted stuff. Most, not all, in the sense that some ‘symptoms’ are taken from serious accidents reported in the medical literature. Some symptoms associated with Apis mellifica (mashed honeybee) are from reports about patients who got an anaphylactic reaction to bee stings. Most of symptoms of Cantharis (Spanish fly) come from accidental overdosing on this purported aphodisiac. But these are exceptions.

    Also one must realise that ‘healthy’ people in the time of the original provings (19th century) probably weren’t very healthy at all.

  11. Harriet Hall says:

    @BobbyG,
    “See Gilbert Welch’s “Overdiagnosed.”

    See http://www.sciencebasedmedicine.org/index.php/overdiagnosis/

  12. pmoran says:

    Some more formal information about the symptomatology of normal, healthy life.

    http://www.medicine.ox.ac.uk/bandolier/band115/b115-4.html

  13. MerColOzcopy says:

    I am new here, and I really don’t get what this site is all about. Ya, I get the part SBM good, CAM bad. I am a science-fact kind of guy which brought me here, some how. From your archives, is this the same stuff rehashed for the last 4 years? These posts, they seem to go on forever and sometimes say very little, sorry. Perhaps I just don’t get most of it because I am not a Doctor.

    “Exploring issues and controversies in the relationship between science and medicine”, I always thought medicine is science. Perhaps it should be “Exploring issues and controversies in the relationship between science/art and medicine”.

    People generally don’t crap themselves…they seem to know when to go to the bathroom. I am guessing they also know when to see a doctor. See, two sentences, accomplished the same thing.

    Why is it when you want to ask a doctor, you have to first talk to a nurse? Usually when I do see a doctor and ask, there are always follow up questions. Make sense?

    Why even doctors offices, how about everything handled through ER? Have the whole team in one place.

    Sorry for any and all grammatical errors.

    If any one answers, please the laymen coles notes version.

    Oh, also, I am a farmer, I liked that “cow pie” analogy:))))

  14. weing says:

    “People generally don’t crap themselves…they seem to know when to go to the bathroom. I am guessing they also know when to see a doctor.”
    I see you’ve never been to a nursing home.

  15. MerColOzcopy says:

    @weing

    Yes, I have been to a nursing home, but I didn’t spend much time checking the diapers. I assume at this point they have been to see a few doctors:))

  16. weing says:

    “Yes, I have been to a nursing home, but I didn’t spend much time checking the diapers. I assume at this point they have been to see a few doctors:))”

    Or not. I’d be very careful not to assume anything.

  17. kathy says:

    LMAO – we had a similar experience in our family in the bad old days of apartheid, when our black domestic worker had something really wrong with her. My parents tried to get her to go to the hospital but she refused point-blank … in fact she was terrified by the suggestion. A hospital was where you went to die, in her opinion, not get healed. Did they want to kill her?

  18. DugganSC says:

    Of course, she may have a point on hospitals… have you ever seen the reports on nosocomial infections? And that’s in modern hospitals where they do frequent sterilization of instruments and hands.

  19. I think part of the problem is lack of access. Relatively few docs give out an email contact for either themselves or a nurse. My husband had bloodwork done recently, and getting the (normal) results took several unreturned phone calls culminating in him just making a follow-up appointment. Time consuming, frustrating, and expensive. A quick email could easily have accomplished the same outcome as the appointment.

    I just completed two 8-week sessions of “Mini Med,” public lectures at a medical campus. It was a fantastic basic overview of health sciences and diseases. What was absolutely fascinating were the audience questions after the lectures. Many people brought questions and concerns about their personal health. The information they needed was more accessible in front of six hundred strangers in a lecture hall than from their own doctors. During the second eight-week session, the dean brought in 4th year med students an hour before the lectures to answer people’s questions. People stood in long lines with fists full of notes and lab reports.

  20. Mark Crislip says:

    I usually start my interview with the patient, after the introduction and why I am there, with “why did you come to the hospital?”

    Often the male says, usually irritated, “My wife/girlfriend made me.”

    That’s when you go to the doctor if male.

  21. DugganSC says:

    Although I can also understand the doctors not wanting to seem too accessible. My sister is in her residency and she’s already getting friends asking her for a quick consultation on this or that ill, sometimes at parties even.

    Of course, that reminds me of the old joke where a doctor runs into a lawyer he knows and starts complaining, “Every time I go to these parties, I get little old ladies coming up to me and asking me about symptoms they’re having. It’s driving me crazy!” The lawyer smiles and says, “Ah, I used to have the same problem. What I did was give them an answer, and then send them a bill in the mail the next day. No one ever paid, but they stopped asking.” The doctor thanks him for his suggestion and went on to enjoy the party. The next day, the doctor finds he has a letter from the lawyer… with a consultation bill attached.

  22. @DugganSC: It was a family secret that my dad was an auto mechanic for the very reasons you’ve described.

    Still, access isn’t always a bad thing. During the lecture series I mentioned above a good-looking ER doc gave his cell number to the audience so they could text questions for the Q&A after the lectures. The next lecture he said, “You may remember that last week I gave my cell number so you could text questions. We’re going to do that again this week, but I have one announcement, and that is that I am married.” Hilarious.

  23. @MerColOzCopy:

    Hahaha your comment cracked me up so much. Yes, your summary of this website is spot on. “SBM good, CAM bad.” Or, as I usually put it, “Hahaha oh look at how dumb everyone else is except for us!”

    Many articles on this site are interesting and informative but they DO go on for freakin EVER. They are not concise at all, which can be quite frustrating. I end up scrolling through the headings and skimming after the first few paragraphs because it truly does seem like I know what the punchline will be every single time. (See my first two sentences.)

    It amazes me that active, working doctors and medical researchers write these blog posts. I work in a medical research lab and the head researcher/PI/Boss is so busy I’m lucky to get a full sentence response from her in an email.

    As far as your other questions about doctor’s offices…I’m not sure why regular family practice doesn’t combine with the ER, but I imagine it is just a matter of keeping the records system less massive. (Imagine keeping track of regular care and emergency care all in the same department? That would be a logistical nightmare.) The one thing that would be nice is if there was more efficient communication between your regular doctor’s office and the ER.

    I would assume you talk to a nurse first at the doctor’s office because the nurse is treated like a doctor’s secretary, although the doctor also usually has secretaries as well that deal with billing and record keeping. It seems like the nurse is there as a buffer between you and the doc….to field anxiety and emotion you might throw at the doctor before you see him..and then to field questions and concerns that you have had information thrown at you about your health. Doesn’t really make sense to me why the doctor can’t do those things himself thereby saving time and money to pay two people to do one job. But, I guess I like that nurses can have jobs, and often doctors are so far into their own heads with all of this objective reality/factual/technical medical knowledge they have, that nurses are often better equipped to interact with people in a … well…personal way.

    Hope that helps. Sorry this was so long.

  24. Oh and another obvious reason they don’t combine the ER with regular family practice is that emergency situations often require a lot more serious, intense, readily accessible equipment and trained professionals than someone with a cold.

  25. Franky says:

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