Monday, July 4, 2011

Must the doctor ALWAYS be in?

First of all, for any of you who decided to read this post because you thought it might be a follow-on to the discussions about whether it's ok to work part-time in medicine, nope, that's not what this is about. Rather, it's about the tendency to wear our doctor hats even when we're off-duty, when it comes to our own health.

It was a Facebook status update, or rather a string of them, that first got me thinking about this issue: the epidemic of medical hypochondriasis among doctors and other folks in medicine. (For my friends in psychiatry, let me apologize for using hypochondriasis in the lay sense, not with any DSM criteria attached, and for my friends in epi, I know it's not really an epidemic.) A friend of mine, who is a mom of three and a critical care nurse practitioner in the PICU of a large academic center, often posts on FB about her anxiety related to her kids' health. One of them has a fever, and she wonders aloud whether she is the only mom checking for petechiae. Another says she's too tired to bike (in the 98 degree weather) and wants to come in and watch TV in the air conditioned living room instead, and she frets about whether she is severely anemic--it could be acute leukemia! It is easy to witness someone else do this and see the absurdity in it, but when it's YOUR lymph node that you think you might feel in your neck or YOUR lumpy breasts or YOUR bone pain, etc, it becomes a lot easier to let your mind spiral off into the crazysphere.

Most of the mothers in medicine with whom I have discussed this freely admit, "Oh yeah, my thing is cancer" or whatever. Everyone seems to have something she is convinced she is going to get, and it's often what she's surrounded by, not what she actually might be at increased risk for due to lifestyle or family history, that seems to drive the fears. My good friend from medical school who is now a pulmonologist in a tertiary care center became convinced that she had pulmonary fibrosis when she found herself out of breath in kickboxing (after taking off 2 mos from it). Another friend who is a high-risk OB attending just about drove herself insane with fear that she would have fetal death in utero. I have seen her on multiple occasions in all of her (3 healthy) pregnancies sitting in the hospital cafeteria with a sugary drink in one hand and the other hand on her gravid belly, brow furrowed, checking for fetal movement. Another who is a rheumatologist is obsessed with developing lupus, and given that lupus can cause any number of symptoms/signs, she gets a near-weekly dose of affirmation that THIS TIME, she really does have lupus. Kind of ridiculous, right? Except when you're in it rather than on the outside looking in.

I find myself worrying about cancer mostly, which I guess isn't shocking since I'm an oncologist. Every patient I see--well, except for a fortunate few who have been misdiagnosed--has cancer, 100% of them. And I see mostly second opinions, so they are usually pretty sick and often complicated patients. Though they all come with a big, thick chart, I always take my own history, and even in patients with several years of metastatic cancer, I always start with how the cancer first presented. I am struck again and again by how subtle the first signs were--that little twinge of pain in the chest that only lasted for a few minutes or noticing that she was slightly winded, just slightly, after dashing up a couple flights of stairs. Or whatever. I don't see the zillions of people who also had little twinges of pain in their chest or mild dyspnea who turned out to have costochondritis or an albuterol deficiency or absolutely nothing at all. I don't see ANY of those people. In other words, I have no denominator to provide me with perspective. Of course, these histories I'm taking are all retrospective, and maybe the "first signs of cancer" patients report were in fact utterly unrelated to their diagnosis, but have taken on significance in the wake of being diagnosed and repeatedly asked these questions by oncologists. All of this, I know, but I can't seem to remember any of it when it really matters.

So, I wonder: does this worry simply come with the territory when one works in a field where life-threatening diseases are the price of admission? Would I still worry if I were a primary care pediatrician, where the majority of my patients are so healthy they are actually labeled "well child"?

Do you find yourself worrying more than you feel is reasonable about your own health or that of your family/friends? Do you worry about the diseases you see in your own practice, or do you have "a thing" like cancer that you worry about, even if it's outside of your usual practice? And if so, how can we do a better job of being a voice of reason to each other? Because we are doctors. And we are mothers. Which means we have more than enough REAL things to worry about!

16 comments:

  1. My sister has CF, my dad had retinoblastoma as a kid and prostate cancer 5 years ago, my mom had heart problems my entire growing up life and finally was correctly diagnosed with an ASD my freshman year of college. 2 open heart surgeries later she was fixed. It seems like every minor thing in my family becomes something major. My dad is giving my sister a kidney tomorrow and everyone thinks I'm nuts because I'm still working tonite and I said it's just a little surgery ... And in my family it is. There is absolutely nothing wrong with me ... Yet I am firmly convinced that I am dying every time I get a cold or a bruise or a tickle in my throat. Thank goodness I have an understanding doctor! :)

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  2. I'm not a doctor and I still have fears. Family histories play a large role in those fears. I'm constantly worried that my lumpy breasts are more than just lumps, but the mammograms and ultrasounds are fine. I feel that once we have kids our health matters more, we don't want to miss our kids growing up.

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  3. Great post! I go both ways, here. I have days when I see breast cancer in a 30 year old lactating breast and freak out,lock the door to my office, and do self-breast exam, but mostly I think I'm the other way with my health and my kids - ignoring too much and not sweating over little things. I did check them for Wilm's tumor a lot in the tub during my pediatric path oncology rotation, however.

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  4. What I have noticed is that I worry about big, scary, unlikely things sometimes(could she have an insulinoma? are those thigh petechiae a sign of leukemia or just from slapping herself over and over in dance class?), but when it comes to reality, I tend to minimize and overlook illness/injury. No, you can't have broken your wrist because it's just too inconvenient when we're on vacation. Convince me ("Mom, I really think my wrist is broken. Usually when I hurt myself one sip of soda makes me feel better, but I have had 3 sips and I am still crying.") Why do I have such a whiny child who is taking herself out of the line up in basketball for two weeks complaining of a headache? Oh, oops, sinusitis. Honey, you're pinky is fine; a month later, it's pretty misshapen-- oops, tore a tendon. Someone asked me once how often my child has a fever. Wouldn't know. Only have taken it a couple of times. To be fair, she has never had a febrile seizure, so maybe she just knows better than to get sick.

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  5. Oh, how I relate to this post. I'm a generalist OB/Gyn, but I do a lot of high risk OB, so I've seen far too many zebras. I just had my first baby, and it was an awful pregnancy because of my anxiety. That said, I did have several complications to be anxious about. Part of me would like to believe that if everything had been normal and uncomplicated, I wouldn't have had the same anxiety. As it was, I took each new development and ran with it. And I managed to terrify my husband and family--none of whom have any medical training--with so many what-ifs that they ended up even more anxious than I was. I wish I weren't so darn persuasive. My partners, who were caring for me, were anxious as well, and I think my care was far, far more conservative than it would have been if I had just been a regular patient. We all really needed a reality check, and it's a shame that there wasn't anyone around who could provide one.

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  6. Don't know what to say. I have been on a bad side. Innocent chronic symptom turned out to be a brain tumor. Non-medical professional insisted I get MRI, my doctor felt it was not warranted. Thank God for the lady who saved my life. I do not take my health for granted anymore.I try to pursue more aggressive healthcare than before. When you work 80-100h a week and have a newborn you are supposed to feel tired, right? Well, I also suffered from increased intracranial pressure.

    Had a colleague who ignored her symptoms for months = stage III cancer. Only too bad she was an oncologist. I recommend - listen to your body and do not be ashamed of seeing your doctor.

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  7. I lean towards the "not worrying enough" side. I see lots of horrible, life-changing and sudden, life-ending problems in my practice. Brain hemorrhages of all descriptions, brain tumors, spinal cord injuries, the list goes on.

    I know, boy do I know, how suddenly and catastrophically everything can change, often with no warning at all. I think in order to deal with this and keep functioning, keep living, I engage in a lot of denial.

    I know it can happen to me or my family, but it's easier to assume that it won't. Maybe that's not healthy, but it keeps me sane.

    Many of the things I see can't be foreseen or headed off at the pass. I guess one of my philosophies is not to worry about things I can't change or prevent.

    That said, obviously I vaccinate my child and take any potential symptoms seriously. I tend to be more concerned than my husband, who is much more reluctant to "bother" our pediatrician. I am actively working on improving my own fitness (finally).

    In the end, a strong faith helps me avoid too much worry. I figure the "man upstairs" has a plan for us all, and everything happens for a reason. Simplistic, but it's a comfort for me... and for many of my patients who desperately need something to help them through life's trials.

    Maybe this is one reason religion has survived through the whole history of humanity (so far), for better or worse.

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  8. I'm an internist doing outpatient primary care. I really do believe that seeing all those truly 'worried well' patients helps alleviate my worries about minor symptoms. I tend to lean towards the 'let's wait it out and see what happens' end of the spectrum when it comes to myself or my kids. I am, however, a fanatic about making sure everyone in my family, including my parents, gets all their age-appropriate preventive visits and screenings.

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  9. Since I've had several miscarriages, I have become that medical student who has run the list of all the bad things that could be causing my problems in my head. It's not especially comforting to hear from the doctor that my next pregnancy has a 60% chance of going to term. Woo! That means a 40% chance of NOT, and I know exactly what that entails. Yes, things could turn out ok, but there's also a good chance they never will.

    So I guess I can't really relate to this since bad shit is happening to me, and as a medical professional I know what all of it means.

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  10. @hh, I tend that way too. I'm a peds ER doc and both of my kids have scars from injuries that I would have sewn up in other kids but in mine, meh, they'll be ok. But trauma season in our level 1 ED brings out some serious anxiety when I know my kids are in the car. I keep it to myself, but I am on pins and needles until I hear that they've made it safely to their destination. And I have recurring nightmares of being in the trauma room with a kid and realizing that it's one of mine. I think this is part of the burden we shoulder as physicians..... I work really hard to not let it impact how I parent, that is, I try not to be over protective, but I still haven't figured out the healthiest way to manage the internal anxiety

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  11. I don't really worry too much about what could happen. In medicine you see all the time diseases that happen out of the blue in someone who is perfectly healthy. All you can do is take care of your own health and your children's the best that you can. I don't think excessive worry and obsessive thoughts help anyone. I have too much on my plate to deal with in the here and now to worry about something I can't control in the future.

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  12. Best thing I've done in my own care is go to a doctor who doesn't know me from anyone. My specialty is overrun by doctors getting cancer because they came up with their own stories about why they have symptoms or saw a friend for treatment. Do the diagnostic workup then say it's nothing...

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  13. I'm afraid of menopause. I see a lot of women who have a really difficult time with 'the change.'

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  14. I lean to the "don't worry enough" side as well. Had a time where I went in to the doctor's office because I was having "a bit of trouble with my asthma" - my words. Ended up sent to ER by ambulance because my O2 was 85%, my heartrate was in the 130s and my BP was 85/50 which is low even for me (normally, I'm around 100/55). I've smartened up a bit since then (in part because my doc read me the riot act about following my asthma action plan meaning go to the flippin' ER when I can't say more than a word at a time and threatening to fire me as a patient if I ever scared her like that again, in part because it scared the crap out of me, and in part because I can't afford another ambulance ride), but I'm still more likely to let it wait until I can get in with my normal doc than to go to after-hours or emerg. That said, I monitor my PEF and breathing almost obsessivly when I'm flaring and check with the action plan every hour until I turn the corner.

    I blame dad, who was a doctor and had pretty much that "suck it up and tough it out" attitude - though if I think back, I ended up admitted a few times as a kid for asthma attacks that probably could've been headed off with a pred burst.

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  15. As a hypochondriac NOT in the medical field, I can only imagine what you guys are going through...

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  16. Thanks for the wonderful post! As a 4th year medical student I often wonder if my med school-induced hypochondria will ever abate - good to know that if it doesn't, at least I'll be with friends :)

    I've also fallen into "hypochondria-by-proxy," where I can't help but imagine all the horrible things that could be happening to my loved ones...

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