The worried well

PRIORITISING THE PHYSICAL OVER THE MENTAL

The ‘worried well’ are not a clearly defined group — the only shared characteristic being that the doctor does not see pathology. Patients with this label could range from someone with a concerning symptom that turns out to be nothing, to someone with severe health anxiety. The term suggests that these patients are well; however, for some patients, the condition of health anxiety, for which the term ‘worried well’ is often used, is a serious and potentially debilitating condition. When investigated, one group labelled as ‘worried well’ were found to have substantial mental illness¹ and therefore these patients need medical help.²

For doctors, it is wrong to imply that worry in patients does not matter and is a lesser symptom than others. The implication of the phrase is that pathologically based disease is more important than emotionally based disease, so the phrase reflects old-fashioned ideas about mental health being less important than physical health.

UNDERVALUING PATIENT CONCERNS

Patients are (mostly) not doctors and should not be expected to evaluate whether symptoms are serious or not. Public health and charity awareness campaigns are constantly urging patients to see their GP about potentially serious symptoms. Often, very little thought has been put into considering the actual prevalence of these symptoms in the ‘well’. The media is full of stories about people who had some minor symptom or accident that turned into something extremely serious. Such stories often end with the message of ‘if you have this, see your doctor’. Patients are worried about such symptoms when they see these kinds of campaigns or stories and might reasonably want to consult their doctor.

Use of the term may lead to patients being inadequately investigated. The more popular the term becomes, the easier it is for doctors who cannot quickly identify physical signs of disease to label the patient as ‘the worried well’. This can mean that the patients’ symptoms do not get thoroughly investigated and diseases may get missed. Research on this group has revealed that only 14% of those who frequently present without clear physical findings have somatisation disorder and that 86% have organic disease or minor acute illness.³

General practice is considered to have a problem in the early diagnosis of cancer⁴ and Cancer Research UK has recently called on GPs to react more to ill-defined symptoms.⁵ Patients continue to report unfortunate anecdotes of missed diagnoses of cancer. It is easier to miss something significant when the doctor is thinking in terms of ‘worried well’. Furthermore, if a doctor is in a negative mindset, they are less likely to take the opportunity provided by the consultation to foster health promotion and build relationships.

DISMISSING THE PATIENT’S CONCERNS

The term itself is now used as a diagnosis,⁶ despite the fact that it has never been properly defined. Without clinical guidelines, doctors are labelling patients, having made a judgement call over which side of the very hazy rational/irrational line patients’ anxieties fall upon. Making this diagnosis leads to a dead end. Maybe further research in this area, as suggested by Pontious,⁷ would enable doctors to quantify the problem and then explore the best forms of management.

The phrase inevitably represents a breakdown of communication between doctors and patients. This casual and dismissive term is one used between doctors and almost never between doctor and patient. This breaks transparency and trust in the doctor–patient relationship. Using a term that is more clinical, such as health anxiety, would mean that the doctor can be more open with the patient about their concerns. It also means that the patient is more likely to understand their situation and the doctor’s response. This increased trust is likely to result in better outcomes for the patient.

Ultimately, the term is simply patronising. The mocking tone of the alliteration used is unpleasant and can be seen as doctors stooping to use ‘playground-like’ names. This is unprofessional and, when patients hear about it, it is likely to reduce their confidence in the profession.

In general practice, there is a great emphasis placed on patient education, early detection of disease, patient engagement, and disease prevention, and therefore well patients should be encouraged to take responsibility for their health. The phrase ‘worried well’ represents a misunderstanding of the nature of general practice in the front line of the national health system, where it is important that patients have a place to go when they have feelings and symptoms that they do not understand. An important part of the GP’s job for 200 years has been to provide reassurance, and this is an implicit and valuable aspect of general practice. GPs sometimes see patients who arrive crying and leave laughing, when something that was worrying them greatly was resolved through reassurance. Rather than labelling patients, GPs might share the patient’s relief where appropriate, and also reassure the patient.

CONCLUSION

It is inappropriate to distinguish worthiness between patients, and the essence of person-centred medicine is to respond to each patient as a valuable human being who can be treated with respect. Calling patients ‘the worried well’ is disrespectful and doctor centred. It should stop. It devalues general practice, which is the branch of medicine that has the most to do with the group of patients given this epithet and can do most to help them.