Consumer Driven = Anxiety Driven?

What if, every time a passenger got nervous on a commercial airliner, the pilot had to land the plane?

This is often how I feel we are running the practice of obstetrics.

Most of us who work in the field know that most little aches and pains during pregnancy are just that. Fifteen years ago, when I started out as a midwife, we used to call them "the general miseries of pregnancy," we gave a pat on the shoulder, a dose of sympathy, and that was that.

Now, fifteen years later, I find that we are letting our patients' anxiety (and they are an anxious lot indeed) drive our medical decision making process.

Pt. calls doctor and says "I don't think it's anything, but I thought I should call and check it out..." Doctor says to triage midwife, "I'm sure it's nothing, but she sounded really anxious..."

I still pat my patients on the shoulder. I still tell them about the general miseries of pregnancy. But I'm also obliged to act as though their minor concerns are serious when I know that they are not.

Things that I used to triage over the phone-- like bloody show at term-- now need a full scale evaluation

I don't believe this is harmless.

Why have trained professionals with years of clinical experience if you train them not to trust their own clinical judgement.

Every time a passenger on a plane "hears a funny noise" the plane is not about to crash.

And every time a pregnant patient feels a twinge, it doesn't mean impending disaster.

Munchausen's Syndrome by MD?

There is a medical practice that serves the big-city hospital where I work whose patients are highly anxious. Sometimes the nurses and midwives debate which comes first-- the patients' anxieties or their doctors overtreatment.

That got me thinking about Munchausen's syndrome, in which people try to create symptoms of serious health problems in order to get attention from healh care providers, and Munchausen's syndrome by proxy, when parents try to create symptoms in their children. I started wondering if there could be a third category, Munchausen's syndrome by healthcare provider proxy, in which health care providers, by giving dignity to complaints that we believe not to be signs of substantive health problems, are encouraging attention from our patients.

To wit, I saw a young woman recently during her second trimester for vague abdominal pain. When I saw her, she was afebrile and had a normal appetite. No nausea, vomiting, diarrhea. No feelings of pelvic pressure or back pain. She was sent in to the hospital to rule out preterm labor. When she arrived at the hospital, I discovered that her abdominal pain was very non-specific, sometimes it was in her upper abdomen, above the uterus, sometimes in her lower abdomen.

My impression was that she was worried but well. Her abdomen was soft and non-tender, her vitals were stable, she did not appear to be in a significant amount of pain. But because she was there, we did a battery of tests, ruling out everything from gall stones to preterm labor to appendicitis.

When I put in the order for the abdominal ultrasound, I saw that she had been evaluated before for non-specific stomach pains.

Now, here's the thing. Had this patient belonged to another MD, she would not have gotten all this expensive medical testing. If she had been my patient, I would have done a quick evaluation and a minimum of testing. I would have been confident in my judgement that she was okay.

This is not radical. I would have done the same if my daughter came to me with a similar stomach pain. As a mom, I have a pretty good idea of when I can tell her to take a couple of TUMS and when I need to call the doctor.

I don't honestly believe that her doctor thought there was anything wrong with her either. I think she's just someone who habitually orders every test, and who does it because it's easier, and because she thinks it protects her from liability, and because her hyper-anxious patients like it that she leaves no stone unturned.

But the patient, as many of the healthy middle-class women I see, seemed disappointed that all her tests were coming back normal. She was resistant to being reassured. Eventually, after thousands of dollars worth of tests, she went home. We told her to take TUMS.

Whose fault is this?

Don't we owe it to our patients to reassure them? Don't we owe it to say, these are normal aches and pains and you don't need to worry?

By overtesting our patients whom we don't believe to be unwell aren't we providers participating in Munchausen's by Medicine?

I wonder