23 November 2018

Keep calm and don’t panic

Communication General Practice

It happened to me again this week. 

What starts out as a quick consult to discuss a non-life-threatening, abnormal result turns into an exercise in damage control as it becomes clear the detection of a non-16/18 HPV strain on the CST is causing major panic in my patient, despite my reassurances.

Despite me explaining that the evidence-based recommendation is that we simply repeat the screening test in a year because it is likely the body will have cleared the virus, all my patient is hearing is wart virus and cervical cancer!

I’ve inadvertently caused major health anxiety in this poor woman. 

No doubt you will have had a similar experience. In these times of heightened awareness of health and, more particularly, of lives dramatically cut short through illness and disease, such acute health anxiety appears to be becoming more common. Google-fuelled knowledge of worst-case scenarios certainly don’t help.

 And you can’t always pick who will react this way, can you? 

You can’t know which patient is going to go to pieces when they hear they now have type 2 diabetes, or their BP is slightly raised and should be checked, or that it might be worthwhile having that unusual skin lesion removed. We can offer the same explanation of the situation to six different patients and get six different reactions.

You could say it’s me. You could suggest that I’m obviously doing something wrong – believe me – I have. 

But the reality is we, as GPs, walk a fine line in the reassurance stakes. 

I need this woman with the non-16/18 HPV strain to come back for a repeat test in a year – I can’t afford to be too dismissive of the implications of the findings and have her fail to return for follow-up. 

Similarly, we need patients to take our advice about future monitoring and treatment of their BP, blood glucose or skin cancers seriously, while at the same time quelling the panic.  

Added to the equation is the fact that GPs live with the constant fear of missing something. We don’t deal in absolutes. We never say never. We talk “most likely” or “hardly ever” – which a highly anxious patient rarely finds all that reassuring.

This juggling act was highlighted in a recent study in JAMA Internal Medicine.1 US researchers looked at the pelvic ultrasound findings in a large cohort of adult women, and the correlation of these findings with a future diagnosis of ovarian cancer. 

One of their findings was that the detection of a simple ovarian cyst on ultrasound (either pre or post-menopause) in no way predicted a diagnosis of ovarian cancer in the future. Not that surprising you might say as we know simple cysts are not pre-malignant lesions, but remember this was an ultrasound finding not a histological diagnosis. 

However, as the researchers pointed out, most guidelines recommend that these simple cysts get monitored via rescreening. 

Whether this is because we shouldn’t completely trust the appearance of the lesion on ultrasound or we shouldn’t completely trust the interpretation of the appearance is unclear, but ultimately it puts GPs again in that position of saying to the patient: “Don’t worry. You have a cyst on your ovary that is benign, but we going to check it regularly just in case!”

Even the study authors concluded this wasn’t ideal.

“While surveillance may not seem harmful, there is a growing realisation across all areas of medicine that unnecessary imaging is associated with morbidity, including wasted time, false-positive results, over diagnosis, unnecessary surgery and anxiety,” they said.

So how do we manage this? How do we balance this medicolegal reality of practising due diligence with creating an overly and unnecessarily concerned patient population? What can be done to foster pragmatism in place of this upsetting anxiety?

Well, as you might have already noticed, I’m no expert. However, what I have learned over many years, is to be sensitive that it can happen. And often in people who you might not expect would react in such a way. 

It’s sometimes very easy to forget, that for many people medicine is a bit of foreign language. My HPV patient is a case in point – she’s very intelligent and well-educated and an expert in a very different profession – however her knowledge of medical matters is superficial. 

Like many people, her emotional reaction to this abnormal result is based on preconceptions, prejudices and popular press information. And sometimes this isn’t easily countered with discussions about statistics and natural history of disease states, especially at first.

It is recommended that patients be informed of what an abnormal test result might mean prior to having the test – especially for tests such as the CST, PSA (not on the same patient obviously), NIPT and HIV to name a few. 

I’m not sure of your experience with this, but I have found it isn’t a guarantee to preventing patient panic. 

Acute health anxiety is a condition of the heart rather than the head. 

It is certainly real and certainly a problem. Now I’ve just got to work out how I can more a part of the cure than part of the cause.

Reference: 

1. JAMA Intern Med. doi:10.1001/jamainternmed.2018.5113