Doctored to Death?

What is a Doctor Junkie?

A commenter on the Medical Mafia post brought up the subject of doctor-junkies, and readers seemed fascinated by the idea.

Yes, doctor-junkies are real and they are everywhere!

Just as Doctorphobia is hazardous to your health, Doctorphilia can be equally disastrous.

Any regular reader of AskAnMD is aware that while MDs are useful, we can also be dangerous. An addiction to doctor-visiting will lead to lots of risky tests and medicines you don't need. Too much doctoring can take you to an early grave and make you miserable on your way there.

Who are these Doctor-Junkies?

Doctor-Junkie: (n) -a person who believes that every uncomfortable or unusual physical sensation must be evaluated by a doctor.

While most hypochondriacs are doctor-junkies, not all junkies are hypochondriacs. Some doctor-junkies aren't paranoid they have a horrible illness, but just feel every little thing must be "checked out."

Dangerous Doctorphilia is often an inherited condition. Doctor-junkies start out as those kids whose parents rush them to a doctor every time they sneeze or scrape their knee:

Once a mother brought her child to Doctor D's ER because the toddler had made an especially loud sigh. "A sigh?" I asked. "Yes, like this" and she made a sighing sound "so I just wanted you to check his lungs." Doctor D assured mom that we all sigh on a regular basis, but perhaps this sigh was louder because of her child's frustration that he had a mother with nothing better to do than gauge the volume of his sighs. She demanded a Chest X-ray just to make sure. Then Doctor D let out a loud sigh of his own.

You would think after a childhood spent in ER and clinic waiting rooms that someone would want to escape the world of needles and medicines, but the junkie is hooked by the time they reach adulthood. Any runny nose or sore muscle and the doctor-junkie gets that overpowering urge to visit somebody in a white coat quick. The doctor-junkie isn't satisfied with just an exam and reassurance, "No doc, I've been waiting a long time to see you so give me the good stuff—lab tests, X-rays, and lots of pills!"

To the doctor-junkie no symptom is too mild or too brief: every physical discomfort needs blood work and prescription medicine ASAP. If you doctor's office is on lunch break then junkies call an ambulance for that mild sense of nausea!

In addition to wasting billions of dollars, all those visits likely shorten the lives of the junkies. Radiation from imaging studies leads to cancers. Lab studies eventually uncover benign abnormalities that junkies need fixed. Junkies get some really nasty side effects from meds, because they've often been prescribed every medicine in the pharmacy.

Rather than forcing the junkie at rock bottom to change his ways, being harmed by healthcare has the opposite effect: a doctor-junkie who is sick from over-doctoring feels the compulsive need for more and more and more.

Who is to blame for this epidemic of Doctorphilia?

Doctors!

Yup, it's us. We have the stuff that junkies crave, and docs give out unnecessary care like candy till we get everybody hooked.

Why shouldn't we? Docs get paid to see people whether they are really sick or not. A proper exam followed by educating a concerned patient is difficult and time-consuming, while ordering tests and writing prescriptions is just so quick and easy. Doing unnecessary care and writing unnecessary prescriptions keeps patients happy with us because they feel they are getting something done.

Plus, it's nice to feel needed.

I know a doctor who shall remain nameless that gives antibiotics to every single person with a runny nose. Now almost all runny noses are caused by mild viruses that cannot be cured by any medicine. Dr. Zpack gives everybody a useless antibiotic and they all assume that the medicine worked when the symptoms resolve on their own. His patients are apparently unaware that human beings have immune systems. Dr. Zpack's junkie patients love him because he always "cures" their infection, and it's good business for him because half his visits are simple colds he can easily "fix" with one prescription. When Dr. Zpack's office is closed his patients panic and rush to the ER at the first cough. He's a nice old doc, but who knows how many superbugs and dangerous reactions have originated with Dr. Zpack's prescription pad?

The fact that doctors give out unnecessary care immediately legitimizes it. Patients accept that it must be safe and necessary if doctors order it. Some patients casually dabble in being over-doctored, but some susceptible patients fall over the edge into full-fledged addiction.

The Addiction Gets Ugly:

It's a win-win situation for the dealer and the junkie until something goes wrong: The junkie gets too demanding or overdoses on unnecessary care resulting in an iatrogenic injury. Then Dr. Dealer freaks out and cuts off the junkie cold turkey.

Doctor D has seen it too many times: panicked patients in withdrawal from over-doctoring pitching fits in the ER that they have to wait an hour to be seen for their runny nose.

Recovery:

Coming to Doctor D's office (or his blog) is like detox for doctor-junkies. Appropriate medical care is often a shock to the doctor-junkie's system. Doctor D has to explain to recovering junkies that the human body is actually capable of healing itself. Who knew?

Fortunately Doctor D has a 12 step program for the Doctor-Junkie epidemic. Tune in next week for my prescription for curing the over-doctored!

What do you think? Have you or loved one ever suffered from Dangerous Doctorphilia? How did you recover? Do you blame MDs for this problem?

Did you miss Doctor D? Where were you when you first heard the word iatrogenic? What other irreverent medical topics should this blog tackle?

As always, Doctor D loves to hear your thoughts and stories in the comments!

What Is A Proper Work Up?

Doctor D's post on Mystery Illnesses last week was pretty controversial. Some readers were concerned that D suggested we should sometimes give up looking for answers after a thorough work-up is negative. An intelligent reader remarked that Doctor D over-simplified because he didn't define what a thorough work up is. Excellent point:

What is a proper work-up?

Of course it's tricky to define because a good work-up varies significantly depending on the patient, the symptoms, and the situation. It would be tedious to go into the details of any specific work-up. Instead D will give you a simple answer:

The correct work-up is an investigation of your symptoms that is more likely to benefit you than harm you.

Work-Ups Are Dangerous

Okay, let's take a moment to consider a well-known but poorly-understood fact: doctors hurt people. I'm not talking about just bad doctors here, I'm talking about good responsible doctors. Yes, I know the whole motto of our profession is "First, do no harm" but doctors have to be reminded of that because the tools of our trade are inherently dangerous.

Running tests on a person is not harmless. We stick you with needles. We zap you with radiation. We inject stuff into you. Then we find abnormalities that require more tests. Don't get me wrong, this type of thing is often helpful and even life-saving, but every time we start down this path we risk hurting you. Even perfectly correct work-ups carry real risks and harm real people.

We have worked very hard to decrease these risks. In some ways the medical work-up is a victim of its own success: we have decreased the risk so much that we begin to assume it's harmless. Health care does a lot more good than harm, so we forget about the harm all together.

You can safely carry a weapon if you respect the danger it presents, but you'll end up shooting yourself in the foot if we forget it's a weapon at all.

Doctor D has seen enough people hurt by medical care that he has a healthy respect for the danger he puts you in every time he orders a test or a medicine. Unfortunately, most patients have little or no concept of the dangers posed by health care. Even patients who distrust doctors trust our machines and laboratories.

Work-up First—Ask Questions Later

When faced with illness there is a natural urge to do something! You feel rotten and you go to a doctor for a solution. You expect the doctor will do something, and if that doesn't work the doctor will do even more.

There is a very old medical term called, Benign Neglect. It means that if the symptoms are not likely dangerous and the best course of action is just to watch patiently without doing anything. Doctor D has never heard a physician younger than 70 use this term.

Today's doctors are men (and women) of action. We have the tenancy to work up everything just because we can—because we are scientists and want to get to the bottom of things. Then the legal system reinforces this behavior. Doctors are frequently sued for not doing enough, but almost never sued for over-testing or over-treating although these things are also dangerous. We protect ourselves legally and keep our patients happy by ordering big work-ups for every symptom. More is always better!

Consequently US healthcare is the most expensive in the world, and Americans get more tests and scans than anyone else, but we aren't any healthier or live any longer. In fact, the opposite is true. We forget that healthcare should be used with caution.

The Proper Work-Up

Diagnosis is the heart of medicine. You come to Doctor D sick and he will do his best to give you a good answer. Keeping you safe, however, is more important than giving you answers, and no doctor should forget that our first duty is to "do no harm."

Seeing a doctor about your symptoms is like hiring a trigger-happy bodyguard. It might be worth it if you're life is threatened, but if you life in a safe neighborhood the jumpy security might be more likely to accidentally shoot you than save you.

Before your doctor goes nuts with a big work up you may want to ask, "Do you think these symptoms represent a dangerous disease or is it safer to ignore them?" Some symptoms need the big work-up and some need nothing at all.

If you come to me with an uncomfortable runny nose and low grade fever for a couple days you probably won't get any more work-up than a careful physical exam. If I don't find a problem I'll say "It's probably a virus" and advise you to ignore it. I could order a CT scan of your head, but that radiation that is more likely to harm you than provide any useful answers.

If you come to Doctor D with "red flag" symptoms like significant unexplained weight loss he'll probably keep testing until he finds an answer—but not every situation:

Doctor D once had a 97 year old that came to him with unexplained weight loss and weakness. Doctor D said, "This could be a lot of things, many of which are serious, but at your age aggressively finding and treating the serious ones are more likely to cause you pain than prolong your life. My advice is a few basic blood tests to rule out things that would be easy to treat. If that doesn't show anything then let's just treat the symptom with high-calorie shakes." The patient agreed and we did a tiny work-up that gave no answers. We treated the symptoms and he lived comfortably for several more years before dying in his sleep. I have no idea what finally killed him, and I really don't mind not knowing.

You Are The Boss

The harms or benefits of a work-up can extend beyond just the physical effects. Many comments on the last post mentioned the amount of personal reassurance people felt upon finding out the name of an illness. Personal values and perspectives on disease, diagnosis, and medical care vary drastically between people. Some hate the anxiety and discomfort of a work-up far more than their illness alone. Some hate the uncertainty of not knowing their disease and will undergo any painful or risk test just to find an answer.

Your work-up is a personal thing being done to your body and it should reflect your values.

Your body is yours and your doctor works on it for you. You are supposedly directing the care. Unfortunately, you don't always get to exercise your authority in the situation because your doctor is usually responding to what he or she guesses you want. First your doctor comes up with a large work-up because they assume you want it. Who wouldn't want lots of tests, right? If by chance the work up is inconclusive your doctor (or doctors) decide you must want it stopped, because further testing is risky without offering a lot of expected benefit (since most scary diagnoses have already been ruled out). Then if you say you want to keep going with the work-up the doctor suspects you are neurotic since you are acting against your own best interest.

A thorough work-up is complex, but your busy doctor may not take the time to discuss it. But the good news is you are in charge and don't even know it.

It is important for you to take charge of your work-up. Tell your doctor your values. Say what you want from your work-up. Ask about the risks and the benefits of tests. Remember the doctor is a dangerous ally, and communication is the safest way to take control of your healthcare.

In next week's post Dr. D will give practical tips for working with a doctor to manage your work-up.

What do you think? Do you think much about the risk of medical testing? Does your physician ever discuss risks of work-up? How would do you think your personal values would affect your approach to a work-up? Doctor D loves hearing your stories and thoughts in the comments.