C. Little: Advance Catastrophication

Imagining and then worrying about the worst possible outcome, even when really unlikely, and then acting on that fear I characterize as advance catastrophication. (Others may use the alternate “catastrophization.”) A headache? Must be a brain tumor. Pain in my belly? Colon cancer, OMG! If you as a patient get carried away occasionally, you can be forgiven, since you most likely have insufficient medical knowledge to get to an answer calmly and accurately, and searching on the Internet almost always will increase rather than allay your fears.

Preparing for the Worst

During our regular medical interactions, I work hard to evaluate your health status, to listen to you carefully, to think about your personal health context and what data we have about you, when appropriate to suggest new data be gathered by tests, and in general to evolve a medical risk analysis for you that puts into perspective how healthy you are and what types of medical (or social risks) could endanger your well-being or even your survival. In that fashion we are well prepared for unexpected symptoms or illness.

Then, should a substantial medical concern arise for you, my job as your physician is to help each of you to calmly confront the situation, work together to identify the medical cause, and then provide a remedy. In that process, I focus first on the likely culprits, but also make sure to screen for highly unlikely but possibly really serious issues if they could be time sensitive.

Time Dependency of Catastrophe

Sometimes doctors feed a tendency to advance catastrophication. Headache? Probably sinus, the doctor says, but could be aneurysm or brain tumor. Better get that MRI right now. You, the patient, who just thought you had a sinus problem, now get panicked that you might have a brain tumor and can’t sleep till you get that MRI. After all, your doctor was worried about it. OMG.

Perhaps you were the one who asked, Doc, could this headache be a brain tumor? And the doctor’s reply was, Sure could. And that’s accurate, because without a brain imaging study no doctor can tell you it isn’t a brain tumor. There is no absolute “yes” or “no” in medicine.

What the doctor might better have said would have been, Most likely to be sinus because the symptoms are typical for that, and really really unlikely to be a tumor because the symptoms don’t really match. But we will do an imaging study in 2-3 weeks if you are not back to normal. If you, heaven forbid, have a brain tumor, a delay of several weeks in diagnosis is extraordinarily unlikely to make a difference in the outcome. If you could be cured now, you will be able to be cured in 3 weeks. But you with high probability just have a sinus infection.

Proceeding Rationally, Safely and Effectively

In other words, the trick to proper care and advice is first to be prepared with thorough preventive risk evaluation for each person. Then in the context of any illness or adverse event, carefully evaluate what conditions are most likely and then test and treat for them. But also think through all those unlikely conditions that might be at play and determine if extra diagnostic tests or preventive measures must be taken right now, because the risk of irretrievable damage is high if there is any delay, or whether such further measures can be taken calmly and equally effectively a bit down the road if the most likely diagnosis and treatment turns out to be wrong or inadequate. In other words, pay careful attention to the time dependency as well as severity of alternative diagnoses.

Advance catastrophication, by patient or doctor, usually leads to unnecessary worry for the patient as well as too many interventions with risk of adverse effects not to mention excessive cost. It rarely is warranted. Prepared, thorough, thoughtful and calm analysis and timely staging of tests and therapies is the correct approach and that which I espouse and try to follow.

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