What Doctors Could Learn From People With Hypochondria … er, Illness Anxiety Disorder

Health and medicine explained.
July 6 2014 9:09 PM

Doctors Could Use a Little Hypochondria

Why medical students panic too much and M.D.s too little.

Doctors and Interns, Miami
First- and second-year medical students think they’ve contracted whatever disease it is they’re studying. Doctors think they are indestructible. Above, physicians and interns at a hospital in Miami in 2013.

Photo by Joe Skipper/Reuters

Here is a partial list of conditions I have read about in the past few days: tinnitus, intermittent explosive disorder, Morgellons disease, high metabolism, low metabolism, and rabies.

Katy Waldman Katy Waldman

Katy Waldman is a Slate staff writer. 

And here is a partial list of conditions I subsequently thought I might have in the past few days: tinnitus, intermittent explosive disorder, Morgellons disease, high metabolism, low metabolism, and rabies.

The old medical term for believing you are sick when you’re not was hypochondriasis. (According to medieval learning, such morbid musings were prompted by melancholy humors released from the viscera under, or hypo, the cartilage, chondrion, of the breastbone.) Hans Christian Andersen was a hypochondriac, speculating that a spot above his eye might grow to cover half his face. He traveled around with a note—“I only seem dead”—to prevent anyone from burying him alive. Charles Darwin transcribed the symptoms of nameless, proliferating maladies in his bedtime reading (and kept fart logs).

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Last year, the fifth edition of psychiatry’s Diagnostic and Statistical Manual of Mental Disorders replaced the DSM-IV’s hypochondriac diagnosis with two new complaints: somatic symptom disorder and illness anxiety disorder. The first describes an excessive preoccupation with medical ailments that may or may not have physical origins (e.g. you have a slight gastrointestinal issue that you obsess over). The second, a subset of anxiety disorder, is an intense fear of health problems that persists in the face of professional reassurance. These diseases, which often unfurl in early adulthood, afflict men and women in equal measure. Their milder cousins are everywhere: at work, where your co-worker squirts Purell on his hands 20 times a day, and at home, where your spouse is Googling “stomach pain” and growing increasingly panicked.

The Web has inflamed all of our worst hypochondriac tendencies by making data on far-fetched syndromes readily available. But what about the people who already live and breathe that information? If my momentary Internet exposure to the science of my own metabolism was enough to make me sweat about horrible pathologies, then what is it like to be a doctor? Does every pang inspire dread? Do the seductions of self-diagnosis increase when you know whereof you speak?

They seem to for medical students. Medical student syndrome is a well-documented phenomenon, a one- to two-year phase during which aspiring physicians think they’ve contracted whatever disease it is they’re studying. A stomach gurgle becomes appendicitis. A mosquito bite heralds hemorrhagic fever. Everything is cancer. The research on medical student syndrome is less robust than the anecdata: Though one study from the 1960s found that more than 70 percent of medical students develop phantom illnesses, another study two decades later suggested that the effect was exaggerated—and that law students are just as neurotic about their health as their M.D.-seeking peers. (A third study revealed that psychology students grew more confident in their own mental health as training progressed, but were ever more likely to start diagnosing their family members with psychological disorders. Lovely.)

Doctors talk about medical student syndrome as a rite of passage. “I had the syndrome. We all did,” says Leana Wen, an emergency care physician at the George Washington University hospital. Five other white coats I contacted for this article (some of them occasional contributors to Slate) agreed. Matt Morrison, an emergency room doctor at St. Luke’s-Roosevelt Hospital in New York writes:

I was once CONVINCED I had Boerhaave syndrome, an extremely rare condition where your esophagus is ruptured and acid and air spill into your chest, because my chest tickled after a small bout of coughing. I spent two hours in the dark, unable to sleep, listening to my chest with a stethoscope, and UpToDate-ing (our version of WebMD) the various ways in which I'd be dead before morning. I ran to the Emergency Room and told them I needed a stat Gastrografin Esophogram, stat as in: yesterday. The attending took one look at me and said, “Congratulations, you're a cliché! Go Home.”

The cliché makes sense. Medical students are swimming in new information about terrifying diseases, but they don’t have the experience to recognize how unlikely those diseases are or how they fully manifest. The students’ snowballing knowledge knows no context. “They’ve got all these facts, but no patients to pin them on,” says Catherine Belling, author of A Condition of Doubt: The Meanings of Hypochondria. “They just have themselves.” It doesn’t help that, as placebo studies keep demonstrating, our bodies are highly suggestible to inferences from our minds. “The automatic processes of the body are in general performed best when the attention is directed elsewhere,” wrote George Walton in Why Worry?, the doctor’s 1908 treatise on “undue mental solicitude.” “Too minute attention to the digestive apparatus, for example … is like pulling up seeds to see if they are growing.”

But something happens in your third year of medical school, when you begin your clinical rotations. Look more closely at the study that compared medical students with law students, and you’ll find that, while the average quantities of angst were similar, the med students fretted far more than the law students during the first two years of their program and far less during the last two years. As patients flow in and the dichotomy between doctor and doctored begins to solidify, a switch seems to flip. Beginning medical students think they’ve got every disease under the sun. Practicing physicians think they are indestructible.

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