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.
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).
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.
Doctors make the worst patients, the adage goes. They seek medical treatment less and “tough it out” more. If you were to pick a population that was least likely to contain hypochondriacs, it might very well be physicians (though it is also true that, on average, physicians are healthier than the typical person). “I think I minimize more now,” says Jacob Sunshine, an anesthesiology resident at the University of Washington. “Once you have the expertise and the experience with people who are very sick, you can triage yourself and think things are probably OK.” And New York M.D. Randi Epstein echoes: “I tend to be really optimistic when it comes to my health, as I thought most doctors were.”
Things only got more frank from there: “I know I’m fine,” Wen said on the phone. “My husband, too—he has to be dying to make me pay attention.”
Journalists read journalism. Soccer players watch soccer. Chefs patronize restaurants. Why are doctors so resolutely convinced they don’t need medical treatment?
Perhaps these anti-hypochondriac doctors are simply behaving rationally. As Sunshine notes, physicians are often qualified to diagnose themselves, and they realize that the most common afflictions are generally the least dangerous. Rather than endure the vagaries of the medical system (with which they can be all too familiar), some opt to let conditions resolve on their own. Plus, “we’re really, really busy,” adds Jordan Metzl, who specializes in sports medicine in New York. In the few hours that residents get away from the hospital or the clinic, they are unlikely to wish for further contact with the medical establishment. (When I asked Metzl about his doctor-going habits, he replied: “Hate it. Never go. Never.”) A New York Times article from 2013 points to another factor: The piece, which reported on the less aggressive routes that doctors tend to take with end-of-life care, implied that working in medicine may give you a more realistic sense of the field’s limits.
In addition, doctors are … different. “Most of us have a reasonably high threshold for unpleasant things,” says Sunshine. I heard from several physicians who believed their white-coated fellow travelers were “tougher” than the typical patient. Again, these psychic calluses seem to develop in the third year of medical school: As Danielle Ofri observes, that is the time that “figures prominently in studies that document the decline of empathy and moral reasoning in medical trainees.” Spending your day among the truly sick and suffering hardens you. Not only is there a self-protective impulse to shut out the pain of others, but you have less emotional bandwidth for minor complaints, particularly your own.
Hypochondria also represents a challenge to medical authority. “I’m not surprised you’re not finding many” doctors with the condition, Belling told me. “The main question of hypochondria is, ‘How can you know for sure?’ ” Often, it is a doctor’s job to be certain, to assure a patient that a negative test signifies a clean bill of health. But hypochondria arises from uncertainty, and “uncertainty exposes the difficult truth about medicine: There’s always room for doubt.” No wonder physicians resist such a subversive mindset. Hypochondriacs, Belling points out, are right about one more thing: Disease and degeneration never fail to win in the end.
Of course, not all doctors see themselves as magically impervious to illness. Chavi Karkowsky, who practices in the field of high-risk pregnancy, believes that her knowledge of all the things that might go wrong for expecting mothers has changed her frame of reference. “I felt much more nervous when I was pregnant,” she said. “I’d seen the pathologies; they felt very present to me. In pregnancy, the world functions under this illusion of ease and certainty, this idea that pregnancy is totally safe. But those who work in it know that’s not true.”
Is it a problem that physicians rarely imagine they suffer from a serious disease? Sunshine might prescribe an occasional dose of hypochondria to members of his profession. “Doctors see crazy and heartbreaking stuff all the time,” he wrote. “To put yourself in your patient’s shoes, even for just a moment … makes you realize how lucky you are. Not just to have the privilege to help someone during their worst time, but also to put things in your own life into perspective. My sense is it makes you a bit more human.”
Then he reassured me that I don’t have rabies.