Samir Dawlatly: Sabre-toothed tigers and the lottery

The other day an older gentleman* was brought to the GP surgery where I used to work. He was feeling nauseous, and his concerned family had initially taken him to the local pharmacy to see if there was anything they could buy over the counter to ease his symptoms. As he was on a number of medications, the pharmacist was reluctant to sell them anything and advised them to see a doctor, so he was squeezed into my morning surgery as an emergency appointment.

I assessed him, examining his stomach and respiratory system, and taking measurements of his pulse and blood pressure. He looked like he was perhaps coming down with a stomach bug. Common things are common after all. I explained that it was impossible to diagnose the cause of nausea when it had only started six hours ago. We discussed whether some anti-sickness medication would be appropriate. I offered to review him if things changed or to discuss the family’s concerns.

The patient and the family seemed disappointed that I couldn’t make things better straight away. Later that day, I phoned them up to see if his symptoms had developed into anything that could support a diagnosis and perhaps change the management plan. He had started vomiting, which was distressing to him and his family.

“We’re really worried about him, doctor,” the family member said to me on the phone, “So we’re taking him up to A&E.”

“Well, I don’t think A&E will do much,” I commented, but wished them all the best. A few days later, I got a letter from the local hospital to say that the patient had attended and been discharged home the same day with a presumed viral vomiting bug.

I find the level of anxiety over health, which is displayed by the general public I see, intriguing. I believe that—as well as “bed blockers,” pressure on GP appointments, hospital bed availability, and winter pressures—the crisis afflicting A&E departments is also affected by the low threshold that some members of the public have to attend.

I read through letters sent to me by the local hospital each day, where patients turn up to A&E with conditions that are neither accidents nor emergencies; a sore throat, ear pain, or a cough are just some of the examples that I frequently see. When I was a junior doctor I remember a teenager coming in, by ambulance, perfectly able to walk after having been kicked in the shin during a play fight; and the over-anxious family who brought their child with a nappy rash in; and the over-anxious grandmother who brought in her grandchild because they had cried differently when she put them in the bath. Despite her grandchild having blemish free skin, she wanted a doctor to check that they weren’t scalded.

One could blame the patients. I personally blame the National Lottery and sabre-toothed tigers.

First, the National Lottery. “It could be you!” was the strapline of the first advertising campaign for the lottery when it was launched as a tax on the stupid, to fund charitable causes and Camelot Group. The chances of winning the jackpot in the main lottery are roughly one in 14 million for the sake of convenience. So, if you play the lottery, it COULD be you, but more likely than not it won’t be. What has this got to do with health? Well, everything. It is all about the perception of statistics and chance, which in turn informs our perception of risk.

If the general public thinks that a one in 14 million chance is one worth taking, along with the shorter odds for less money (one in 117 600 to get three numbers), then their understanding of statistics may leave something to be desired. There is always the thought, “It could be me.”

So when someone, or their relative, goes on to develop a symptom, the same sort of thought process kicks in: “This headache, heartburn, this itch, this tingle, this nausea, it could be me. It could be me that has the rare cancer or overwhelming infection that will get missed because it has non-specific symptoms; it could be me that develops dehydration.”

And sabre-toothed tigers? When mankind was primitive, surviving in what was to become eastern Africa, his/her survival depended not only on intelligence but also on a hardwired neural mechanism: the “flight or fight” system of the autonomic nervous system, the response to danger or potential danger. Natural selection would dictate that the more cautious members of the species were the ones that passed on their genes; those that avoided unnecessary confrontation with large beasties with long, sharp teeth. I would go so far as to say that the more anxious primitive humans had a survival advantage—those that were constantly looking over their shoulders for danger.

Ironically, I often use the example of primitive mankind needing to survive to explain the physical symptoms of anxiety to my patients. That is, those symptoms of increased adrenaline owing to the “flight or fight” system hardwired into our neurobiology.

I’m beginning to come to the belief that the default position for humans is actually one of anxiousness and worry, a predisposition that previously conferred an evolutionary advantage to our ancestors. Except in the recent past, people would worry about their next meal, their shelter, the prospect of war, and/or nuclear Armageddon. These big things to worry about have disappeared for the vast majority of our patients, so the next most important thing to worry about is our health, which, when combined with an inability to assess risk and statistics, means a deluge of patients needing their health anxiety managed in both A&E and general practice.

Patients need to take part of the blame for turning up at A&E—sometimes inappropriately calling an ambulance. I don’t get so frustrated anymore, as I am not on the frontline. I would like to be part of the solution, if I can, and that will be enabling the general public to understand what they should and shouldn’t worry about. But I can only educate my own patients, and in 10 minutes chunks wedged in between their own reasons for consulting me. Perhaps an overhaul of personal and social education in schools would be a good place to start. Researching health anxiety and developing strategies to support health professionals who manage patients with it could also help. Perhaps we need more balanced public health campaigns.

Turning the tide won’t be easy, as this will be in conflict with thousands of years of the evolution of the propensity to worry.

*This scenario is fictional, but represents the reality experienced by many general practitioners.

Samir Dawlatly is a GP partner at Jiggins Lane Surgery in Birmingham. He combines clinical practice with being a part time house husband and an interest in social media, as well as publishing poems, essays, and blogs. He can be found on Twitter as @sdawlatly.

I have read and understood BMJ policy on declaration of interests and declare the following interests: I am a member of the RCGP online working group on overdiagnosis.