“Examine Thoroughly, Explain Simply”


“Fear is more pain than is the pain it fears.”

Sir Philip Sidney

“In our specialist age it has, in fact, become a major function of the general physician to examine thoroughly, to explain simply, to reassure as far as may be, and to protect his patients from unnecessary medical or surgical interventions.”

John A Ryle, MD, 1948 in The Journal of Mental Science, published by The Royal Medico-Psychological Association


Re-reading my post about Morbus Propedeuticus, Medical Students’ Disease, I realized I had inadvertently used the word “gracefully” in my account of how my instructor examined my enlarged lymph nodes and reassured me that they were not suspicious. My intention had been to say “graciously”. For a moment I thought I should correct my slip-up, but then I realized that what Dr Bruun did wasn’t just gracious, but actually quite graceful. His whole demeanor conveyed sincerity, kindness and patience. He made me feel completely reassured and relieved of my fears.

Every day, I encounter fear of some degree in patients, often unfounded; it is not the patients with cancer or heart disease or poorly controlled diabetes that share their fear behind my closed exam room door, but the patients with ill-defined symptoms or no symptoms at all.

I have a few patients who always seem to be concerned about one bodily sensation or another, but then there are some that have only one disease they are worried about getting. This predicament is different from hypochondriasis. It goes by the name nosophobia, literally “fear of disease”.

Nosophobia can be triggered by learning about a disease affecting someone we know, by reading or watching accounts of dreadful diseases, or by receiving inadequate information or reassurance when we do seek medical evaluation of a symptom.

In our “information age” patients often look up their symptoms on the Internet, and come across endless possible explanations, or differential diagnoses. The problem with random searches is that the results also tend to be randomly arranged and not ranked according to the person’s specific presentation or risk factors, and not at all according to how common or rare each disease is.

When we as physicians evaluate patients with undiagnosed symptoms or concerns over a specific disease, our thoroughness, thoughtfulness and demeanor can feed or quell nosophobia.

John A. Ryle, MD, in his Maudsley Lecture, quoted at the beginning of this post, writes about physicians inadvertently causing nosophobia in their patients:

“Again and again patients discharged from hospital, when asked what the doctors have told them, say, “ Oh, they didn’t tell me anything”. Often they have spent long periods in the ward and been elaborately investigated, all the time waiting and wondering and uninformed. Could anything be more conducive to the initiation or aggravation of anxiety than experience of this kind? Probably the divided responsibilities…..in institutions and the inexperience of house-officers are partly to blame, but the mechanistic, objective character of modern investigations also tends to distract the doctor’s from the patients’ thought and to direct attention away from private sensibilities and present needs. I have even watched air-raid victims being admitted, examined, X-rayed and transfused without a word of comfort or reassurance being given to them by those concerned.”

Ryle’s lecture was published in an obscure journal dedicated to what we now call Mind-Body Medicine. Today, even large mainstream institutions like Harvard Medical School have entire Mind-Body Medicine departments. But before thinking we have come a long way since 1948, we should remember that Mind-Body Medicine isn’t something separate from everyday primary medicine; it is possibly the biggest part of primary care. That doesn’t mean every primary care physician needs to practice full-fledged psychiatry. It does, however, require us not to be mere body technicians, but real doctors; human, humane, humanistic.

Ryle puts it this way:

“As a profession we are losing, in the process of developing our technologies, something of the philosophy, humanism and courage of the older physicians.

Our loss of philosophy is shown in our inability to piece together the components of an illness or an individual, to assess the roles of mind and body in morbid experience and to balance the needs of both –  in brief, in our inability to see things “whole”. Our loss of humanism appears in our too partial success in assessing the psychological needs of the individual and the social needs of the community. Our loss of courage is chiefly manifest in our present-day unwillingness to make pronouncements without subjecting our patients to elaborate investigations. These, while often necessary and valuable, can also prolong anxiety, and leave our own doubts and questions still unanswered.

Without courage to accept clinical responsibilities we cannot impart courage to our patients. Without a reasoned clarity in diagnosis and a reasoned hopefulness in prognosis we cannot properly counter fear. In the majority of cases it is possible to give to patients a simple interpretation of symptoms; a simple idea as to how they should be regarded; a set of sound reasons should further inquiry become necessary; a provisional prognosis, in which the emphasis should be on the better chance whenever possible; and an intelligent plan of action. For the busy practitioner or hospital surgeon or physician, it may well be impossible to devote time and thought to the more profound psychiatric methods, but there should always be time to examine carefully, to explain clearly, and to reassure as fully as the circumstances allow.”

I think it is easy for us doctors of today to lose our courage with all the scrutiny and second-guessing we are subjected to. I also think it has become more difficult to find the time to “examine thoroughly” and “explain simply”, as Dr Ryle puts it, and to take a good history. But without those ingredients our reassurance carries no weight. Without them the health care squirrel wheel keeps turning faster and faster at ever greater cost as insecure and worried patients churn around and around.

Ryle’s call to protect our patients from “unnecessary medical or surgical interventions” is, of course, another way of saying “first, do no harm”. In our continuing efforts to never leave any stones unturned, tests undone or cautions undelivered, we are probably causing more harm, at least in the form of fear and anxiety, than we would ever like to admit.

1 Response to ““Examine Thoroughly, Explain Simply””

  1. 1 NPs Save Lives August 11, 2013 at 5:19 pm

    I absolutely agree about getting as much accurate history on a patient as we can. Unfortunately, it slows down the flow and makes me run behind. Most of my patients don’t mind because they realize that I actually listen to their concerns. Often, the original complaint is not what really brought them to the office in the first place. Reassurances that a patient is not going to die from “an internet disease” is most need but some will literally worry themselves into symptoms that they didn’t have.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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