The Threads of White Coat Syndrome:

by Steven Duncan

THE OLD WELSH PROVERB “an apple a day keeps the doctor away” has a subtle double meaning. The straightforward interpretation is that eating fruits and vegetables is a healthy, sensible choice. On the other hand, some people joke that the true benefit of good nutrition is avoiding interaction with doctors. Illness isn’t very appealing, but when it comes to healthy motivation there’s nothing compared to the discomfort of a doctor’s office.

Maybe that seems farfetched, but most people face some anxiety when it comes to seeking medical attention. The fear of needles (affecting 20% of adults), disease, and even death can be intensified by simply entering a healthcare environment.[1] The phenomenon of white coat hypertension (or white coat syndrome) is well-documented; data show 35% of individuals experience a significant spike in blood pressure when measured in a doctor’s office compared to normal levels at home.[2] General uneasiness and the anticipation of bad news are common factors that heighten this response. The unfamiliarity of a sterile atmosphere along with the awkwardness of disrobing and being examined by a relative stranger (on a glorified booster seat covered with tissue paper) contribute to the feeling too.

Unfortunately, popular media only stoke the fire. Lawyers advertise compensation for frightening, unintended medical events and offer their services in litigating malpractice. Public health campaigns dramatize the seriousness of disease with extreme portrayals that appeal to emotion. Many pharmaceutical commercials have devolved into lists of terrifying possible side effects: who knew that aspirin could cause massive internal bleeding? Medical TV dramas further distort reality by depicting hospitals as tense environments, full of stressful situations and depravity. When it’s time for someone to visit an actual physician, it’s no wonder they might feel unsettled.

Fear and anxiety are universal experiences, and each has a widespread influence on healthcare outcomes. Their effects aren’t always singular or predictable, but each is worth discussing in order to alleviate unnecessary consequences for patients and their families. Overcoming problems associated with white coat syndrome will ultimately require conscious assessment and renewed focus on nurturing a therapeutic doctor-patient relationship.

AVOIDANCE

One reaction to fear in healthcare is avoidance. Studies show that people may reject or dismiss distressing information about serious illnesses, particularly important facts about cancer screening and genetic testing. [3] When a patient notices a concerning symptom, they may rationalize it away as nothing. This pattern can increase the delay to diagnosis and worsen a patient’s outcome; depending on the circumstance, it can impact their chance of survival.[4]

An additional reason why people avoid seeking medical attention is a fear of the cost. In the United States, healthcare costs are rising faster than the average household income; the medical industry has tripled its share of the GDP since 1960.[5] Research from Princeton estimates that U.S. services now cost 60% more than their European counterparts.[6] Fear of poor prognosis coupled with a potentially catastrophic financial burden causes people to stay home and hope their symptoms go away on their own.

Some people prefer to think about health as little as possible. It can be unpleasant to dwell on the uncertainties that accompany human mortality, and younger people may prefer to placate themselves with feelings of invincibility. In many ways, the sociocultural climate has not transitioned to fully embrace preventative measures (i.e. healthy eating and exercising is only for people battling disease). Besides interfering with general prophylaxis, misinformation can produce anxiety over vaccines and lead to more cases of preventable illness.

EXCESSIVE ENGAGEMENT

Another way people respond to their fear is by overseeking screening tests and medical intervention. Instead of ignoring or minimizing health concerns, people may blow their symptoms out of proportion. WebMD is no help, as relatively innocuous symptoms can suddenly represent debilitating diagnoses to the gullible and afraid. Blog entries of people who received a much-feared diagnosis can make the dreaded outcome seem even more realistic. It’s been shown that patients with high health anxiety are more likely to search for their symptoms online and are often less satisfied by doctor visits. [7] Pediatricians should note that such individuals may project this anxiety onto their children.[8]

The availability heuristic can be a chief contributor to health anxiety. In psychology, this type of bias causes people to falsely assume that whatever comes to mind first must be the most realistic. Medical students are capable of this to an alarming degree, as they are constantly inundated by ways the human body can dysfunction. Pathological health anxiety disrupts daily function and sometimes induces the development of physical symptoms. For this reason, hypochondriasis is classified in the Diagnostic and Statistical Manual (DSM-5) as two mental disorders differentiated by the extent of somatic involvement.[9]

The elimination of fear through unnecessary care is effective, but only temporarily. New symptoms can easily push the patient back into another anxious cycle. In some ways, healthcare professionals are burdened to alleviate the uneasiness they created in the first place by spreading awareness about disease. Heightened awareness isn’t all bad; for one thing, it can help raise money for research (remember the ALS ice bucket challenge?). However, the healthcare system can quickly become encumbered by gratuitous requests and backed-up waiting rooms as people wrestle with their anxiety over unlikely diagnoses, assuming innocuous symptoms indicate something sinister. False negatives lead to additional testing which can be both expensive and invasive.

Dr. E. Mitchell summarized this problem with screening tests in the British Journal of Cancer, “The challenge lies in achieving a suitable balance, which targets the appropriate population without creating undue fear, overburdening primary care services with patients seeking reassurance or clogging up scarce investigative services.”[10] It’s okay to seek reassurance. Early detection and treatment are highly correlated with better prognoses in a wide range of diseases. But panic doesn’t have to be part of the equation.

SOLUTIONS

Combatting white coat syndrome must begin with the doctor-patient relationship. Interactions are easier for anxious patients when their provider has a warm demeanor and tone, appropriate eye contact, reassuring touch and kind facial expressions. One study found that the phrases “I know this is a hard time for you” and “we are in this together” consistently lower patient anxiety and increase perceived compassion.[11] Nurturing trust through effective communication requires empathy, positivity, and active listening skills. A physician who includes these elements in their regular communication will create a safe environment for patients to ask questions and voice concerns – a vital step in overcoming anxiety.[2]

Other effective strategies to help minimize patients’ health anxiety have been proposed and evaluated in recent literature. It is recommended that physicians not only provide accurate health information, but also educate patients about where they can find reliable health information online (consider MedlinePlus.gov).[12] It can be beneficial to discuss and evaluate the information that caused distress. Instead of having patients feel bad about doing their own research, they can be encouraged to read from credible sources and ask follow-up questions.

Patient literacy and numeracy (numerical literacy) are important in correct medical decision making; deficiencies contribute to worse outcomes and more emotional reactions to health information.[13] Low levels of health numeracy can damage a patient’s ability to understand risk. Physicians can help mitigate this problem by repeating statistical terms a few times and being careful to explain less familiar concepts.[14] For example, learning you are five times more likely to develop mesothelioma is scary without knowing mesothelioma is a very rare condition (with a general incidence of 0.001%).[15] It’s the physician’s job to bring relevant statistics into focus, as well as decode unfamiliar scientific jargon that can be distressing and confusing. Patients may falsely believe certain diseases are a death sentence until their doctor speaks up. When people discover there are resources available to them, they can feel more empowered and proactive about their health.

People are prone to make poor decisions when they’re anxious.[16] Therefore, it is in the best interest of patients and physicians to fight anxiety together. Building trust and demonstrating empathy allow patients to feel more at ease. A balanced view of risks and probabilities in line with adequate health literacy is essential to prevent unwanted anxiety. It bears mentioning that cognitive behavioral therapy works to curb persistent health anxiety and is even effective for individuals whose levels are considered subclinical.[17] All of these tools can be used to help provide the best experience for patients dealing with white coat syndrome. Avoidance and excessive engagement are not necessarily signs that a patient is uncooperative – they may just be afraid. A better understanding of the root causes of fear, its effect on patients, and appropriate interventions are all key to helping people heal better. So relax. It’s just a white coat.