This one’s very topical given the news bombarding us about A&E’s in crisis. The worried “well” represent a decent proportion of patients in our Emergency Department waiting rooms.

They’re the reason you’re waiting over 4 hours to be seen for your real medical emergency!

They’re the reason the NHS is at breaking point!

This is the victim blaming attitude that the government would like us to adopt whilst they quietly sell off our NHS bit by bit.

But, I don’t want to talk about government policy or healthcare privatisation. I’m interested in patients, not policy, and over the past months I have developed great sympathy towards these patients in particular. They are far from “well”. Can we really describe somebody who would spend 6 hours waiting in A&E to be reassured that there’s nothing physically wrong with them, as “well”?

In my experience, these patients tend to present with chest pain more than any other symptom. In the past I’ve had a very efficient method for dealing with them. They’re usually young, have no risk factors for heart disease, and a history which is inconsistent with cardiac chest pain. I request an electrocardiogram and a troponin blood test and when both come back negative, I, politely, show them the door.

That was that, and on to the next. But they always annoyed me with their final question, “Doc, what’s causing this pain if it’s not my heart?” After years of studying and training, and an ego to boot, it’s difficult to admit “I don’t know”, and maybe this was part of what fostered my resentment towards these worried well.

One day though, I had a breakthrough. By pure chance. My eureka moment…

Several weeks ago I saw a middle aged lady in A&E with chest pain. She gave me the typical history of intermittent central chest pain and palpitations’ for the past 2 weeks. The ECG and blood tests were negative, as I knew they would be, and I was just about to discharge her when she asked the dreaded question

“So what’s causing the pain?”

I don’t know what possessed me to do it. Maybe I was bored; maybe something about her had suggested some underlying anxiety. Anyways, I responded with my catchphrase,

“I don’t know”

But this time I followed up with “did anything happen 2 weeks ago?”

She looked baffled. She looked to her neighbour who’d kindly accompanied and waited with her throughout. Her neighbour shrugged. And then her expression changed as the truth slowly dawned on her.

“The first time I felt this pain was on the anniversary of my husband’s death”. And she started to well up.

“I’m sorry to hear that; he must have been young, what happened?” I asked

“He had a heart attack”. And then the words came pouring out, along with the tears.

Her brother was just diagnosed with cancer at the age of 55 and given 6 months to live. And her eldest child, who had just flown the nest, was really struggling as she was very close to him. The floodgates had well and truly opened. All the while she had no support, no social network to rely on, and no community to turn to. Except her very kind neighbour, who had prompted her all the way in opening up about these countless stressors.

I’d like to think that that space she’d been given to express herself, even if it delayed her discharge and caused her to ‘breach the 4 hour wait’, had been somewhat therapeutic. God knows if she is still having the chest pain or if she ever sought any further support whether professional or not. I hope she found the emotional support she needed from somebody.

And now, without fail, when I see these patients I ask them “did anything happen?” or “is there any reason you might be worried about your heart or your health?” And, without fail, whether they had realised it before or not, they divulge some emotional trauma which immediately preceded their symptoms. Real examples that I’ve seen in just the past few weeks include:

witnessing their partner commit suicide before their eyes!

having a 20 something year old cousin die from a heart attack

losing their job and partner

These are just the most extreme examples. I don’t remember the umpteen less dramatic ones. And they don’t make for good story telling anyway.

However it’s probably useful to give some examples given that the above are more of the exception than the rule.

More commonly the patient may have;

2 young children to look after and a messy house

upcoming exams

an unwell cat

So it turns out this is a known thing called Somatisation.

I had a vague recollection of this term from medical school but nothing sticks until you can relate it to a patient. It’s where the body produces physical symptoms as a manifestation of mental distress which has not had a chance to express itself in a healthy way. Despite being so prevalent it’s not given much attention, I guess because there’s no drug on the market to treat it.

But it’s ideal for patients! Because once aware of the phenomenon you can recognise it yourself and avoid being one of these patients in A&E so berated by the Health Secretary!

My wife suffers with anxiety and experiences occasional chest tightness when it’s particularly acute. And the best treatment I’ve found is a caring ear.

She’s an artist and writer and expresses her personal experiences of anxiety in the form of poetry (www.munzysmusings.com) and art (www.muneerahyateart.com). She finds expressing herself artistically to be highly therapeutic. She has also started practising Mindfulness and meditation as effective alternatives to medications which she (and I) were keen to avoid.

Keep tuned as I plan to write again soon about dietary considerations and natural remedies for anxiety and depression which can augment psychological treatments in helping to avoid medicating.