For the acutely ill patient who begins to confront the concept of chronicity of complaints, there are four sources of emerging fear.
The patient fears that the diagnostic studies are incomplete, that treatment has been insufficient, that residual complaints will be unmanageable and that the support system upon which they are reliant will begin to falter. The patient becomes increasingly anxious that there is decreasing investment in determining a source and solution to their subjective complaints.
When subjective complaints fail to resolve rapidly, the patient is confronted with the dilemma that either residual complaints are inevitable and the chronic sequelae must be managed, and/or that diagnostic investigation of the complaints has been insufficient to adequately rule-out a potentially resolvable condition.
Compounding this fear of the health care delivery system is the concurrent apprehension that those upon whom the patient has grown increasingly dependent will fatigue with providing support services and begin the process of withdrawal.
The patient begins to perceive that the potential for complete recovery is an offering which must be made to those providing assistance, in order to now bargain for continued attention. If their support system cannot be assured of the timeframe in which recovery will occur, the patient becomes increasingly fearful of abandonment by those who are central to nurturance and often daily functioning.
In order to address the fear factor, the doctor must determine from the patient the following concerns:
a.Do you feel that all reasonable attempts have been made to diagnose your problem, or do you feel that there are diagnostic concerns that have not been addressed?
b.Do you feel that the problem for which you are being treated is not the central problem and that the main problem is more severe than anyone has as yet realized?
c.Do you feel that your friends and family have tired with your condition and your needs and are now in the process of withdrawing their support from you?
d.Are you afraid that even with accurate diagnosis and good support that you personally will be unable to cope much longer with your complaints and may lack the capacity to deal with these problems if they continue to exist?
It is central to this issue of fear that these concerns need not be perceived as irrational beliefs but may, indeed, be based upon a valid assessment of the treatment process, the support system and the patient’s self-assessment of functional capacity for coping. Resolution of fear may emerge from illustrating to the patient that the fears are irrational, but it cannot be overemphasized that the patient’s fears may, in fact, be based upon a realistic appraisal of the context in which the patient now exists.