The label ‘attention-seeking’ does healthcare more harm than good

Doctors must change their perspective on vague complaints. It starts with listening to patients with unexplained complaints. It is crucial for trust in healthcare, says psychiatrist Merel Boas.

As a resident I already got to know them. Patients, usually women, of whom you know in advance that they have a list of diagnoses, such as fibromyalgia, ME and atypical abdominal complaints. The knowing looks among caregivers in the emergency room. A deep sigh, casual remarks. And sometimes, mockery.

The women with chest pain 'eci', lying there with all the wires and beeps: chest pain e causa ignota. That sounds nicely scientific but literally means 'without known cause'. Essentially true, but in practice often dismissed as theatrical nonsense. After all, nothing to see on the heart film.

These women were systematically taken over; that was imprinted on us as residents. Fortunately, we now know better. The same pain complaints are now understood and known as the female heart.

But why did it go like this? And why does it unfortunately still go like this with complaints that we cannot directly categorize, complaints that are too heterogeneous to easily understand the coherence?

We call them vague complaints, but the complaints are not vague. We find them vague. They are simply harder to interpret because we do not yet (re)cognize the pattern. Just as COVID-19 also confronted us with the reality of a virus that did not behave as we had learned in our training.

As a caregiver, we find it difficult not to understand something. You cannot provide help, solve nothing. In this – increasingly – makeable world, that 'not solving' stands out even more as a contrast. Especially given the large amount of (dis)information available online. As a doctor, you have to deal with that more and more. Certainly in the case where someone is sitting opposite you for whom you do not have the answers.

If someone uses many types of psychopharmaceuticals, then you know it concerns someone with borderline personality disorder, I heard during my training to become a psychiatrist. Later I heard: if someone uses many types of psychopharmaceuticals, this reflects the despair of doctors.

Despair leads to an endless search outside the usual paths.

Does it matter from which perspective you look? The answer is a resounding 'yes'. It makes all the difference. With the first perspective, as a doctor I no longer need to think further about the patient's complaints or the diagnosis. With the second, I give myself as a doctor the space not to know yet and to think further. And especially to listen. And to take the complaints seriously. Time and again we are called back – by advancing insight. Complaints that we dismissed as attention-seeking turn out to be grounded in a biomedical explanation. As happened with the female heart, but also with perimenopausal complaints, post-COVID and ME.

Alternative information and alternative healing methods exist for a reason. They reflect that we have not been able to help everyone. And their right to exist shows that they apparently do help a select number of patients from this group. Everyone knows someone who was cynical but was helped by it anyway. Why does it help one person and not the other? Perhaps because there are different biomedical causes for all these 'vague' complaints, which we had lumped under the common denominator 'vague'.

When we don't know something, it gives us mental discomfort. Our brain solves this by using a prejudice that has moreover been imprinted on us for years. Attention-seeking. Case closed.

Having complaints is unpleasant. They become unbearable when you are not taken seriously, are not listened to, and no one can tell you how – and if – they will ever stop. That despair then leads to an endless search outside the usual paths, everyone understands that. At the same time, something else happens: loss of trust in your doctor. And thus in the healthcare system. That is not helpful in a world with access to the internet and information that potentially leads to nasty consequences (such as the sale of illegal medicines).

It is up to us as caregivers to be aware of this, to let go of prejudices and to keep taking complaints seriously, even where we do not yet know or understand. To keep standing beside our patients and thinking along, even if we do not understand it. That asks a lot – possibly too much – within a system under high work pressure. But the alternative is much more serious.