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Opinion
As We Look to Save Health Care Dollars, What to Do About the Valetudinarian?
By Richard P. Mills, MD, MPH, Chief Medical Editor, EyeNet
 
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August 2012 OpinionIn each of the several ophthalmic practices I have captained so far in a 40-year career, I gradually accumulated a peculiar breed of patient. I’m sure you have your share, too, if you have been in the same practice for a while. I used to think it was just me, that these patients sought me out as a moth seeks a flame, but now I know better. Their numbers in any practice are not large, but they are particularly nettlesome. I refer, of course, to the worried well.

So why did it take me four decades to write about this? Because just last week, I learned a word to describe them: valetudinarian. So, naturally, I wanted to share it with the EyeNet readership. The word interests me because it conjures images of high school graduation and pet doctors, but has to do with neither. Had I been a better student of American history, I might have encountered it earlier in a quotation from Thomas Jefferson, in discussing the pursuit of happiness, “The most uninformed mind, with a healthy body, is happier than the wisest valetudinarian.”

Valetudinarians are sometimes confused with hypochondriacs. They couldn’t be more different. The hypochondriac thinks he’s always ill, but the valetudinarian takes excessive care to make sure that he doesn’t fall ill. So, in my glaucoma practice, these are the patients with a family history of glaucoma in a distant relative, a once-recorded intraocular pressure of 23, or perhaps a myopic disc with an indeterminate cup. Retina specialists accumulate patients with a few hard drusen or those who are addicted to the AREDS vitamin supplement.

They are among our most reliable patients, arriving for follow-up within a day or two of the suggested interval. They are also among our most grateful patients; they are so relieved by the news they are still not ill. But they are disproportionately time-consuming, and they make me wonder whether I am really using my medical education to its highest purpose by looking after well patients. They are also extremely resistant to the notion that they might need to be examined less frequently. Once a four-month interval has been established, it would take an act of Congress to lengthen it. Especially if a certain Dr. Duane in Philadelphia suggested that was appropriate 50 years ago.

A variant of this breed is the genetic valetudinarian. As we further “crack” the genome and discover more genetic variations associated with disease, there are laboratories eager to screen a patient’s DNA for each of them. This is a match made in heaven for genetic valetudinarians: a bona fide test result showing whether their DNA is “defective” and presages doom of one sort or another. The trouble is, the genome doesn’t work that way, and the presence of a specific genetic variation is no guarantee of disease—or of health, for that matter. This year, a new clinical statement was issued by the Academy entitled “Recommendations for Genetic Testing of Inherited Eye Diseases.” It lays out in logical detail why indiscriminate testing can actually be harmful, as well as the circumstances in which testing is useful. It’s a great resource to show your genetic valetudinarian patients. For the other valetudinarians, I’m afraid you’re on your own.

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