The Folder and the Shrug

Two patients. Two ways of living with fear.

For years, I thought the anxious patients were the ones who kept showing up. The ones who needed another visit. Another test. Another reassurance.

I’m not so sure anymore.

One patient arrives with a folder. Lab results. Smartwatch tracings. Blood pressure readings recorded three times a day. He apologizes for “wasting my time” before asking whether we should repeat a test that was normal six weeks ago.

Another says almost nothing at first. He shrugs, smiles too quickly, and calls the chest pain “probably stress.” Then, just before leaving, he mentions it has actually been going on for more than a year.

I used to think these patients were opposites. That was when I thought fear behaved logically. I learned later that it doesn’t.

Some people move toward uncertainty. Others spend years trying not to look directly at it.

The first patient usually arrives prepared. Questions highlighted. Articles printed. Symptoms tracked with exhausting precision. Sometimes he has already diagnosed himself three times before sitting down. A skipped heartbeat becomes a late-night search. A headache becomes something terrible by two in the morning. A normal test helps for a while. Then the doubt slowly returns.

He arrives three months later with a list of lab tests he wants performed. He tells me how much ChatGPT has helped him. He has spent nights reading about sudden cardiac death in endurance athletes and people with zero calcium scores.

Not surprisingly, doctors sometimes become impatient with these patients. Too many visits. Too many messages. Too many fears attached to symptoms that appear harmless.

By the third visit, even my own reassuring voice starts sounding slightly rehearsed.

Sometimes I hear myself repeating the same sentences in the same order and wonder how much reassurance actually survives the drive home.

But beneath all of it there is usually something recognizable: the wish for certainty in a world that offers very little of it.

The second patient is often harder to read. He might sit rigidly still, hesitate, or answer questions too quickly. Sometimes he jokes too much. Sometimes he talks in long, uninterrupted stretches, circling symptoms without ever quite approaching them.

He says the symptoms are “probably nothing,” but his knee keeps moving beneath the chair. Being in the office already feels dangerous. Once certain words are spoken aloud, they become harder to contain.

These patients may also spend nights awake imagining the worst possible explanation for every symptom. A pressure in the chest. A skipped beat. A headache that lingered too long. But eventually, the possibility feels easier to live with than the answer.

So they postpone things quietly.

An appointment gets moved again.
The walk outside stops happening.
The fatigue goes unmentioned.

Sometimes, entire families adapt around the avoidance without fully noticing it.

“He never complains.”
“He doesn’t like doctors.”

Years can disappear this way.

And occasionally, these patients arrive carrying more fear than the anxious patient who came five times that same year.

Because avoidance does not erase fear. It just gives it somewhere darker to sit.

I remember a man who rescheduled his cardiac exercise test four times.

First, his daughter was visiting from Norway.
Then he had the flu.

Later, he said he wanted to “get in better shape” before exercising in front of us. Patients say things like this sometimes. As though improving themselves a little first might somehow bargain with whatever answer is waiting at the end. I didn’t argue with him much.

When he finally came to see me, I wasn’t quite sure what to make of him.

He kept joking at odd moments, smiling too quickly, moving the conversation away just as it started getting close to something real. I remember trying to listen to his heart while he was halfway through a story I no longer remember, the cold stethoscope making him flinch slightly against the exam table.

Later, I realized the joking wasn’t avoidance exactly. It was more like keeping the room emotionally bearable.

After enough years in medicine, the distance between these patients starts to shrink a little.

The behaviors are different. The fear underneath often isn’t.

I’m not always sure reassurance works as cleanly as we hope it does. Sometimes patients leave calmer for a while. Then something small happens later that night, a skipped beat, a sensation in the chest, a thought that returns in darkness, and the whole structure starts building itself again.

We often think doctors belong outside these categories. That they are more rational, they better understand risk.

But it doesn’t work that way. Some doctors monitor themselves obsessively in private. Quiet hallway consultations. Informal ECGs. A colleague casually listening to another colleague’s chest between patients as though this were a completely normal way to live.

Others postpone things they would never tell a patient to postpone. They explain symptoms away. Stay busy. Wait longer than they should.

I once knew a doctor who delayed seeing anyone about chest discomfort for months. Not because he didn’t understand the possibilities. Because he understood them too well.

Knowledge does not eliminate fear. Sometimes it sharpens it.

I often think the waiting room is one of the few places where modern people are forced into honesty. Not spoken honesty. Something quieter than that. The executive checking his pulse beneath the sleeve of an expensive jacket. The stoic man suddenly unable to explain why he finally came. The woman rehearsing reassuring explanations she no longer fully believes.

Most people tolerate a known hardship better than an undefined possibility. A diagnosis, once named, at least has edges. Uncertainty behaves differently. It spreads into sleep. Into relationships. Into ordinary moments that suddenly feel less ordinary.

It often shows up in tiny things.

A test result sits unread in the patient portal for six days.

A man arriving only because his wife finally lost patience with him.

After a while, the labels stop helping much. The worriers. The deniers. The difficult patients. Those words often conceal more than they explain.

The screen fills with numbers: troponins, blood pressure, calcium scores, risk estimates. We use them to make uncertainty feel more organized. More manageable.

Sometimes it works.

Sometimes it doesn’t.

Yesterday, I walked the first patient to the door after the fifth visit in one year. He was still talking when he left, telling me about a fascinating book he was reading on the science and art of longevity.

Afterward, I sat alone in the office longer than necessary, scrolling through emails on my phone without really reading them. At some point, I found myself thinking about the colonoscopy I had postponed twice already that year.

I still haven’t booked it.