As a GP this is a fascinating question. Some patients seem to come in with trivia while others sit at home with chest pain determined not to worry the doctor. An understanding of medical sociology helps explain why this might be happening. What is seen in the consulting room really is the ‘tip of the iceberg’. This phenomenon was described by Hannay in 1979 and illustrates the fact that most people self-treat at home.
Figure 4a from the British Thoracic Society illustrates the symptom iceberg well, taking the example of cough. Of an estimated 120 million episodes of upper respiratory tract infection (URTI) in the UK each year, about one-third have a cough, of those half choose to self-medicate and one-quarter see their GP. So, overall, only 1 in 10 patients with a URTI actually makes an appointment with their GP.
Lay Referral System
So what makes some people attend and others not? Sociologists have developed many different models.
Friedson described the lay referral system in 1970. He said ‘the whole process of seeking help involves a network of potential “consultants” from family members through successively more select, and authorative laymen until the “professional” is reached.’
How many lay contacts the patient makes before they reach us has been found to depend on the degree of congruence between the subculture of the potential patient and that of the doctor. That is higher socio-economic backgrounds require less ‘permission’ from others to attend.
Zola’s Triggers
In 1972, Zola noted that symptoms alone were often not a sufficent reason to decide to see the doctor: something else had to happen. He identified five types of trigger:
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