"I don't want to waste their time"

In Britain this reason has a special force. People know the health service is stretched. They've sat in full waiting rooms and heard the news about pressures on GPs. Taking an appointment for something that's probably nothing feels selfish. A decent person, the reasoning goes, leaves the slot for someone who's properly ill.

Researchers have looked closely at this worry. Susanne Cromme, Katriina Whitaker and colleagues interviewed 62 adults aged fifty and over in England. All of them had reported a symptom on a health survey that could be a warning sign of cancer, and still had it three months later. Many hadn't seen a doctor about it. The interviews asked why, and the worry about wasting the GP's time came up again and again.

The researchers found that the worry had particular sources. It was stronger when people could see the time pressure for themselves, in a rushed consultation or a packed surgery. It was stronger after an earlier visit where the GP had seemed dismissive. Many people felt a symptom only deserved a doctor's attention if it was persistent, getting worse or plainly dangerous. Surgery rules such as one problem per appointment made people feel they'd be breaking etiquette by raising anything extra.

They also found what eased the worry. A friendly relationship with a GP helped. Some people reasoned that they'd paid for the service through their taxes and were entitled to use it. Others took the view that assessing symptoms is what a GP is for, and that deciding whether something is trivial is the doctor's job and not the patient's.

I think that last view is the right one, and I'd put it more strongly. This is my own reasoning. Nobody can tell a harmless mole from a harmful one by looking in the bathroom mirror, and that includes you. The whole value of a doctor lies in being able to tell. So "I don't want to waste their time with something trivial" contains a hidden claim, which is that you've already worked out that it's trivial. You haven't. If you had, you wouldn't be thinking about it at ten past three in the morning. Sorting the trivial from the serious is the doctor's work, and a patient who turns up with something that proves trivial has given the doctor that work to do. It's the most common kind of consultation there is, and nothing about it is out of the ordinary.

From the doctor's side, the expensive patient is the one who brings the mole after two years when it has become something that needs surgery and months of treatment. The one who brings it early and turns out to be fine costs far less. If the aim is to save the health service trouble, going early is how you do it.

There are also lighter ways in, which exist so that a GP appointment needn't be the first step for everything.

A pharmacist can look at a good many minor things and tell you whether you need a doctor. You don't need an appointment for that.

NHS 111, by phone or online, will ask you a set of questions and tell you what level of care you need. The NHS's own page on breast lumps suggests it for people who are worried about symptoms.

Many surgeries now have an online form where you can describe the problem in writing. Someone at the surgery reads it and decides whether you need to be seen, and how soon. For people who dread taking up a slot, that's ideal. The surgery makes the decision about whether you're worth an appointment, which is the very decision you didn't trust yourself to make.

If embarrassment is part of it, because the thing is somewhere private or to do with a bodily function, I can only give you my view. Doctors and nurses examine such things many times a week. What feels mortifying to you is routine to them. The review in chapter 2 found that embarrassment about a sensitive part of the body was one of the two big reasons people delayed over symptoms that turned out to be cancer. It's a common obstacle and a serious one, and the way through it is usually one awkward sentence. "I've got a problem that's a bit embarrassing to talk about." Clinicians hear that sentence often, and they know how to make the next minute easy for you.