For the past two months, I have had ringing in my ears and a much greater sensitivity to sound. (For example, it hurts my ears to hear a paper bag being opened.) I went to an ear, nose and throat doctor who said I must have slight damage from a virus. I had a hearing test that turned out fine. He then said the sensitivity I am experiencing is caused by unmanaged stress. I was completely floored and feel I need to get a second opinion. He took a quick look in my ears and asked me a few questions before making this diagnosis. Am I wrong to feel that he wasn't giving me a complete exam? Is there anything else that would cause these symptoms?

Sue

It's always loads of fun (in a dangerous kind of way) to second-guess another doctor, armed only with an incomplete set of facts and a firm conviction in one's own righteousness. I'm looking forward to (or dreading?) my first "how dare you" letter from some doc whom I have unfairly slammed in this column.

That said, I will press on ...

With regard to your tinnitus and sound sensitivity (known in the biz as hyperacusis) I certainly cannot hazard a diagnosis, based upon the information you have given me. I would, however, like to comment on your interaction with this doctor.

There are certainly times when, during the initial interview, a light bulb flashes above our wee brains and we say to ourselves, "YES! I KNOW WHAT THIS IS!" At that moment, there is a strong inclination toward skipping large parts of the history and physical examination -- after all, we've figured this one out; time to treat the patient and get on to the next patient.

This is appropriate at times. If a new patient states, "I can't hear; my ears are full of wax," and if I look and see nothing but wax, then there is little reason to look into her nose or throat. In this example, I need only a limited amount of history. (In particular, I ask whether the patient has ever had ear surgery or ear trauma, and I like to know the patient's opinion regarding her pre-wax hearing.) The important thing is to get the wax out and then ask, "There, is that better?"

Indeed, on several occasions when I have looked into such a patient's nose or throat, I have been met with a certain amount of befuddlement. ("It's my EARS, doc!") So ... what this is really about is understanding a patient's expectations. At times, patients expect a thorough interview and exam; at times, patients expect you to "get to it." A patient's expectations do not always coincide with the doctor's opinion regarding how much history and examination are necessary. On the one hand, we may stand accused of being unnecessarily prying ("Honestly, doc, you don't really need to know about every blessed operation I have ever had, do you?"), while on the other hand, we are perceived as being lax and uncaring.

I would like to think that if a doctor is a caring physician, the patient will somehow perceive this and forgive the doctor any other minor shortcomings. In reality, some docs are caring, yet do not project an aura of caring, and some patients have a chip on their shoulders a mile wide and always assume the worst about their doctors' motivations. And, unfortunately, there are some docs who honestly don't give a damn and merely want to herd their patients through as quickly as possible.

Back to you and your ear, nose and throat doctor. In my opinion, stress is a diagnosis of exclusion. That means that in order to make this diagnosis, the doctor must be fairly certain you do not have another, more tangible explanation for your symptoms. Did this doctor delve deeply enough to exclude other possible diagnoses? I cannot say -- I wasn't there to observe the interaction.

What is important is your perception that he did not show due care. You feel that he has already dismissed your case as being medically insignificant. You could give him a second chance, but I suspect that this doctor-patient relationship is irretrievably tarnished. I recommend that you trust your intuition and seek a second opinion.