The doctor demonstrated this by not referring the patient urgently or by emphasizing that the only purpose of the referral is to reassure the patient. Once that is done it will all be ok. Worries about having a serious disease were often accompanied by worries about potential adverse physical consequences of such a disease, such as additional conditions and death. But well, I am worried about the pressure at the back of my head. Then I think of my heart, for that is the pump and the pump is the main thing, and, to be honest, then I worry that I will not live to an old age.
Yes, your heart is in fact the thing of your body and if it is not alright, other things will be wrong as well. For you get a domino effect. Worries about the adverse effects of a complaint were often due to the experiences of family members and friends or to information on the internet. I have high blood pressure with symptoms and then you hear all sorts of stories and you know people, some I know personally, who have suffered attacks due to high blood pressure and were partially paralyzed.
I have two young children and I do not want that. Patients who worried that their symptoms might lead to adverse consequences mentioned to feel reassured after the cause of their symptoms was explained to them. In some cases a clear explanation helped patients to understand that the symptoms were easy to treat. Having control over their complaint by being able to treat it themselves was reassuring as well. I know what causes it. Things are in my own hand now, I know what I can do about it, and that is reassuring. Patients felt reassured also when they were convinced that their complaint would disappear or when they believed it would not get worse or return.
This depended on adequate treatment as well as close monitoring, preferably by their GP, who was considered to be the most capable of judging how the complaint would develop. Some patients believed that treatment would lead to serious consequences. This could relate to treatment that already had been performed, in this case a hip replacement.
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Your can read a lot about new hips, metal on metal can cause all sorts of things. My sister still has these complaints, pain in her leg, swollen. I have the same. Then I rather go back on time. This cognition however mostly arose when the doctor prescribed medication during the consultation or when the patient thought the doctor might prescribe medication in the future.
I know someone who also has something like that and when he reads the side effects of the medication, then you start to think, do I really have to take that? Patients who worried about potential adverse effects of medication use mentioned no reassuring cognitions that counteracted these particular concerns. This patient felt partly reassured because her doctor referred her for an additional investigation. Several patients expressed difficulties in coping with their health problems as they worried about the impact of these problems on their life, e.
A few patients also indicated non-supportive family members, friends and working environment as one of the reasons for their experienced difficulties.
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Well, I find it difficult to deal with that this is the case for several things. It really makes me feel like, hey guys is there anything that is not wrong with me, just put me out with the garbage. I find this very discouraging, like, well you are getting old, shortly you will be written off completely …. While a trusting relationship seemed to have an indirect reassuring function for most patients, patients who struggled with the impact of their complaints on their life, explicitly described the reassurance they obtained from a trusting and supporting relationship.
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This made patients feel their doctor was interested in them as a person and was genuinely trying to help them. Especially patients who felt that people in their environment did not take them seriously appreciated naming concerns. It is reassuring to be listened to.
If I had talked about this with my boss, he would have listened to me for two seconds and told me to go to bed and see how things were in the morning. And he says, no, you should tell your story properly and I will not interrupt you. One is not afraid to have a proper talk with this man, because you know that everything you say will be heard, that he really listens to you.
He gives you time to get it off your chest. He asks some pertinent questions and otherwise he keeps quiet.
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Several patients mentioned that they felt reassured when they believed their complaints would be resolved and not return. These concerns seemed to be dealt with particularly effectively, when the doctor communicated a treatment plan and a positive vision of a future without complaints. It is very much tailored to the person. He says, well you need a little more of this.
That is reassuring. Then they start to work on things you might do better in order to prevent this from happening again. He had this idea, that I can go to that hospital with a team of specialists and try it [treatment] again. Patients related these worrying core cognitions to a range of underlying person-specific and context-specific cognitions. Worrying and reassuring core cognitions appeared to be related, as worrying cognitions were counteracted by specific reassuring cognitions.
Patients who were concerned about having a serious disease expressed to be reassured when the GP explained why the complaint was not serious and moreover gave insight into the harmless cause of the complaint.
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The reassuring cognitions we identified in the present study are in line with the process in which patients with medically unexplained symptoms MUS are supported to re-attribute somatic complaints [ 31 , 32 ] and with giving hypochondriac patients insight into the causes of their tendency to worry as an effective component of Cognitive Behavioural Therapy [ 33 ].
Patients also worried about potential serious consequences of complaints, such as disability. The main reassuring cognition for these patients was the belief to being able to influence their health problem. Buchsbaum also described how an empathic doctor showing genuine interest and compassion can provide support during emotionally turbulent times [ 4 ]. In our study, patients worrying about the impact of health problems on their everyday life explained how a trusting doctor-patient relationship was reassuring for them.
With simple actions, the doctor provided emotional support to patients who did not receive this from their social environment [ 35 ]. Here, a trusting relationship served as the instrument of reassurance while also having an indirect supportive effect on patients with other worrying cognitions. We described earlier in the background that patients and doctors perceived consultations differently [ 20 - 22 ], and hypothesized that this might lead to ineffective reassurance [ 13 - 16 ]. However it cannot be concluded that this overlap will be present on the level of individual consultations.
Furthermore, reassurance may be difficult to achieve in specific patient groups with high anxiety [ 14 , 16 ] and more feasible in the less anxious population we studied. Our findings are consistent with previous research showing that in most patients reassurance is a multifaceted process involving more than just providing normal results of diagnostic tests [ 13 , 15 , 36 ].
Most patients wanted clear explanations to help them understand their complaint, after which they felt no need for any additional diagnostic tests. These differences between patients point to the important observation that worrying and reassuring cognitions can vary considerably among patients, requiring doctors to use situation-specific reassurance strategies.
This may be challenging considering that training in medical communication skills tends to be of a quite generic nature [ 37 ]. Although we did not aim to explore which sorts of cognitions were or were not expressed during the consultations, we noticed that worries about the effects of medication use were never expressed. Obviously, an in-depth interview gives patient much more opportunity to elaborate on their concerns than a minute consultation. Interestingly, none of the patients, including those who remained worried, expressed worrying cognitions about their own doctor, e.
Although we explicitly asked all patients if they could think of anything that would have reassured them more, only one patient described this. The absence of this action was however no cause of increased concern. Patients who mentioned doubts about other GPs and specialists generally remarked that their own doctor did much better.
There are several possible explanations for this phenomenon. Firstly, patients may have given socially desirable answers and be reluctant or not used to making negative comments about their doctor. Secondly, expressing only positive views of their doctor may be used as a personal confirmation that the doctor was right. Since we were not able to select from every practice consultations in which patients gave high ratings of their level of concern, we included several patients who indicated that they were only slightly worried.
During the interview, however, these patients spontaneously mentioned several worrying and reassuring cognitions. We therefore think that the data comprise descriptions of worrying and reassuring cognitions given by patients showing a high degree and patients showing a lower degree of concern. This may well be interpreted as a strength of this study given that the current literature focuses mainly on patients with high anxiety, such as patients with hypochondriasis [ 30 , 33 ] and MUS patients [ 16 , 31 , 32 ].
The variety of the consultations is limited with respect to the absence of consultations in which GPs diagnose or suspect serious disease. It is likely that patients have other worrying and reassuring cognitions in case GPs express their concerns about serious pathology. Another strength is that we interviewed patients about a recent consultation with their GP.
This reduced the risk of unreliable and incomplete answers, though the risk of patients constructing answers using hindsight knowledge is always present. It is not only reassuring in itself, it also gives doctors a focus for their efforts to reassure patients. Once physicians are aware of the worrying cognitions patients have, they may be able to recognize patient cues pointing towards these cognitions.
This is especially important in light of the finding that patients often did not mention all their concerns during the consultation and that these concerns were not addressed, in particular concerns related to treatment. Doctors should therefore pay attention to cues and concerns throughout the consultation, not solely during the opening phase. Furthermore, the reassuring core cognitions that were identified can support doctors in applying reassuring strategies. By not only describing reassuring actions but also the core cognitions supported by these actions and the worrying core cognitions counteracted by them, we aim to offer doctors guidance for strategies to reassure patients in a goal-directed manner.
In this small scale, qualitative study we were only able to describe patterns on the level of core cognitions. Specific underlying worrying cognitions, however, may require specific types of reassurance. It would therefore be interesting to conduct further experimental, systematic studies of the relationship between specific worrying and reassuring cognitions, in order to obtain additional insights regarding effective situation-specific reassurance.
Less intensive methods of data collection such as questionnaires would also allow the investigation of associations between patient characteristics e. What patients experience as reassuring seems to depend on their specific worrying cognitions. Gaining a thorough understanding of these worrying cognitions and tailoring reassuring strategies to them should be an effective way of achieving reassurance. EG was involved in the design of the study, in the collection, analysis and interpretation of the data and drafted the manuscript. WV was involved in the design of the study and in the analysis and interpretation of the data and critically revised the manuscript.
AM contributed to the data collection and analysis and was involved in drafting the manuscript. FB was involved in the interpretation of the data and critically revised the manuscript. TvdW and CvdV contributed to the design of the study and critically revised the manuscript. All authors read and approved the final manuscript. The authors would like to thank the 21 patients who participated in our study. National Center for Biotechnology Information , U. BMC Fam Pract. Published online Apr Author information Article notes Copyright and License information Disclaimer.
Corresponding author. Esther Giroldi: ln. Received Dec 17; Accepted Apr This article has been cited by other articles in PMC. Abstract Background Many patients who consult their GP are worried about their health, but there is little empirical data on strategies for effective reassurance.
Methods In a qualitative study, we conducted stimulated recall interviews with 21 patients of 12 different GPs shortly after their consultation. Conclusions Patients described a wide range of worrying cognitions, some of which were not expressed during the consultation. Background Many patients consult their general practitioner GP because they experience certain symptoms and are worried that these may be indicative of serious illness [ 1 - 3 ].
Ethical approval and informed consent The Medical Ethical Commission of Maastricht University Medical Centre granted ethical approval for the study protocol. Study context The study was conducted in Dutch general practices. Selection procedures GPs were recruited and informed of a study on reassurance with an invitation letter and a follow-up telephone call. The interviews The selected patients were interviewed by trained interviewers, preferably on the day of the consultation or shortly thereafter.
Data analysis The interviews were transcribed verbatim.
Table 1 Patient and consultation characteristics. Open in a separate window. The interviews Twenty patients were interviewed on the day of the consultation and one patient was interviewed seven days later. Worrying cognitions and how reassuring cognitions counterbalance them Patients described four worrying core cognitions. Table 2 Worrying core cognitions and underlying cognitions.
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My treatment will have adverse effects - The treatment I received was incorrect, so my health problem will persist. My health problem will negatively impact my life - Having health problems does not fit with how I see myself and my future. Table 3 Reassuring core cognitions and supporting factors.
Reassuring core cognitions Factors supporting reassuring core cognitions Consultation-specific factors. My doctor: Context-specific factors. There is: I feel safe and supported because I have a trusting relationship with my doctor. Figure 1. Worrying core cognition: I have a serious disease Most of the participating patients expressed concerns that they might have a specific serious disease, such as cancer or a heart condition, often triggered by an alarming symptom, such as chest pain.
Patient 12 I had a blood test showing reduced kidney function, and because my mother died from renal disease I wanted to ask the doctor what might be the matter and if this could cause problems. Patient 15 Often such pre-existing cognitions appeared to be triggered by what happened in the current consultation. Patient 9 Well, it seems to me that it [physical examination] is a part of the consultation, for without it the doctor cannot find out what is going on. Patient 17 Patients also expressed that they needed to be convinced that their complaint was not serious by evidence or signs that denied the presence of severe illness.
Patient 1 In addition, patients stressed the importance of the doctor explaining how test results or findings of the history taking and physical examination excluded a harmful diagnosis. Patient 21 In case of an abnormal test result, patients felt reassured when the doctor used visual tools, such as anatomical models and graphs, to explain why they are reported and that they are no reason for concern. Patient 14 When he explains it you start to think, obviously when I have pain in my left foot end my right hip, walking is difficult and I distribute it.
Patient 21 In contrast, a few patients mentioned that in order to feel reassured, they needed additional tests or a referral to a specialist, after which they would obtain absolute certainty. Patient Worrying core cognition: My health problem will have adverse physical effects Worries about having a serious disease were often accompanied by worries about potential adverse physical consequences of such a disease, such as additional conditions and death.
Patient 4 Worries about the adverse effects of a complaint were often due to the experiences of family members and friends or to information on the internet. Patient 18 Patients who worried that their symptoms might lead to adverse consequences mentioned to feel reassured after the cause of their symptoms was explained to them. Patient 18 Patients felt reassured also when they were convinced that their complaint would disappear or when they believed it would not get worse or return. Worrying core cognition: My treatment will have adverse effects Some patients believed that treatment would lead to serious consequences.
Patient 19 This cognition however mostly arose when the doctor prescribed medication during the consultation or when the patient thought the doctor might prescribe medication in the future. Patient 7 Patients who worried about potential adverse effects of medication use mentioned no reassuring cognitions that counteracted these particular concerns.
Worrying core cognition: My health problem will negatively impact my life Several patients expressed difficulties in coping with their health problems as they worried about the impact of these problems on their life, e. Patient 2 While a trusting relationship seemed to have an indirect reassuring function for most patients, patients who struggled with the impact of their complaints on their life, explicitly described the reassurance they obtained from a trusting and supporting relationship.
Patient 16 Several patients mentioned that they felt reassured when they believed their complaints would be resolved and not return. Patient 16 He had this idea, that I can go to that hospital with a team of specialists and try it [treatment] again. Main findings in relation to the literature Patients who were concerned about having a serious disease expressed to be reassured when the GP explained why the complaint was not serious and moreover gave insight into the harmless cause of the complaint. Strength and limitations Interestingly, none of the patients, including those who remained worried, expressed worrying cognitions about their own doctor, e.
Competing interests The authors declare that they have no competing interests. Acknowledgements The authors would like to thank the 21 patients who participated in our study. What do patients want from doctors? Content analysis of written patient agendas for the consultation. Br J Gen Pract.
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