Opening Pandora's box: the unpredictability of reassurance by a normal test result

BMJ 1996;313:329-332 (10 August)

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Opening Pandora's box: the unpredictability of reassurance by a normal test result

I G McDonald, director, Centre for the Study of Clinical Practice,^a J Daly, senior lecturer,^b V M Jelinek, senior cardiologist,^a F Panetta, cardiologist,^c J M Gutman, cardiologist ^a

^a St Vincent's Hospital, Fitzroy, Melbourne, Victoria 3065, Australia, ^b School of Sociology and Anthropology, La Trobe University, Bundoora, Melbourne, Victoria 3065, ^c Alfred Hospital, Prahran, Melbourne, Victoria 3181

Correspondence to: Dr McDonald.

Abstract

Objectives: To determine the rate of failure of patient reassuranceafter a normal test result and study the determinants of failure.
Design: Replicated single case study with qualitative and quantitativedata analysis.
Setting: University teaching hospital.
Subjects: 40 consecutive patients referred for echocardiographyeither because of symptoms (10 patients) or because of a heartmurmur (30). 39 were shown to have a normal heart.
Interventions: Medical consultations and semistructured patientinterviews were tape recorded. Structured interviews with consultantcardiologists were recorded in survey form.
Main outcome measures: Patient recall of the explanation andresidual understanding, doubt, and anxiety about the heart afterthe test and post-test consultation.
Results: All 10 patients presenting with symptoms were leftwith anxiety about the heart despite a normal test result andreassurance by the consultant. Of 28 patients referred becauseof a murmur but shown to have no heart abnormality, 20 becameanxious after detection of the murmur; 11 had residual anxietydespite the normal test result.
Conclusions: Reassurance of the "worried well"--anxious patientswith symptoms or patients concerned by a health query resultingfrom a routine medical examination or from screening--constitutesa large part of medical practice. It seems to be widely assumedthat explaining that tests have shown no abnormality is enoughto reassure. The results of this study refute this and emphasisethe importance of personal and social factors as obstacles toreassurance.

Key messages

Obstacles to reassurance relate not only to prob- lems of doctor-patient communication but also to the patient's past experience and social circum- stances
Because of the risk of residual anxiety and the epidemiological hazard of a false positive or incon- clusive test result, referral for the test should be avoided if an expert clinical opinion will suffice
Clinical skills in recognising anxiety and identifying innocent murmurs should be rein- forced to minimise unnecessary referrals
The consequences of possible residual doubt and anxiety must be factored into measurements of cost effectiveness of echocardiography and of other imaging technologies

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