BMJ  2007;334:325 (17 February), doi:10.1136/bmj.39121.361910.80

Editorials

Reassuring patients about normal test results

Face to face communication strategies are effective

Every practising doctor recognises that normal test results can fail to reassure patients. One possible cause is that suboptimal reassurance strategies leave some patients distressed about their symptoms.¹ Uncertainty about the meaning or accuracy of normal test results may contribute to making symptoms worse and lead to additional costly and unnecessary medical visits and diagnostic procedures. Despite this, the medical literature provides little guidance about how to discuss normal findings with patients.

The study by Petrie and colleagues in this week's BMJ is one of the few to examine ways of providing reassurance about normal test results.² The findings of this randomised controlled trial show that patients with chest pain who received an intervention comprising an information pamphlet plus a brief pretest discussion with a health psychologist about the implications of "normal" results of an exercise stress test were more reassured by normal findings than patients who received the pamphlet alone or who received "standard information." All patients in the reassurance intervention group reported obtaining and maintaining a high level of reassurance. Moreover, relative to usual care, fewer patients who received the reassurance intervention reported continuing chest pain one month after the stress test.

At its simplest level, this study demonstrates the common sense and empirically supported observation that communication can influence health outcomes.³⁴⁵ It is not particularly surprising that a face to face discussion with a healthcare provider yields better results than communicating the same message with printed materials alone. What is noteworthy, however, is the nature of the intervention and the size of its effect. The intervention was not tailored to each patient's individual circumstances, yet its health effects were substantial, reliable, and enduring. This underscores the important benefits that can be achieved with a relatively modest effort.

Carefully explaining the meaning of normal test results before testing prepared patients to be reassured if test results were normal, strengthening the value of the results. Unfortunately, the study did not investigate whether a similar explanation after testing would have an additive effect. Normal test results might have been even more reassuring if individually tailored messages that included alternative explanations for medically unexplained symptoms were delivered after testing.⁵ Understandably, without such explanations some patients with no objective findings remain worried about undetected medical problems if their symptoms recur.⁶

Although generic reassurance strategies may be useful, the results of this study show that the need for reassurance and optimal methods of providing such reassurance vary in different patients.⁷ For example, some patients within the "standard information" group reported their reassurance level as 0 (not reassured at all), whereas others reported it as 10 (completely reassured). Individual differences known to influence the extent of reassurance include the chronicity of symptoms, the accuracy of patients' medical knowledge, and psychiatric comorbidities.⁸⁹¹⁰ One study found that patients who had persistent chest pain despite negative results on exercise testing were significantly more anxious and depressed than patients who had become pain-free.⁹ Another study found that patients with gastrointestinal symptoms initially reported being greatly reassured when advised that gastroscopy revealed "nothing seriously wrong," but patients with "high health anxiety" experienced resurgence in their worry and illness beliefs as early as 24 hours later.¹⁰ A "one size fits all" method is unlikely to be the best way to reassure patients about normal test results, but it seems to be better than the current system.⁷¹¹

Diagnostic testing is sometimes undertaken mainly to convince patients that their symptoms are benign. Yet this simple well intentioned act can have unintended negative consequences, as many patients are not reassured by negative findings, and merely prescribing diagnostic testing may inadvertently validate and reinforce convictions that the symptoms are serious. The potential for iatrogenesis is increased when test findings are inconclusive and is especially high if further testing is necessary to investigate a false positive result. The eventually negative results of such extended testing may be difficult for the patient to believe.⁸¹¹¹²

¹ University of Mississippi Medical Center, Jackson, MS 39216, USA, ² Center for Sleep Evaluation, Elliot Hospital, Manchester, NH 03103, USA

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Fitzpatrick R. Telling patients there is nothing wrong. BMJ 1996;313:311-2.[Free Full Text]
2. Petrie KJ, Müller JT, Schirmbeck F, Donkin L, Broadbent E, Ellis CJ, et al. Effect of providing information about normal test results on patients' reassurance: randomised controlled trial. BMJ 2007 doi: 10.1136/bmj.39093.464190.55[Abstract/Free Full Text]
3. Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA 2004;291:2359-66.[Abstract/Free Full Text]
4. Teutsch C. Patient-doctor communication. Med Clin North Am 2003;87:1115-45.[CrossRef][ISI][Medline]
5. Price J, Leaver L. ABC of psychological medicine: beginning treatment. BMJ 2 0026;325:33-5.[CrossRef]
6. Nijher G, Weinman J, Bass C, Chambers J. Chest pain in people with normal coronary anatomy. BMJ 2001;323:1319-20.[Free Full Text]
7. Kiesler DJ, Auerbach SM. Optimal matches of patient preferences for information, decision-making and interpersonal behavior: evidence, models and interventions. Patient Educ Couns 2006;61:319-41.[CrossRef][ISI][Medline]
8. Howard LM, Wessely S. Reappraising reassurance—the role of investigations. J Psychosom Res 1996;41:307-11.[CrossRef][ISI][Medline]
9. Channer KS, James MA, Papouchado M, Rees JR. Failure of a negative exercise test to reassure patients with chest pain. Q J Med 1987;63:315-22.[ISI][Medline]
10. Lucock MP, Morley S, White C, Peake MD. Responses of consecutive patients to reassurance after gastroscopy: results of self administered questionnaire survey. BMJ 1997;315:572-5.[Abstract/Free Full Text]
11. Page LA, Wessely S. Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter. J R Soc Med 2003;96:223-7.[Free Full Text]
12. McDonald IG, Daly J, Jelinek VM, Panetta F, Gutman JM. Opening Pandora's box: the unpredictability of reassurance by a normal test result. BMJ 1996;313:329-32.[Abstract/Free Full Text]

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