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PAPERS: Jenny L Donovan and David R Blake Qualitative study of interpretation of reassurance among patients attending rheumatology clinics: "just a touch of arthritis, doctor?" BMJ 2000; 320: 541-544 [Abstract] [Full text]

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Problems with reassurance

D Venugopal   (10 March 2000)

Reassurance in rheumatology clinics

Andrew Frank   (17 March 2000)

Problems with reassurance 10 March 2000
D Venugopal Send response to journal: Re: Problems with reassurance	This qualitative study focusses upon methods of reassurance used by clinicians and patients' perceptions of the same. The results show a distinct disparity between the clinicians' patterns of reassurance and patients' interpretation of the reassurance. This aspect has great significance because the whole purpose of reassurance (one of allaying patients' anxieties) is defeated if 'reassurance' is not perceived as 'reassuring' by the patients. Patients often tend to interpret the doctors' statements in light of their own experiences, circumstances, beliefs and attitudes (2). Therefore, reassuring a patient must entail a process of'empathy' i.e., putting oneself in the patient's shoes and perceiving the world as such. Empathizing with the patient itself has a significant reassuring effect upon the patient. It would enable the clinician to understand the patient's symptoms from the latter's perspective and then reassure him with explanations of the symptoms, current medical understanding of the illness and its treatments. Thus the approach needs to be one of finely blending the medical model of the patient's symptoms and illness with the patient's own belief systems. The other aspects of the consultation which may have a bearing upon reassurance include duration of symptoms/illness, past experiences with symptoms and illness, presence of cognitive distortions, accuracy of patients' medical knowledge and their illness beliefs. Thus, the whole construct of reassurance needs to be approached along a number of dimensions with the final goal being the patient 'feeling reassured'. Perhaps, a query from the clinician regarding the presence of any further concerns bothering the patient and addressing the same might also help the patient feel understood and reassured. Dr. Venugopal D. Assistant Professor, Department of Psychiatry, Kasturba Medical College, MANIPAL-576119, INDIA. References: 1. Donovan JC and Blake DR. Qualitative Study of interpretation of reassurance among patients attending rheumatology clinics: "Just a touch of arthritis, Doctor?". BMJ 2000; 320:7234:541- 44. 2. Howard LM and Wessely S. Reapprising reassurance- The role of investigations. J. Psychosom. Res. 1996; 41(4): 307-311.
Reassurance in rheumatology clinics 17 March 2000
Andrew Frank Send response to journal: Re: Reassurance in rheumatology clinics	As rheumatologists, we were delighted to see your issue devoted to chronic disease. Donovan and Blake are to be congratulated on tackling the important issue of reassurance in chronic disease management 1. However, it appeared to us that the reassurance was directed to the doctors' expectations of the patients' concerns rather than the patients' actual fears. Neither the preliminary interview, nor the consultation, appeared to define what patients' actually worried about. Fear is a powerful emotion experienced by many individuals with musculo- skeletal disorders. Within the back pain field, the disabling effects of fear caused by patients' back pain have been clearly identified 2 and may have significant consequences on their behaviour 3. Consequently a specific questionnaire has been constructed to elucidate the context of patients' fears 4. Patients' fears can often be ascertained by asking the simple question "what is it that worries you most about your condition". In a rheumatological back pain clinic, 86 consecutive new patients were asked what worried them about their back pain. Only 13 (15%) denied specific fears; 55 (64%) admitted to fears about possible future disability (loss of independence/work or being confined to a wheelchair); 18 (19%) were worried about the cause of their pain (cancer, arthritis, degeneration); and 2 (2%) had other concerns (e.g. clicking in the back) 5. It is not surprising that patients with peripheral joint symptoms are also concerned about potential disability 1. The importance of Donovan and Blake's work lies in 2 areas, both requiring attention in rheumatology training programmes. Firstly, rheumatologists should be able to appreciate patients' fears irrespective of their own preconceptions. Secondly, they would be in a better position to allay fears about future disability if they received better training in disability management. The current specialist training in rheumatology appears deficient in both these areas. We conclude that it is illogical to try to offer reassurance in the absence of defining the specific fear(s) worrying the patient, which is often only elicited by direct questioning. Rheumatology training programmes should specifically address both these issues. Bibliography 1 Donovan J, Blake D. Qualitative study of interpretation of reassurance among patients attending rheumatology clinics: "just a touch of arthritis, doctor?". BMJ 2000;320:541-544. 2 Crombez G, Vlaeyen J, Heuts P, Lysens R. Pain-related fear is more disturbing than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999;80:329-339. 3 Main C, Waddell G. Spine Update: Behavioral responses to examination: a reappraisal of the interpretation of "non-organic signs". Spine 1998;23:2367-2371. 4 Waddell G, Newton M, Henderson I, Somerville D, Main C. A fear avoidance beliefs questionnaire (FABQ) and the role of fear avoidance beliefs in chronic low back pain and disability. Pain 1993;52:157-168. 5 Frank AO. Low back pain: diagnosis and management. London: Current Medical Literature, 2000;1-80 - in press