Qualitative study of interpretation of reassurance among patients attending rheumatology clinics: “just a touch of arthritis, doctor?”BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7234.541 (Published 26 February 2000) Cite this as: BMJ 2000;320:541
All rapid responses
As rheumatologists, we were delighted to see your issue devoted to
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.
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".
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
Competing interests: No competing interests
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
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.
Department of Psychiatry,
Kasturba Medical College,
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-
2. Howard LM and Wessely S. Reapprising reassurance- The role of
investigations. J. Psychosom. Res. 1996; 41(4): 307-311.
Competing interests: No competing interests