Fifty four patients took part in the main study.17–19
This paper focuses on 35 patients (28 women and seven men) who had a baseline interview, at least one consultation, and related follow up interviews tape recorded successfully. The table shows the characteristics of the 35 informants, which were similar to those with incomplete tape recordings. The clinics were conducted by consultants, registrars, senior registrars, and general practitioner clinical assistants. All initial consultations followed the same basic pattern despite their varying lengths (mean 21 minutes, range 12-34 minutes), with doctors taking the history, conducting the examination, and delivering the explanation. Patients were mostly passive. Comparisons between transcripts of consultations and subsequent interviews indicated that most patients were able to recall some or most of the information given to them.24
Patterns of reassurance
As expected, clinicians usually attempted to reassure patients towards the end of the consultation by making statements about treatments, diagnoses, and outcomes. The pattern of reassurance varied depending on the clinical diagnosis. When the diagnosis was of a self limiting or non-inflammatory condition (such as muscle strain or osteoarthritis), the doctor tended to emphasise the non-seriousness of the problem:
Dr C: So I want you to try to think of it as being rather reassured rather than no diagnosis being given and we'll just leave things as they are.
Mary: Well, putting all this aside, the pain in my side is the most worrying of all ... I don't think I imagine it.
Dr C: It's not a question of imagining it. If you can find it, it is there. All I can do is assure you that I can't find anything serious going on ... I'm afraid that with a lot of people like yourself we don't always come to a diagnosis.
(Dr C, registrar; Mary, 49 years, probable osteoarthritis)
When the diagnosis was of an inflammatory disorder such as rheumatoid arthritis or where symptoms were suggestive of this, the reassurance focused on the early or mild nature of the disease:
Dr A (to Maud): The kind of arthritis you have is called rheumatoid arthritis. Now rheumatoid arthritis is a peculiar disease. We do not know what is the cause, but in many people it follows really quite a mild course and it doesn't cause much damage. In others it is a bit more crippling and can cause quite a lot of problems. I think you are going to be quite fortunate in being one of the ones that, although you have got it most of the time, I very much doubt that it will go on and cause you a lot of trouble.
(Dr A, consultant; Maud, 71 years, rheumatoid arthritis)
The explanations given by the doctors were clearly delivered with the intention to reassure, and there was no indication in the consultations themselves that patients were not reassured.
Interpretation of reassurance
In this study, we were able to explore the patients' interpretations of the reassurance given in the consultations, and these showed that often patients did not interpret the reassurance in the way doctors had intended.
Maud, for example, recalled that Dr A had reassured her that she would not be troubled by her mild rheumatoid arthritis (see above), but this contradicted her experience of her son's progressive disease:
Maud: He said I've got rheumatoid arthritis. I know I'd got arthritis, but I didn't know I had rheumatoid arthritis. But you see it is only in mild form, thank goodness.... I was surprised when he said that because my son has got rheumatoid arthritis, but he has got it really bad.... I don't know, but the doctor said it is only mild, and, of course, my son's was only mild in the beginning, so I hope to God mine doesn't go like that.
The emphasis on the “mildness” of inflammatory disorders led not to reassurance but to fears for the future:
Dr G (to Rita): I have not been able to find any sign of rheumatoid arthritis, which is good ... . I think the results of the blood tests will be negative. You have a little mild rheumatoid but so do lots of people, and I think it will not turn out to be anything serious to worry about.
Rita (in interview): The doctor tells me it is mild, not very much, but, you know, from mild it is going to be bad. I know that when my sister, when she got this illness, it was [mild], but now it is very bad.
(Dr G, senior registrar; Rita, 49 years, rheumatoid arthritis)
A similar emphasis on the “early stage” of the disease caused concern to patients who felt that they were already suffering enough:
Dr D (to Margaret): I don't think there is any question that you've got an arthritis, and according to the GP's tests it is rheumatoid, but it is in the very early stages and we would certainly do all we possibly can to stop it from damaging your joints.
Margaret (in interview): The doctor said that it was almost definite that it was rheumatoid arthritis, but he thought it was in the early stages. And to me, if that is it in the first stages—I can stand pain, I can grit my teeth and put pain at the back of my mind—but if that is the first stages, then I can see why it gets really bad, that it does cripple.... If that is the pain on the first stages, then what [pause] er, will it be like?
(Dr D, GP clinical assistant; Margaret, 50 years, rheumatoid arthritis)
Patients were also not reassured when doctors contradicted their own views about their problems or seemed not to take their difficulties seriously enough, whether the diagnosis was uncertain (Richard) or clear (Cynthia):
Dr B (to Richard): Certainly examining you today, the trigger finger in your thumb is irrelevant. We can treat that if it is a problem, but I don't think it's anything to worry about. The slight concern is whether the what we call “polyarthralgia”—aches and stiffness in the joints—signifies any underlying disease going on. It's difficult to tell. It's quite likely that there won't be, or that all the tests will be normal ... . Most of the time we get a lot of people who present with aches and pains and we never find anything. Very occasionally, it can be the prodrome—the beginning of a more definite form of joint trouble, but there is very little that at the moment would make me say that's what is going on here.
Richard (in interview): He said the trigger finger is not related to the problem I've got, which sounds really peculiar to me because ... it seems a bit of a coincidence that I have got something totally unrelated which to me is totally related. He doesn't see me in the mornings, hobbling around. Quite honestly, he treats it very differently, which is a shame. I'm not looking for sympathy ... . I think I want him to be aware, really, and a bit more concerned over my health and welfare.
(Dr B, consultant; Richard, 39 years, problems never diagnosed)
Dr E (to Cynthia): I think what we are going to find out is that you've got some wear and tear arthritis, OK? Certainly in your knees and I suspect that's the reason your right hindquarter hurts, because of your back rather than hip .... On examining you, the only real thing I could find was that your knees have got quite a lot of creaking in them and your hands have the early stages of osteoarthritis that tends to run in families.
Cynthia (in interview): He said he didn't think it was in me hip, he said it was in me back, but I'd swear one hip is bigger than the other. They say doctors differ and patients die, and I think that's true ... . I think [the doctor] understands my problems, but they're not that dramatic to him. They are to me because I'm the one who is suffering. He doesn't think it's as desperate as I think it is. He thinks, “you've got arthritis like millions of others.” But I've got to live with it.
(Dr E, registrar; Cynthia, 43 years, osteoarthritis)
Key to successful reassurance
Overwhelmingly, one theme emerged consistently in relation to reassurance: whether patients perceived that the doctor had acknowledged their difficulties. In the quotations above, patients' concerns about doctors not understanding their problems are evident. In contrast, if patients felt their difficulties had been heard by the doctor and acknowledged appropriately, reassurance could be achieved:
Dora: He said, “You are not too bad really, it is only wear and tear of your bones during the years.” He said, “That's because of your five children, that is.” I went in heavy laden, but I came out feeling very light.
(Dora, 76 years, osteoarthritis and rheumatoid arthritis)