At the end of May, I enjoyed reading a special report on 51˶ focusing on "Less is More" for back pain. The author, , gave suggestions on reassuring patients when not ordering unnecessary tests and treatments for back pain.
While Deyo's opinion that "more care is not always better care" made sense, I was surprised that the Kaiser Permanente Professor of Evidence-Based Family Medicine marshaled no evidence in support of his five recommendations. So what are the data on reassurance -- "something the therapist does, with the aim of reducing anxiety and changing beliefs and behaviors?" How should clinicians do it? Could it backfire?
1. Recent evidence supports educating patients to reassure them
This April, a in JAMA Internal Medicine examined the effect of education on reassurance in patients with acute back pain. The systematic review and meta-analysis analyzed 14 studies including 4,872 patients that tested the effect of education in forms ranging from 5-minute consultations to printed materials on various reassurance outcomes like fear, anxiety, or worry. They found "moderate- to high-quality evidence that patient education provided by primary care practitioners can reassure patients with acute LBP [low back pain]." This reassurance effect was maintained for 12 months. Another showed similar results for education-based reassurance.
2. How to best reassure someone remains murky
The noted that the studies included by Traeger and colleagues did not standardize methods or scripts, making it difficult to assess the effect of both the reassurance message and its framing -- the different ways of delivering the reassurance content.
In fact, some research suggests patients' reassurance is affected by how physicians frame what they say. Patients respond differently to reassurance based on facts, statistics, and education, for example, informing a patient they have a less than 1% chance of having cancer, versus emotional appeals like showing empathy and developing rapport. Here the limited data are mixed. A by Pincus and colleagues showed better reassurance outcomes with cognitive framing alone while affective reassurance improved patient satisfaction but not necessarily reassurance. Yet two qualitative studies of and suggest that patients respond best to a mixture of both cognitive and affective framing.
Psychologists like , the current president of Yale University, and his colleagues have focused on the difference between gain- and loss-framed messaging on health behaviors. That is, messages that focus on a behavior's benefits ("you'll feel great if you exercise every day") versus its downsides ("if you don't exercise, you are likely to get diabetes"). Yet this research is rarely cited in the medical literature except in examinations of disease-prevention behaviors like cancer screening.
3. Diverse patients require different strategies for reassurance
Cross-cultural communication studies have shown that effective doctor-patient communication can be stymied by cultural and socioeconomic class differences. For example, found that Aboriginal patients often gave answers they believed the clinician wanted to hear, particularly for yes/no questions, because it is considered impolite to directly contradict someone with higher perceived social standing.
showed that communication between doctor and patient is improved when patients are empowered to actively participate, freely expressing their concerns and preferences. Traeger and colleagues' paper examined studies done only in Anglophone or northern European countries. These cultures are characterized as egalitarian and eschewing of hierarchies (i.e., have low "power distance," according to ) and tend toward individualism rather than communitarianism. Whether those findings hold true for other communitarian or hierarchical cultures remains unstudied.
Despite our diverse patients, many doctors seem to primarily with education and test results. Even more concerning, by Willems and colleagues found that physicians rarely change their communication style from one patient to another, leading to miscommunication especially with patients of lower socio-economic class. While there are little data specifically guiding clinicians how to change communication strategies to overcome differences, clinicians should be cognizant that patients from diverse backgrounds may require divergent strategies for communication.
4. Bad reassurance can backfire
Class and culture matter, but so might a patient's baseline anxiety level. A using affective reassurance alone after negative gastroscopy showed resurgence in the worry of anxious patients, suggesting that affective framing without adequate cognitive explanations can backfire in patients with high health anxiety. The review by Pincus and colleagues supports this, showing patients given affective reassurance alone had higher symptom burden and showed less improvement in those symptoms at follow-up. Unsurprisingly, when patients feel their complaint is dismissed, some respond by seeking even more care and expressing their complaints more emphatically, .
Given that bad reassurance can backfire, more research needs to be done to guide clinicians in how to best reassure our patients. , "the assumption that all aspects of patient-centered consultations have a positive impact on all outcomes, in all patients, demonstrates a case in which implementing a theory may have galloped ahead of evidence."
5. Intuition and experience is not evidence
Unfortunately, Deyo's "intuitive" approach to reassurance is common. Guidelines on managing back pain from the U.S., Switzerland, Finland, U.K., and Holland () also recommend reassurance for patients without any "red flags," yet none of them cite evidence when recommending how clinicians should reassure patients.
Equally concerning is that journals and blog posts dispense such "intuitive wisdom" without references, something we would never countenance in an article or post, for example, on the use of statins for primary prevention of heart attacks.
Clearly, more research using standardized forms of reassurance needs to be done to help us understand how clinicians should frame messages for different patients, taking hierarchical, socioeconomic class, and cultural barriers into account. Just as important, however, is that we should demand that intuitive recommendations cite the literature for any intervention as long as some data exists to guide us.
, is a third year resident in Internal Medicine at Cambridge Health Alliance.