Evidence-Based Reassurance
Written by Editor   
Monday, August 10, 2015 12:00 AM


Recently a report focused on how less intervention is more when it comes to back pain.  The report gave suggestions on reassuring patients when not ordering unnecessary tests and treatments for back pain, however what are the data on reassurance -- defined as "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

The systematic review and meta-analysis of 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 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 systematic review from 2013 by Pincus and colleagues showed similar results for education-based reassurance.

2. How to best reassure someone remains murky

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.

Another systematic review showed better reassurance outcomes with cognitive framing alone, while affective reassurance improved patient satisfaction but not necessarily reassurance. Yet two qualitative studies of patients and experienced physicians suggest that patients respond best to a mixture of both cognitive and affective framing.

Psychologists 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. One Australian study found that Aboriginal patients often gave answers they believed the clinician wanted to hear because it is considered impolite to directly contradict someone with higher perceived social standing.

One American study showed that communication between doctor and patient is improved when patients are empowered to actively participate, freely expressing their concerns and preferences.  Yet despite our diverse patients, many doctors seem to reassure in similar ways, primarily with education and test results.

Even more concerning, one systematic review 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. One study shows that 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, according to one review.

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, an "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.

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.

Source:  http://www.medpagetoday.com/PrimaryCare/GeneralPrimaryCare/52980