The hidden art of reassurance

I have been too quick to reassure and too slow to think about what it means.

For the last few months I have been listening in on the conversations that trainee GPs have with patients, and they have been listening to me. By listening to one-another and seeing how they respond, we have concluded;

The ‘catch-all’ phrase of ‘reassure the patient’, that is used in many medical text books in the management of medical and dental conditions should be edited out.

The Psychologist

 

“I know it’s nothing serious, they keep telling me that. So why can’t they tell me why I’m still in pain? They’re basically just trying to get rid of me, because to them it’s trivial, but to me it’s serious, it’s ruining my life. There are days when I can barely get out of the house, but I have to, I have to get the kids up and get them to school, but I’m in agony, I’m exhausted, I’ve barely slept. I’ve been crying half the night in pain, every time I move it wakes me up, so eventually I give up trying to sleep. I’ve been told, ‘there’s nothing broken’, ‘it’s not cancer’, ‘the scan doesn’t show anything’, ‘the blood tests are all normal,’ but nobody can explain why it hurts so much. I’ve even been told that I’m anxious, but I’m not anxious, I’ve never been anxious. I’m depressed, really miserable a lot of the time, most of the time probably – wouldn’t you be?”

Angie, 34, Low back pain

“I remember the nurse in A&E, I was terrified, my leg was in bits – bone sticking out of my ankle, gas and air on my face, needles stuck in my arms, people everywhere, and this one nurse in the middle of it who never left me. Told me to look at her when I was screaming, calmed me right down, squeezed my hand really tight – I remember that – so tight it took my mind off my foot while the others were manipulating it or something, she stared back at me, firm, calm … loving … can I say that? That’s how it felt, at the time not in a sexual way, but more like, maternal – because when you’re that scared – I thought they were going to have to amputate my foot –  it brings back all those flashbacks of when you were a kid and your mum, or dad for that matter, hugs you and tells you it’s going to be all right. And you believe them, because you’re so vulnerable and so afraid you’ve got no choice, you just let go and trust them completely and then, in that moment the fear melts away.”

Duncan, 26, Motorbike accident

“I never mentioned my heart, but that’s what they always say, “it’s not your heart, you’re not having a heart attack” Every time I go in they do the same things: heart tracing, blood tests, chest x-ray. And then they come round and say “everything’s OK”, and “isn’t that good” and then I say, “well, no, not really because I keep getting the pains and nobody knows what’s going on.”And then you can see, they look disappointed, actually a bit pissed off sometimes, because it’s like I’m supposed to be a bit more grateful, and that’s when they just say I have to go back to my GP.”

Trevor, 56, Chest pain

“My neurologist’s history-taking was so structured, so searching, so thorough, that I felt that, for the first time, my pain was being listened to. The consultation was, in itself, therapeutic”

Hilary Mantel, Migraine

“To be honest I can’t remember half of what the doctor said. There were so many things I had to look out for like the temperature being over something, and the breathing being fast – but how fast? And having a pee – I can’t remember how many times an hour or was it per day – no it can’t have been in a whole day because that’s far too long and anything might happen. But I remember she listed all these things why she wasn’t worried about my baby, but Kai was basically – from what I could see, no different from how he was before and I couldn’t sleep for worrying about what to do if anything changed which is why I’ve bought him back now.”

Kelly, mother of Kai, 9 months viral gastroenteritis.

‘Reassurance’ is not always reassuring.

One difference between young and old doctors is that young doctors’ clinical reasoning is based on a careful review of what they know about all the possible things that could explain their patient’s presenting symptoms. They employ structured principles and use diagnostic sieves considering in turn, infective, inflammatory, neoplastic, endocrine, etc. causes and try to figure out which is most or least likely. Often, none are particularly likely and they conclude that they don’t know what it is, therefore it’s nothing serious (or interesting) and therefore, ‘nothing to worry about’ – or rather, nothing that they themselves are worried about. By contrast, experienced doctors use case-based reasoning. Faced with a patient, they consider how much they are alike or differ from the hundreds or even thousands of similar patients they have seen before. Intuition and experience are as valuable as structured reasoning as this essay from BMJ quality and safety shows. Young doctors I watch often conclude a consultation by reassuring themselves aloud. By contrast, a more experienced doctor can say, in answer to the patients’ question about what to expect, that in their experience of many patients with the same symptoms or condition, this is what usually happens.

More often however, the thing that experience teaches us, is that reassurance is more subtle, more complex and less often warranted than we previously thought.

Reassurance may be cognitive or affective. In the example above, Duncan was given affective reassurance. The nurse recognised his fear and there was an empathic connection. Affective reassurance come from the way we behave; calm, assured, confident, kind and gentle. Eye contact, appropriate touch, a hug even. The way we dress – smart but not overly formal, and the way we move; at ease, but not slovenly, can be reassuring to patients. The way we arrange chairs in a room, even lighting, pictures on the walls, space on our desk, tissues to hand, but not too obvious. Buildings can put patients and clinicians at ease with clear signs and helpful receptionists, considered acoustics, quiet spaces and immediately accessible lavatories. Continuity of care is an important aspect of reassurance – a familiar clinician, receptionist or other member of staff, in a familiar place, especially in the context of a serious, ongoing illness makes a great difference.

Cognitive reassurance includes information – not only clinical details about the condition, treatments and prognosis, but also facts about waiting times and how to get help and support.

Knowing what kinds of reassurance are appropriate and what the patient needs to be reassured about is important. Trevor needed affective reassurance, and got it. Kelly needed cognitive reassurance, but did not.

 

The dark side of reassurance

Reassurance often concludes a consultation but it is also used to conclude a consultation. It is a way for the clinician to draw a conversation to a close and get the patient and their relatives out of the room. Even if this is not the intention, and it quite often is, then it may be perceived this way.

There are times when reassurance may not be appropriate or even possible, especially when the prognosis is very poor, as in this wonderful essay by David Steensma about a young woman with metastatic cancer,

It’s not that I can’t understand the impulse. Medicine would be a chilling enterprise without the motivation to do whatever possible to make bad situations a little better. But a lie breathed through silver is still a lie. Careless or glib reassurances do harm. Worse than platitudes, they are a betrayal. In the face of this woman’s darkness, it seems to me that any reassurances must come from the sphere of the chaplain, not the honest physician.

 

It cannot be assumed that patients want reassurance. Attempts may be perceived by patients like Angie and Trevor (above) to be patronising, a dismissal of their underlying concerns or a cover for the fact that the clinician doesn’t actually know what’s going on.

The effects of reassurance can be intoxicating. The most addictive drugs: alcohol and benzodiazepines especially, are potently anxiety relieving and many patients who are addicted have a history of anxiety. When the drugs wear off, the rebound effect is a heightened and more intense anxiety than before. Reassurance can be addictive too. A clinician can, like their patients, be intoxicated by the short-term relief that comes from repeated reassurance, but they soon discover that over time, the effects are diminished and shorter lasting. There is a considerable literature on the harms of repeated reassurance in anxiety – with guidance on more appropriate behaviour, e.g. here and here.

The paper quoted at the beginning of this piece highlights how children may perceive reassurance as a prelude to something bad about to happen, like an injection. The oft repeated, ‘this won’t hurt a bit’ or ‘just a little scratch’ doesn’t help.

A silver lining

For many patients, an unspoken fear is that they won’t be taken seriously and they won’t be understood. They fear that they might not be able, or be given the opportunity to say what it’s really like for them. Philosopher Havi Carel, in her wonderful book, Illness, about her experiences as a patient, describes this experience as epistemic injustice. Too often doctors control the conversation by asking the questions whose answers they want to hear and do not allow patients the opportunity to say what they need to say. Very often, especially patients who struggle with words, or whose symptoms cannot easily be described, need to improvise with clinicians to create descriptions. Paul Haidet has compared this  with improvisation and jazz,

I find that I am at my best when I can give patients space to say what they want to say, using my communications to gently lead patients through a telling of the illness narrative from their perspective, rather than forcing the narrative to follow my biomedical perspective. In this space, patients often either tell their story, allowing me to understand the context around their symptoms, or ask the questions that allow me to tailor my explanations to their unique concerns. Unfortunately, in our culture, we are not generally comfortable with pauses or quiet. When the situation is compounded by the chaos of a busy clinic, it becomes difficult to remain focused and open to the directions that patients take us. For most practitioners, space does not come naturally; it takes practice and discipline to develop.

Not all illness warrants reassurance just as not all illness is accompanied by suffering. Recognising suffering may be far from straightforward. Barry Bub, in his wonderful long essay, The Patient’s Lament, writes,

in order to listen better, physicians need to know what to listen for; to understand the significance of what is being heard, and to know how to respond therapeutically.

For clinicians whose main job is listening, like GPs, – listening is a clinical skill that needs to be continually developed and practiced. It is analogous to a surgeon’s craft and cannot be taken for granted and can always be improved. As Atul Gawande has argued in his 2011 essay, ‘Personal Best’, it is extraordinary that while professional athletes can see the value of a coach when they are at the top of their game, medical professionals go it alone for almost their entire career once their training is over. Reassurance, for example is a skill that I’ve never been taught and after twenty years in practice, I’ve discovered it’s something I’ve barely considered. I am not alone, Professor Tamar Pincus concludes in a recent review of the literature,

The area [reassurance] is incredibly under-researched, and we are hampered by poor measurement of the complex interactions that take place during the consultation.

I am not entirely sure that ‘more research is needed’. This is a philosophical and pedagogical problem, as much if not more than an empirical one. What David Steensma recognised when faced with a young woman with a terrible prognosis was that there remained may things about which he could be reassuring, for example,

Reassurance that when all your hair is gone, and wasting or open sores have stolen your beauty, that we will choose our words carefully.

Reassurance that we will not be bound by rigid protocols and will use all of our creativity to try to solve your problems.

Reassurance that there are no foolish questions in the consultation room.

Reassurance that when you visit me in the clinic, I will let you finish your sentences and will not hint to you that you are overstaying your welcome.

I think that reassurance is a clinical skill that is as vital as any other. It begins with listening to patients and depends on empathy, which can be taught and learned. And this, for me, is just a start.