Table 2 GPs’ strategies for reassurance: goals, mechanisms and actions

Goal 1. Influence emotions: create trust

Patient trusts GP’s expertise.

- Give detailed explanations instead of only answering the patient’s questions.

- Show that you are fully informed about the patient’s situation.

- Calm and unconcerned demeanour.

- Refer to scientific evidence.

- Emphasize experience and expertise.

Patient has trust in doctor-patient relationship.

- Inform patient honestly, also about diagnostic uncertainties.

- Long-lasting GP-patient relationship.

- Create comfortable atmosphere.**

- Make patient feel heard and understood.**

Goal 2. Influence emotions: create safety and comfort

Patient finds him/herself in a comfortable atmosphere.**

- Approach patient in a friendly manner.

- Make small talk with patient.

- Use humour.

- Make sure the patient understands what will happen during the consultation.

- Comfortable, homey interior of doctor’s office.

- History taking/small talk during physical examination.

Patient feels heard and understood.**

- Allow the patient to tell his/her story.

- Listen attentively.

- Ask the patient to clarify statements.

- Explore patient’s beliefs and ideas about diagnosis and treatment.

- Pay attention to patient’s whole situation.

- Repeat/summarize patient’s statements.

- Announce that you are about to take the patient’s history.

- Name patient’s concerns.

- Acknowledge that you understand the patient’s complaint/reason for visit/concerns.

- Respond to complaints and uncertainties expressed by the patient.

Patient feels GP takes responsibility to properly investigate, treat and monitor patient’s complaints.

- Make clear what will be done during: the consultation, history, physical examination, investigations to help diagnose the patient’s complaint.

- Explain actions during the physical examination.

- Perform: history focused on the feared diagnosis/careful physical examination of the part(s) of the body related to the symptoms and concerns/investigations/referral/consult with specialist/recommend specialist.

- Repeat what was examined before discussing the findings.

- Propose treatment that is tailored to the patient’s wishes and needs.

- Treat symptoms that are causing anxiety.

- Ensure continuity of care.

- Offer opportunity for/schedule follow-up appointment.

Goal 3. Influence cognitions: challenge belief that symptoms are indicative of serious disease

Patient is reassured about his/her misconceptions as GP understands patient’s beliefs and concerns.

- allow patient to tell his/her story.

- ask open-ended/closed questions.

- name/summarize concerns.

- explore the burden of the complaint.

- respond to (non-)verbal expressions of concern.

- explore patient’s beliefs about possible causes of the complaint.

- explore concerns early in the consultation.

- explore concerns after sharing the findings or the diagnosis.

- explore concerns in a setting of physical proximity (e.g. during the examination).

Patient receives information that helps him/her to conclude that the complaint is not serious, both in this consultation and when the patient may experience similar symptoms in the future.

- Emphasize reassuring signs.

- Describe alarm signals of the feared diagnosis.

- Ask questions related to the feared diagnosis (e.g. symptoms) which elicit answers that contradict that diagnosis.

- Explain how the findings of history, physical examination, and other investigations rule out the feared serious diagnosis

- Explain that if the physical examination or investigations reveal no abnormalities, the patient has the harmless condition.

- Remind the patient of similar complaints in the past that turned out to be no cause for concern.

- Discuss the cause of the patient’s tendency to be concerned.

Patient does not interpret abnormalities and GPs’ medical actions as indicative of serious disease.

- Play down relevance of abnormalities by explaining: the interpretation of abnormalities in test results and (ir)relevant values/that the symptoms are not necessarily related to the feared diagnosis/that the complaint should be viewed as a discomfort rather than a threat/that not normal does not necessarily imply the presence of disease.

- Explain that history, physical examination, investigations, referral, treatment do not signify that the doctor is worried but are done: to exclude something/to reassure the patient/because it is standard procedure/because the patient experiences complaints.

Patient’s belief that there is no reason for concern is strengthened.

- state: I am not worried/I can reassure you/I am absolutely sure that serious disease has been excluded/you are worrying more than is necessary/you were thoroughly examined and no abnormalities were found.

- demonstrate non-verbally that you are not worried.

Goal 4. Influence cognitions: promote belief that symptoms are benign

Patient’s attention is shifted toward an alternative explanation.

- Explore patient’s thoughts about the harmless diagnosis.

- Announce that you will examine the area related to harmless diagnosis.

Patient receives information that supports or suggests a harmless diagnosis.

- Correct misconceptions about a harmless diagnosis.

- Explain what causes the symptoms.

- Demonstrate the cause of the symptoms.

- Outline a normal, realistic prognosis.

- Explain that it is normal to experience these symptoms given the patient’s situation.

- Make sure that the harmless diagnosis fits with the patient’s self-image.

- Explain that the complaint is self-limiting/easy to manage.

- Recommend home remedies.

Patient is able to talk him/herself into a reassuring conclusion.

- Let the patient tell his/her story.

- Check whether the patient is reassured.

- Ask questions about the harmless diagnosis which elicit answers that support that diagnosis.

Patient does not develop new worries that might overshadow the reassuring conclusion.

- Change the subject shortly after the patient has arrived at a reassuring conclusion.

- Ignore expressions of new complaints, uncertainties, and assumptions.

- Link newly expressed symptoms to the benign diagnosis.

- Emphasize/show with impatience that consensus has been reached about the diagnosis.

- Show that you are certain about the diagnosis and do not share with the patient any doubts you might have.

- Do not perform a physical examination or make a referral.