Art and Science of Providing Reassurance

A 22-year-old patient, SR, presents to my clinic stating that he has an intermittent sensation of a lump or foreign body in his throat. SR reports no alarming symptoms, such as pain, difficulty swallowing solids or liquids, coughing, vocal changes, or weight loss. He has no known medical conditions, does not smoke or take any medications. SR states that the sensation is most noticeable when sitting quietly or trying to fall asleep. After completing an appropriate history and physical examination, I determine that a serious medical condition is unlikely. How can I best approach SR’s concerns to effectively reassure him that these symptoms are not related to a serious underlying disorder?

In primary care settings, patients typically present with symptoms rather than diagnoses.¹ Many presenting symptoms are not related to an underlying serious medical condition and do not require further evaluation beyond a careful clinical assessment.² The act of providing reassurance is therefore a core skill for family physicians, particularly when serious medical conditions are unlikely.

Reassurance is a multifaceted interaction between a physician and a concerned patient that aims to reduce fear, worry, and doubt about the etiology of symptoms or possibility of a serious medical condition. Reassurance results in positive changes in patient perception, understanding, and behavior regarding their health condition.³

Most physicians develop a variety of reassurance techniques over time; however, the skill is rarely explicitly taught or evaluated. Performed well, reassurance can relieve suffering, limit unnecessary testing, and help allay doubts and fears. When performed poorly, attempted reassurance may inadvertently increase symptoms, exacerbate anxiety, contribute to harmful overtesting, damage the patient-physician relationship, and lead to unproductive health behaviors. These behaviors include using unnecessary consultation of multiple practitioners and invalid information sources and also seeking unproven or even dangerous treatments.^4–6

Although providing reassurance is a valuable skill for physicians, high-quality evidence from large trials about ways to best reassure patients is limited. In the absence of clear data, primary care physicians should take an individualized approach to providing reassurance by incorporating affective and cognitive reassurance techniques, considering patient and physician factors that influence reassurance, and using a skillful history and physical examination to demonstrate conscientiousness and ease patient-specific fears.

One helpful approach categorizes reassurance into affective vs cognitive reassurance.⁴ Affective reassurance uses verbal and nonverbal communication, including demonstrations of empathy and active listening, to build rapport and decrease anxiety. Cognitive reassurance focuses on clear explanations and advice to change the way a patient understands or responds to a medical concern. Affective reassurance may temporarily improve patient outcomes such as satisfaction, whereas cognitive reassurance has an immediate and more durable effect on outcomes such as satisfaction, improved symptom burden, and decreased health care use.⁴ Affective and cognitive reassurance can be used in combination as part of an empathic and durable strategy to decrease bothersome, but nonthreatening, symptoms.

Certain patient characteristics may influence the effect of a clinician’s attempt to reassure. Many symptoms that lead patients to seek medical care are related to interoception (the internal system that monitors and interprets body sensations).⁷ Having a high level of health anxiety or history of medically unexplained symptoms predicts ongoing concern despite reassurance, whereas low levels of health anxiety are associated with more positive and long-lasting responses.^3,8,9