0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter |

Patients’ Fears and Expectations: Exploring the Hidden Agenda in Our Consultation FREE

Kashif Ahmad, MB, MSc, MRCPI; Bart Ramsay, MD, FRCP
Arch Dermatol. 2009;145(6):722-723. doi:10.1001/archdermatol.2009.102.
Text Size: A A A
Published online

Dermatology patients have unexpressed fears, therapeutic expectations, and varying levels of understanding about their skin conditions. These aspects may be ignored or overlooked in many consultations while the physician tends to focus on diagnosis and treatment. We used a novel tool to explore these factors from the patient's perspective.

Questionnaire 1 was completed by patients immediately before the consultation and consisted of 3 open-ended questions eliciting their level of understanding about their skin condition, their related fears or concerns, and what they wanted from the physician that day. During the consultation the physician asked himself whether he was aware of the patient's fears and expectations.

Questionnaire 2 was completed by patients after the consultation and consisted of 2 questions eliciting level of satisfaction with their visit. The data were collected from January to September 2007 on a FileMaker Pro 8.5 database (FileMaker Inc, Santa Clara, California).

Questionnaires were given to 750 patients seen at the dermatology outpatient clinic. Completed questionnaires were received from 678 patients (271 male and 407 female; 472 new and 206 review; age range, 1-93 years; mean age, 52 years). A total of 363 patients had inflammatory disease and 315 had noninflammatory disease. Of the 315, 219 had benign lesions (69%), and 96 had malignant lesions (31%).

Patient's Fears and Concerns. There were 9 different categories of fears based on the patient's responses (Table). A total of 323 of patients had a single fear (48%), while 276 had multiple fears (40%). The commonest categories were fear of cancer (28%), symptoms (25%), persistence of condition (24%), future deterioration of the condition (23%), and unsightliness (13%). Fear of infectivity or scarring was low, and 11% had no fears. Fear of cancer was more common in male patients (145 of 271) than female patients (46 of 407). Multiple fears were more common in review patients (n = 158; 23%) than in new patients (n = 118; 17%) and also more common in patients with inflammatory dermatoses (n = 212; 31%) than in patients seen for lesion checkup (n = 43; 6%). The physician was unaware of the patient's fears in 32% of consultations.

Table Graphic Jump LocationTable. Extract Examples of the Written Responses of the Patientsa

Patient's Expectations. Of 9 categories of expectation, the commonest were reassurance and advice (42% each), followed by looking for treatment (ie, control of skin condition) (40%), and seeking diagnosis (17%). Sixty-one patients had unrealistic expectations (eg, sought a cure for an incurable condition like lupus or psoriasis). Thirty-eight percent of patients had multiple expectations. The physician was unaware of the patient's expectations in 15% of consultations.

Postconsultation Satisfaction. Ninety-five percent of patients were satisfied or very satisfied with the consultation. However, 4% felt no change, and 1% had unresolved fears after the consultation.

Patients have a wide range of fears about their skin conditions, and these are often multiple and unexpressed. Our results provide valuable insight into the range of fears and treatment expectations of patients with common skin diseases. The findings augment the consultation by enabling both patient and physician to see exactly what the patient is currently worried about in relation to their skin condition at that time. It allows the consultation to focus on the patient's fears and expectations. If these fears are not elicited, expressed, and dealt with in the consultation, they remain and may multiply and block the therapeutic process.

Previous studies have described the importance of giving information, maintaining good communication, being listened to, and having choices over how patients are treated.13 Patients with inflammatory dermatoses have more fears and expectations than those with noninflammatory dermatoses. In a busy clinic, the physician may not be fully aware of a patient's expectations, as happened in 15% of consultations in our study. Patients with multiple fears may have multiple expectations (23% of patients), revealing hidden layers within the consultation.

Although most patients in our study expressed moderate or high levels of satisfaction (95%), it is important to highlight that in the context of patient satisfaction literature, most respondents express positive satisfaction. One possible reason for these high levels of satisfaction is that patients are reluctant to criticize health professionals, the so-called normative effect.4 However, we suspect that the positive questionnaire feedback comes from patient appreciation that their opinions were being sought—even if the physician did not always anticipate their answers. Although most patients had their expectations met, 5% (39 patients) had unresolved fears, or they felt no change in their fears.

We focused on sequential dermatology outpatients but without a control group to compare our findings. We had to perform this study, in a sense, unblinded (ie, you would expect the study physicians to elicit the patients' fears and expectations). However, even allowing for its unblinded nature, the study physicians were unaware of patients' fears in a third of cases. We do not know if patients' fears and expectations of treatment remain fixed over time. The strengths of this study are that it elicited the wide range of fears and treatment expectations that patients have. The questionnaire is short, easy to fill out, and was completed by more than 90% of patients. Many patients commented favorably on being asked to fill in the answers because they were aware it helped them express what was bothering them.

In conclusion, this short and easy-to-administer questionnaire yielded a range of fears and expectations experienced by dermatology outpatients. We see it as a useful tool to help optimize the dermatologic consultation and to improve quality of care.

ARTICLE INFORMATION

Correspondence: Dr Ahmad, Mid Western Regional Hospital, Dooradoyle Road, Limerick, Ireland (kashifaa2002@gmail.com).

Author Contributions: Both authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Ahmad and Ramsay. Acquisition of data: Ahmad. Analysis and interpretation of data: Ahmad and Ramsay. Drafting of the manuscript: Ahmad and Ramsay. Critical revision of the manuscript for important intellectual content: Ahmad and Ramsay. Administrative, technical, and material support: Ahmad. Study supervision: Ahmad and Ramsay.

Financial Disclosure: None reported.

Coulter  A Paternalism or partnership? patients have grown up—and there's no going back. BMJ 1999;319 (7212) 719- 720
PubMed Link to Article
Salmon  PQuine  J Patients' intentions in primary care: measurement and preliminary investigation. Psychol Health 1989;3103- 110
Link to Article
Ley  P Communicating With Patients.  New York, NY: Croom Helm; 1988
Fitzpatrick  RHopkins  A Measurement of Patients' Satisfaction With Their Care.  London, England: Royal College of Physicians; 1993:57-75

Figures

Tables

Table Graphic Jump LocationTable. Extract Examples of the Written Responses of the Patientsa

References

Coulter  A Paternalism or partnership? patients have grown up—and there's no going back. BMJ 1999;319 (7212) 719- 720
PubMed Link to Article
Salmon  PQuine  J Patients' intentions in primary care: measurement and preliminary investigation. Psychol Health 1989;3103- 110
Link to Article
Ley  P Communicating With Patients.  New York, NY: Croom Helm; 1988
Fitzpatrick  RHopkins  A Measurement of Patients' Satisfaction With Their Care.  London, England: Royal College of Physicians; 1993:57-75

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

823 Views
2 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

Care at the Close of Life: Evidence and Experience
Prognostic Consultation

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis