Influence of Watchful Waiting on Satisfaction and Anxiety Among Patients Seeking Care for Unexplained Complaints

Marloes A. van Bokhoven, MD, PhD; Hèlen Koch, MD, PhD; Trudy van der Weijden, MD, PhD; Richard P.T.M. Grol, PhD; Arnold D. Kester, PhD; Paula E.L.M. Rinkens, BSc; Patrick J.E. Bindels, MD, PhD; Geert-Jan Dinant, MD, PhD

Disclosures

Ann Fam Med. 2009;7(2):112-120. 

In This Article

Abstract and Introduction

Abstract

Purpose: We undertook a study to determine whether test-ordering strategy and other consultation-related factors influence satisfaction with and anxiety after a consultation among patients seeking care for unexplained complaints.
Methods: A cluster-randomized clinical trial was conducted in family medicine practices in the Netherlands. Participants were 498 patients with unexplained complaints seen by 63 primary care physicians. Physicians either immediately ordered a blood test for patients or followed a 4-week watchful waiting approach. Physicians and patients completed questionnaires asking about their characteristics, satisfaction with care, and anxiety, and aspects of the consultation. The main outcomes were patient satisfaction and anxiety. Data were analyzed by multilevel logistic regression analysis.
Results: Patients were generally satisfied with their consultation and had moderately low anxiety afterward (mean scores on 11-point scales, 7.3 and 3.1, respectively), with no difference between the immediate testing and watchful waiting groups (X 2 = 2.4 and 0.3, respectively). The factors associated with higher odds of satisfaction were mainly related to physician-patient communication: patients' satisfaction with their physician generally, feeling taken seriously, and knowing the seriousness of complaints afterward; physicians' discussing testing and not considering complaints bearable; and older physician age. The same was true for factors associated with higher odds of anxiety: patients expecting testing or referral, patients not knowing the seriousness of their complaints afterward, and physicians not seeing a cause for alarm.
Conclusions: Test-ordering strategy does not influence patients' satisfaction with and anxiety after a consultation. Instead, specific aspects of physician-patient communication are important. Apparently, primary care physicians underestimate how much they can contribute to the well-being of their patients by discussing their worries.

Introduction

Unexplained complaints in primary care can be defined as those complaints for which a primary care physician, after clarifying the reason for the encounter, taking the patient's history, and performing a physical examination, is unable to establish a diagnosis.[1] Unexplained complaints are rather prevalent, especially in family medicine; on average, 3% to 39% of consultations involve complaints considered to be unexplained by the primary care physician.[2,3,4,5]

In many cases, blood tests are ordered for these patients. Since testing in such situations is often superfluous from a diagnostic point of view, several strategies have been promoted to reduce the ordering of tests.[6,7,8] One of these strategies is to use a watchful waiting approach.[1] So far, in the medical literature, this strategy has been used more in the treatment setting than in the diagnostic setting.[9,10,11] In the context of unexplained complaints, which are usually self-limiting, this approach is thought to reduce the number of patients tested and to improve the predictive values of tests in patients tested after a watchful waiting period.[12]

Primary care physicians report, however, that they order tests for a variety of reasons other than diagnostic ones -- an important one being patient requests.[13,14] Patients often ask for tests, and primary care physicians feel that testing is an efficient way to reassure them.[13,14,15] Satisfying and reassuring patients appear to be 2 important goals, especially in light of the long-term relationships between primary care physicians and patients, and the aim of preventing malpractice lawsuits.[16,17] The literature shows that many patients do indeed expect blood tests to be ordered and have high expectations about the value of such tests.[3,18,19] Their satisfaction with the care they receive may largely depend on such testing. It remains unclear whether testing does indeed influence patients' satisfaction with care, however. Some studies show that patients place greater importance on alternate aspects of care, such as being listened to and getting a clear explanation about the nature of their problem.[20,21] In other studies, patients have stated that they would be very dissatisfied if their expectations were not met.[18,22,23,24] None of these studies specifically looked at unexplained complaints, however.

The literature provides little support for patient reassurance as a reason for ordering tests. Qualitative studies have shown that patients may be uncomfortable with clinical uncertainty, and that they expect to obtain definitive information about their health from test results.[18,22] Reassurance is recognized as an important aspect of the physician-patient relationship, which in turn is a dimension of patient satisfaction.[25,26] A review of the concepts of patient satisfaction concluded, however, that a direct association of reassurance with satisfaction remains unproven.[27]

In summary, whereas reducing superfluous testing by using a watchful waiting approach seems a matter of rational decision making, it remains questionable if this approach is acceptable to patients. We hypothesized that watchful waiting would decrease patient satisfaction and increase patient anxiety.

The purpose of this study was to determine whether immediate test ordering, compared with watchful waiting, influences satisfaction with and anxiety after the consultation among patients seeking care for unexplained complaints. We also wanted to assess the relationship between the test-ordering strategy and other characteristics of the primary care physician and practice, the patient, and the complaints and consultation.

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