Jane Smith: The dangers of normal

ALL medical practitioners have patients we consider anxious and very unlikely to have much wrong with them — the ones we describe as the “worried well”.

It is hard to deal with many symptoms that have no diagnostic fit. Many words have been coined to enable us to vent, terms such as diagnostic dilemma, medically unexplained physical symptoms (MUPS), somatisation and heartsink.

An inexplicable mix of symptoms generates anxiety in the doctor as well as the patient in all types of medical practice. Tests on such patients are often ordered as a triage tool without any clear diagnosis, or specific physical findings — “just in case, to make sure we are not missing anything” that could be the cause of such “illness” in a patient.

There is a presumption that ruling out a diagnosis by getting normal results is a good thing. There is an assumption that the normal results will provide reassurance.

Our perception is that normal results followed by some variation on a positive “you are in good health” or negative “nothing is wrong” will reduce concern both in us and the patient, and reassure the patient and doctor alike that nothing serious is going on.

However, contrary to our expectations this process does not usually result in reassurance.

A review has shown that providing normal test results to patients with a low probability of disease does not have any meaningful impact on patients’ illness worry, anxiety, ongoing symptoms, medication use and health-seeking behaviour in the short and longer term. Tests included in this review were endoscopy, Helicobacter pylori testing, electrocardiography, blood tests or continuous event monitoring (for chest pain or palpitations respectively) and imaging (for back pain or headaches).

The impact of investigations with normal test results on patients is not what we think it is. Most of the time this does not reassure them, make them feel any better, or make them less likely to seek help.

The patient with normal results continues to exhibit the same frequency of symptoms, consultations and medication use.

Medical interventions may unintentionally reinforce somatisation and, more importantly, the way we communicate information can amplify the adverse effects.

The good news is that discussing the meaning of normal results and giving printed information before testing can create some reassurance, but simply performing tests with normal results, or providing printed information after the test does not.

We commonly order diagnostic tests in patients with vague symptoms such as tiredness, but when “tired patients” had investigations performed, only 3% had abnormal results.

Most patients with vague symptoms rather than specific diagnostic symptoms or signs are unlikely to have any serious illness, and it is unlikely investigations will provide abnormal results, or a diagnosis.

We define “normal” as beyond two standard deviations, which is the 5% either side of the mean. So for every 20 tests, roughly one will be abnormal in a healthy person.

From discussions with colleagues, much of this is counterintuitive to us.

In the doctor–patient relationship, reassurance — defined as removing someone's doubts or fears, or restoring confidence — requires effective communication to understand a patient’s illness concerns, which may be very different from ours. If someone believes they are ill, it takes more than a normal test result to change that belief.

Contrary to our clinical behaviour and beliefs, there is no reassurance provided to patients by normal test results. In fact, some studies suggest we may just be increasing anxiety.

Perhaps we could do less and achieve more.

Dr Jane Smith is associate professor of general practice in the Faculty of Health Sciences and Medicine at Bond University, Queensland.

Acknowledgements to Professor Chris Del Mar and Professor Paul Glasziou for their support.

Jane McCredie is on leave.