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Table. 
Extract Examples of the Written Responses of the Patientsa
Extract Examples of the Written Responses of the Patientsa
1.
Coulter  A Paternalism or partnership? patients have grown up—and there's no going back. BMJ 1999;319 (7212) 719- 720
PubMedArticle
2.
Salmon  PQuine  J Patients' intentions in primary care: measurement and preliminary investigation. Psychol Health 1989;3103- 110Article
3.
Ley  P Communicating With Patients.  New York, NY: Croom Helm; 1988
4.
Fitzpatrick  RHopkins  A Measurement of Patients' Satisfaction With Their Care.  London, England: Royal College of Physicians; 1993:57-75
Research Letter
June 2009

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

Arch Dermatol. 2009;145(6):722-723. doi:10.1001/archdermatol.2009.102

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.

Methods

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).

Results

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.

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.

Comment

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.

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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.

References
1.
Coulter  A Paternalism or partnership? patients have grown up—and there's no going back. BMJ 1999;319 (7212) 719- 720
PubMedArticle
2.
Salmon  PQuine  J Patients' intentions in primary care: measurement and preliminary investigation. Psychol Health 1989;3103- 110Article
3.
Ley  P Communicating With Patients.  New York, NY: Croom Helm; 1988
4.
Fitzpatrick  RHopkins  A Measurement of Patients' Satisfaction With Their Care.  London, England: Royal College of Physicians; 1993:57-75
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