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Old Curiosity Shop: The importance of being positive

Old Curiosity Shop

Bandolier

tries to face the world with a cheerful face, but like all of us can be cast down by incidents as disparate as the weather, bureaucracy or a particularly dense referee. Nil illigitimi carborundum

might be a useful motto, though, since being positive has a payback. There is evidence that the doctor herself is a powerful therapeutic agent, and that patients can benefit from a positive approach from their GP.

The importance of being positive

A randomised trial of a positive attitude in GP consultations was made by a single GP in consultations where no firm diagnosis could be made. All such symptomatic patients could have one of four consultations:

  1. A positive consultation in which the patient was given a firm diagnosis, given a prescription, and told that it would certainly make them better.
  2. A positive consultation in which the patient was given a firm diagnosis and told that they required no prescription to get better.
  3. A negative consultation in which they were told (honestly) "I cannot be certain what is the matter with you", given a prescription and told "I am not sure that the treatment I am about to give you will have an effect".
  4. A negative consultation in which they were told "I cannot be certain what is the matter with you", followed by "and therefore I will give you no treatment".

Negative consultations were closed by the GP telling patients to come back after a few days if they felt no better. Wherever a prescription was given, it was 3 mg thiamine hydrochloride. Two weeks after the consultation each patient was sent a card asking:

  1. Did you get better?
  2. How many days after seeing the doctor did you get better?
  3. Did you need any further treatment?

Results

The patients in whom no firm diagnosis could be made had a variety of complaints. The commonest complaint in the 200 patients was cough, sore throat, nasal congestion, or cold (in 81 patients), pain in abdomen, back, leg, head, chest, ear, muscles, arm, breast and neck (in 69), giddiness (9) and tiredness (8).

Effect of a positive consultation by general practitioner
Positive consultation (better/total) Negative consultation (better/total) Relative benefit (95%CI) NNT (95%CI)
Prescription given 32/50 21/50 4.6 (2.4 - 34)
No prescription given 32/50 18/50 3.6 (2.1 - 10)
Total 64/100 39/100 1.6 (1.2 - 2.2) 4.0 (2.6 - 8.6)



A positive consultation produced a higher proportion of patients (64%) getting better than a negative consultation (39%). There was no effect of giving a prescription. Overall the number needed to treat (NNT) for a positive consultation was 4.0 (2.6 to 8.6) for the patient to get better within two weeks.

Comment

The only treatment used in this study was that of a positive consultation in patients who were symptomatic but in whom no firm diagnosis could be made. The report made a number of attempts to analyse other information collected, but no other factors were important.

The NNT of four means that of four patients visiting their GP with symptoms but in whom no firm diagnosis can be made, and given a positive consultation, one will get better within two weeks who would not have if they had received a negative consultation. But that underestimates the power of the positive consultation, because other factors also play their part, including self-limiting disorders. Sixty four percent of such patients got better with a positive consultation.

Reference:

  1. KB Thomas. General practice consultations: is there any point in being positive? British Medical Journal 1987 294: 1200-2.



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