'No need to worry': an exploration of general practitioners' reassuring strategies

'The MRI-scan says it is completely normal': Reassurance attempts in clinical encounters among patients with chronic musculoskeletal pain

In clinical guidelines for patients with chronic musculoskeletal pain, reassurance is a key element. The purpose of reassuring patients is to change their views on their illness and, thereby, their actions. However, when symptoms persist without pathological findings, reassurance can be difficult to achieve. Drawing on observations of nineteen naturally occurring hospital consultations with chronic musculoskeletal pain patients, followed by individual interviews with both patients and clinicians, we study how they interact in relation to reassurance. Our main aim is to explore the ways in which clinicians explicitly attempt to provide reassurance, and how patients receive these attempts, before reflecting on facilitating and hindering factors for successful reassurance in relation to the sociocultural context in which their interaction takes place. Through a thematic analysis, four dominating elements of explicit reassurance were identified: (1) education through visualisation, (2) validation through technological findings, (3) validation through physical examination and (4) normalising pain. To gain a deeper understanding of the reassurance process, we then narratively explored dialogical extracts containing these elements. The analysis shows a potential lack of congruence between what patients experience, and the biomedical knowledge clinicians rely on. Despite employing a combination of affective and cognitive modes of reassurance, clinicians tend to build their final conclusions not on patients experiences but on biomedical knowledge, which is knowledge that holds epistemic primacy for themselves. In that sense, their efforts to reassure the patients might also be a way in which they seek to reassure themselves.

How COVID-19 illness perceptions and individual shocks are associated with trust during the COVID-19 pandemic in Australia, France, Germany, and South Africa

The COVID-19 pandemic jeopardized individuals' health and economic stability, and the associated shocks might have decreased individuals' trust. In this paper, we study the relationship between subjective perceptions of the pandemic and individuals' institutional and interpersonal trust (e.g., trust towards the government or health representatives), while considering objective health and economic shocks due to the pandemic as drivers. We collected data across Australia, France, Germany, and South Africa during a later stage of the COVID-19 pandemic (i.e., from mid-April to early-June 2021) when individuals had time to personally experience the pandemic and its effects. COVID-19 illness perception was associated with lower institutional and interpersonal trust. The health shock of having experienced COVID-19 was associated with higher interpersonal trust, while economic shocks were associated with lower institutional trust when they were due to the pandemic. The results suggest that public policy interventions in a later stage of a pandemic should consider objective economic and health outcomes as well as subjective ones, such as individual's perceptions. Authorities should communicate in a way that helps concerned people understand that they can take control of their health and the possibility of infection, and reassure them that health measures such as vaccination can help prevent the spread of the virus.

How therapeutic relationships develop in group-based telehealth and their perceived impact on processes and outcomes of a complex intervention: a qualitative study

BACKGROUND

Therapeutic relationships are a key domain in healthcare delivery. While well-understood in in-person interventions, how therapeutic relationships develop in more complex contexts is unclear. This study aimed to understand (1) how therapeutic relationships are developed during the telehealth delivery of a group-based, complex intervention and (2) the perceived impact of these relationships on intervention processes, such as intervention delivery and engagement, and patient outcomes, such as patient safety and satisfaction.

METHODS

This qualitative study, nested within a randomised controlled trial, used an interpretivist approach to explore the perceptions of 25 participants (18 patients with shoulder pain and 7 clinicians) regarding developing therapeutic relationships in a group-based, complex intervention delivered via telehealth. Semi-structured interviews were conducted within 4 weeks of the telehealth intervention period and then analysed through in-depth, inductive thematic analysis.

RESULTS

We identified six themes: (1) 'Patients trust clinicians who demonstrate credibility, promoting the development of therapeutic relationships'; (2) 'Simple features and approaches shape the therapeutic relationship', including small talk, time spent together and social observation; (3) 'A sense of belonging and support fosters connections', facilitated by clinicians providing individualised attention within the group; (4) 'Developing therapeutic relationships can impact the delivery of core intervention components', reflecting challenges clinicians faced; (5) 'Therapeutic relationships can facilitate intervention engagement', through enhanced patient understanding and confidence and (6) 'Therapeutic relationships can contribute to patient safety and satisfaction', with patients feeling more comfortable reporting intervention-related issues.

CONCLUSIONS

Therapeutic relationships were developed during group-based telehealth sessions through a set of factors that may require additional skills and effort compared with in-person interactions. While these relationships have a perceived positive impact on intervention engagement and patient outcomes, clinicians need to find a balance between building relationships and delivering the telehealth intervention with fidelity.

TRIAL REGISTRATION NUMBER

ACTRN12621001650886.

Providing recurrence risk counselling for parents after diagnosis of a serious genetic condition caused by an apparently de novo mutation in their child: a qualitative investigation of the PREGCARE strategy with UK clinical genetics practitioners

BACKGROUND

Diagnosis of a child with a genetic condition leads to parents asking whether there is a risk the condition could occur again with future pregnancies. If the cause is identified as an apparent de novo mutation (DNM), couples are currently given a generic, population average, recurrence risk of ~1%-2%, depending on the condition. Although DNMs usually arise as one-off events, they can also originate through the process of mosaicism in either parent; in this instance, the DNM is present in multiple germ cells and the actual recurrence risk could theoretically be as high as 50%.

METHODS

Our qualitative interview study examined the views and reflections on current practice provided by UK practitioners working in clinical genetics (n=20) regarding the potential impact of PREcision Genetic Counselling And REproduction (PREGCARE)-a new preconception personalised recurrence risk assessment strategy.

RESULTS

Those interviewed regarded PREGCARE as a very useful addition to risk management, especially for cases where it revised the risk downwards or clarified that a couple's personalised recurrence risk meets National Health Service thresholds for non-invasive prenatal testing, otherwise inaccessible based on the generic DNM recurrence risk.

CONCLUSION

Participants said it could release some couples requiring reassurance from undergoing unnecessary invasive testing in future pregnancies. However, they regarded mosaicism and PREGCARE as complex concepts to communicate, requiring further training and additional appointment time for pre-test genetic counselling to prepare couples for all the possible outcomes of a personalised risk assessment, including potentially identifying the parental origin of the DNM, and to ensure informed consent.

Qualitative study evaluating the expectations and experiences of Dutch parents of children with chronic gastrointestinal symptoms visiting their general practitioner

OBJECTIVES

Chronic gastrointestinal symptoms are common among children and affect their daily activities and quality of life. The majority will be diagnosed with a functional gastrointestinal disorder. Effective reassurance and education are, therefore, key components of the physician's management. Qualitative studies have shown how parents and children experience specialist paediatric care, yet less is known about general practitioners (GPs), who manage most cases in the Netherlands and have a more personal and enduring relationship with their patients. Therefore, this study evaluates the expectations and experiences of parents of children visiting a GP for chronic gastrointestinal symptoms.

DESIGN

We conducted a qualitative interview study. Online interviews were audio and video recorded, transcribed verbatim and independently analysed by the first two authors. Data were collected and analysed concurrently until data saturation was reached. Using thematic analysis, we developed a conceptual framework reflecting respondent expectations and experiences. We performed a member check of the interview synopsis and the conceptual framework.

SETTING

Dutch primary care.

PARTICIPANTS

We purposively sampled participants from a randomised controlled trial evaluating the effectiveness of faecal calprotectin testing in children with chronic gastrointestinal complaints in primary care. Thirteen parents and two children participated.

RESULTS

Three key themes emerged: disease burden, GP-patient relationship and reassurance. Often, the experienced disease burden and the pre-existing GP-patient relationship influenced expectations (eg, for further investigations or a sympathetic ear), and when a GP fulfilled these expectations, a trusting GP-patient relationship ensued that facilitated reassurance. We found that individual needs influenced these themes and their interrelationships.

CONCLUSION

Insights provided by this framework could help GPs managing children with chronic gastrointestinal symptoms in daily practice and may therewith improve the consultation experience for parents. Further research should evaluate whether this framework also holds true for children.

TRIAL REGISTRATION NUMBER

NL7690.

Small Changes in Patient Arrival and Consultation Times Have Large Effects on Patients' Waiting Times: Simulation Analyses for Primary Care

(1) Background: Workflows are a daily challenge in general practices. The desired smooth work processes and patient flows are not easy to achieve. This study uses an operational research approach to illustrate the general effects of patient arrival and consultation times on waiting times. (2) Methods: Stochastic simulations were used to model complex daily workflows of general practice. Following classical queuing models, patient arrivals, queuing discipline, and physician consultation times are three key factors influencing work processes. (3) Results: In the first scenario, with patients arriving every 7.6 min and random consultation times, the individual patients' maximum waiting time increased to more than 200 min. The second scenario with random patient arrivals and random consultation times increased the average waiting time by up to 30 min compared to patients arriving on schedule. A busy morning session based on the second scenario was investigated to compare two alternative intervention strategies to reduce subsequent waiting times. Both could reduce waiting times by a multiple for each minute of reduced consultation time. (4) Conclusions: Aiming to improve family physicians' awareness of strategies for improving workflows, this simulation study illustrates the effects of strategies that address consultation times and patient arrivals.

An integrative review of the use of the concept of reassurance in clinical practice

Aim

To synthesize evidence on the concept of reassurance in nursing practice.

Design

Integrative review.

Review Method

PubMed, OVID MEDLINE, CINAHL and PsycINFO were searched from their inception to the 30 May 2020. The search results were screened. We assessed the quality of primary studies using the Mixed Method Appraisal Tool. Included studies were analysed using narrative synthesis. The review protocol was pre‐registered (PROSPERO‐CRD42020186962).

Results

Thirty‐two papers out of the 2,771 search results met our inclusion criteria. The synthesis of evidence generated three intricate themes, namely “antecedents of reassurance,” “defining attributes of reassurance” and “outcomes of reassurance.” Emotional distress was the main antecedent of reassurance. The three sub‐themes identified under defining attributes of reassurance include self‐awareness, emotional connectedness and verbal and non‐verbal techniques. Ultimately, reposing the confidence of patients and their families in healthcare professionals and the care delivery process to enable them to overcome their challenges constitutes the outcomes of reassurance.

The effect of shared decision-making on recovery from non-chronic aspecific low back pain in primary care; a post-hoc analysis from the patient, physician and observer perspectives

Background

Although shared decision-making (SDM) is increasingly accepted in healthcare and has demonstrated merits for several psychological outcomes, the effect on recovery from somatic conditions is still subject to debate. The objective of this study is to measure the effect of SDM on recovery from non-chronic aspecific low back pain (LBP).

Methods

This study is a post-hoc analysis of data from a cluster-randomised trial that evaluated the effectiveness of SDM on recovery in patients with non-chronic aspecific LBP. In this analysis, we re-evaluate the impact of SDM from three perspectives: that of external observers, participating GPs and participating patients. Recovery was measured with the Visual Analogue Scale (VAS) for pain and with the Roland Morris Disability questionnaire (RMD) and defined as a VAS < 30 and an RMD < 4. Logistic regression was used to analyse the effect of SDM on recovery at 6 and 26 weeks.

Results

At 26 weeks, 105 (74%) of all 176 included patients had recovered. No significant effect of SDM on recovery at 6 or 26 weeks after the consultation was found when considering SDM from an observer perspective or a patient perspective. From a GP perspective SDM had a significant effect on recovery, but at 26 weeks only, and with the lowest probability of recovery observed at a medium level of GP-perceived SDM.

Conclusions

We found no evidence that SDM as perceived by the patient or by external observation improves recovery from non-chronic aspecific low back pain. The long-term recovery may be better for patients in whom the GP perceives SDM during their consultations. Further research should highlight the hierarchy and the relation between the perspectives, which is needed to come to an integral effect evaluation of SDM.

Trial registration

The Netherlands National Trial Register (NTR) number: NTR1960.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01624-y.

Views of healthcare consumer representatives on defensive practice: 'We are your biggest advocate and supporter… not the enemy'

Background

The patient–clinician interaction is a site at which defensive practice could occur, when clinicians provide tests, procedures and treatments mainly to reduce perceived legal risks, rather than to advance patient care. Defensive practice is a driver of low‐value care and exposes patients to the risks of unnecessary interventions. To date, patient perspectives on defensive practice and its impacts on them are largely missing from the literature. This exploratory study conducted in Australia aimed to examine the views and experiences of healthcare consumer representatives in this under‐examined area.

Methods

Semi‐structured interviews were conducted with healthcare consumer representatives involved in healthcare consumer advocacy organisations in Australia. Data were transcribed and analysed thematically.

Results

Nine healthcare consumer representatives participated. Most had over 20 years of involvement and advocacy in healthcare, including personal experiences as a patient or carer and/or formal service roles on committees or complaint bodies for healthcare organisations. Participants uniformly viewed defensive practice as having a negative impact on the clinician–patient relationship. Themes identified the importance of fostering patient–clinician partnership, effective communication and informed decision‐making. The themes support a shift from the concept of defensive practice to preventive practice in partnership, which focuses on the shared interests of patients and clinicians in achieving safe and high‐value care.

Conclusion

This Australian study offers healthcare consumers' perspectives on the impacts of defensive practice on patients. The findings highlight the features of clinician–patient partnership that will help to improve communication and decision‐making, and prevent the defensive provision of low‐value care.

Patient or Public Contribution

Healthcare consumer representatives were involved as participants in this study.

A participant perspective on collaborative reflection: video-stimulated interviews show what residents value and why

The potential of reflection for learning and development is broadly accepted across the medical curriculum. Our understanding of how exactly reflection yields its educational promise, however, is limited to broad hints at the relation between reflection and learning. Yet, such understanding is essential to the (re)design of reflection education for learning and development. In this qualitative study, we used participants' video-stimulated comments on actual practice to identify features that do or do not make collaborative reflection valuable to participants. In doing so, we focus on aspects of the interactional process that constitute the educational activity of reflection. To identify valuable and less valuable features of collaborative reflection, we conducted one-on-one video-stimulated interviews with Dutch general practice residents about collaborative reflection sessions in their training program. Residents were invited to comment on any aspect of the session that they did or did not value. We synthesized all positively and negatively valued features and associated explanations put forward in residents' narratives into shared normative orientations about collaborative reflection: what are the shared norms that residents display in telling about positive and negative experiences with collaborative reflection? These normative orientations display residents' views on the aim of collaborative reflection (educational value for all) and the norms that allegedly contribute to realizing this aim (inclusivity and diversity, safety, and efficiency). These norms are also reflected in specific educational activities that ostensibly contribute to educational value. As such, the current synthesis of normative orientations displayed in residents' narratives about valuable and less valuable elements of collaborative reflection deepen our understanding of reflection and its supposed connection with educational outcomes. Moreover, the current empirical endeavor illustrates the value of video-stimulated interviews as a tool to value features of educational processes for future educational enhancements.

Patients' experiences of the use of point-of-care ultrasound in general practice - a cross-sectional study

BACKGROUND

The use of point-of-care ultrasonography (POCUS) performed by general practitioners (GPs) in primary care settings is increasing. Previous studies have focused on GP-reported outcomes and little is known about patients' perspectives on the use of POCUS technology within the general practice consultation. The purpose of this study was to examine patients' experiences with POCUS in general practice within the areas where GPs have indicated that POCUS affected aspects of the consultation.

METHODS

A questionnaire was developed using a mixed methods sequential design. Analytical themes from interviews with GPs were converted into items in a questionnaire by the research team. The questionnaire was then further developed in several rounds of pilot tests involving both patients and GPs. The final questionnaire was used in a cohort study conducted in 18 Danish office-based general practice clinics from January 2018 to August 2018. All patients examined with POCUS were asked to complete the questionnaire on tablets immediately after their consultation.

RESULTS

Out of 691 patients examined, 564 (81.6%) questionnaires were available for analysis. The patients reported that they were well informed about the purpose (98%) and the results (97%) of the POCUS examination; however, 29% reported that they were not informed about the difference between POCUS and an imaging-specialist's ultrasound examination. Almost all patients (99%) reported that POCUS was integrated naturally into the consultation, and 45% reported that POCUS improved the doctor-patient relationship. The majority of patients felt that they had been more thoroughly examined (92%) and taken more seriously (58%) when POCUS was part of the consultation. They felt POCUS gave them a better understanding of their health problem (82%), made them feel more secure (86%) and increased their trust in the physician's assessment (65%). Moreover, the patients reported that POCUS use improved the level of service (95%) they experienced and the quality of care (94%) in general practice.

CONCLUSION

We found that an examination including POCUS in general practice was a positive experience overall for the majority of patients. Future research should further explore reasons for patient confidence in POCUS and whether or not the reassuring value of POCUS is valid.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03416608.

A Comparison of Perceptions of Reassurance in Patients with Nontraumatic Neck Pain and Whiplash-Associated Disorders in Consultations with Primary Care Practitioners-An Online Survey

OBJECTIVES

Neck pain remains highly prevalent and costly worldwide. Although reassurance has been recommended as a first line of treatment, specific advice on the best ways to provide reassurance has not been provided due to lack of evidence. Pain symptoms and experiences differ between patients with whiplash-associated disorder (WAD) and those with nontraumatic neck pain (NTNP). The aims of this study were to 1) identify and compare the concerns, fears, and worries of patients with WAD and NTNP; and 2) determine if patients believe their concerns are addressed by primary care providers.

METHODS

These questions were investigated through an online survey, with a convenience sample of 30 participants with NTNP and 20 with WAD.

RESULTS

A thematic analysis of survey responses resulted in the following seven themes related to common concerns, and two regarding how well concerns were addressed. Common concerns expressed by both groups shared four themes: 1) further structural damage, 2) psychological distress, 3) concerns about the future, and 4) hardships that eventuate. Theme 5), pain/disability is long term, was specific to WAD. Themes 6), pain is current or reoccurring, and 7), interference with daily life, were specific to NTNP. Regarding how well patient concerns were addressed, two overarching themes were common to both conditions: 1) concerns were addressed, with both groups sharing the subthemes "successful treatment," "reassurance," and "trust"; and 2) concerns were not addressed, where all subthemes were shared with the exception of two unique to NTNP.

CONCLUSIONS

This detailed comparison provides information about neck pain patients' concerns and fears, while providing health practitioners support for selecting strategies to promote reassurance appropriately for individual patient needs. Our findings from patients' perspectives enhance the understanding for providing reassurance for neck pain as proposed by our analysis.

The importance of contextual aspects in the care for patients with functional somatic symptoms

Functional somatic symptoms refer to physical symptoms that cannot be (bio) medically explained. The pattern or clustering of such symptoms may lead to functional syndromes like chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, among many others. Since the underlying pathophysiology remains unknown, several explanatory models have been proposed, nearly all including social and psychological parameters. These models have stimulated effectiveness studies of several psychological and psychopharmacological therapies. While the evidence for their effectiveness is steadily growing, effect-sizes are at most moderate and many patients do not benefit. We hypothesize that the context in which interventions for functional somatic symptoms are delivered substantially influences their effectiveness. Although this hypothesis is in line with explanatory models of functional somatic symptoms, to our knowledge, studies primarily focusing on the influence of contextual aspects on treatment outcome are scarce. Contextual research in the field of somatic symptoms has (irrespective whether these symptoms can be medically explained or not), however, just begun and already yielded some valuable results. These findings can be organized according to Duranti's and Goodwin's theoretical approach to context in order to substantiate our hypothesis. Based on this approach, we categorized empirical findings in three contextual aspects, i.e. 1) the setting, 2) the behavioural environment, and 3) the language environment. Collectively, some support is found for the fact that early identification of patients with functional somatic symptoms, starting treatment as soon as possible, having a neat appearance and an organized office interior, a warm and friendly nonverbal approach and a language use without defensiveness are contextual parameters which enhance the assessment by the patient of the physician's competence to help. Nonetheless, in vivo studies addressing the most aspects, i.e. nonverbal behaviour and language, are needed for better understanding of these contextual aspect. Moreover, future research should address to what extent optimizing contextual aspects improve care for functional somatic symptoms.

How doctors recognise that their patients are worried: A qualitative study of patient cues

OBJECTIVES

Recognising patient cues indicating worry is essential for successful reassurance. To obtain more insight into the variety and nature of patient cues that may arise in practice, this study explores doctors' reflections on patient cues they recognise during consultations.

METHODS

We performed a qualitative study during which GPs participated in stimulated recall interviews, using their own video-recorded consultations to enhance reflection. First, we reanalysed an existing dataset of 15 interviews during which GPs elaborated on the doctor-patient interaction. Additionally, 12 GPs were interviewed specifically about recognising patients' cues.

RESULTS

GPs described four categories of patient cues that indicate worry. GPs recognised worry based on non-verbal cues such as visible bodily reactions, and verbal cues that can be further categorised by type of worry (e.g. about serious disease). Moreover, GPs described behavioural cues, e.g. the patient bringing a list of symptoms. Lastly, GPs recognise worry based on prior knowledge about the patient.

CONCLUSIONS

GPs reflections have given insight into a wide variety of non-verbal -, verbal -, behavioural- and foreknowledge-based cues.

PRACTICE IMPLICATIONS

The identified cues can guide other clinicians in recognising worries and inform medical communication training and future research on the effectiveness of recognising cues and patient reassurance.

Functional Somatic Symptoms

BACKGROUND

Approximately 10% of the general population and around one third of adult patients in clinical populations suffer from functional somatic symptoms. These take many forms, are often chronic, impair everyday functioning as well as quality of life, and are cost intensive.

METHODS

The guideline group (32 medical and psychological professional societies, two patients' associations) carried out a systematic survey of the literature and ana- lyzed 3795 original articles and 3345 reviews. The aim was to formulate empirically based recommendations that were practical and user friendly.

RESULTS

Because of the variation in course and symptom severity, three stages of treatment are distinguished. In early contacts, the focus is on basic investigations, reassurance, and advice. For persistent burdensome symptoms, an extended, simultaneous and equitable diagnostic work-up of physical and psychosocial factors is recommended, together with a focus on information and self-help. In the pres- ence of severe and disabling symptoms, multimodal treatment includes further elements such as (body) psychotherapeutic and social medicine measures. Whatever the medical specialty, level of care, or clinical picture, an empathetic professional attitude, reflective communication, information, a cautious, restrained approach to diagnosis, good interdisciplinary cooperation, and above all active interventions for self-efficacy are usually more effective than passive, organ- focused treatments.

CONCLUSION

The cornerstones of diagnosis and treatment are biopsychosocial ex- planatory models, communication, self-efficacy, and interdisciplinary mangagement. This enables safe and efficient patient care from the initial presentation onwards, even in cases where the symptoms cannot yet be traced back to specific causes.

Eliciting tacit knowledge: The potential of a reflective approach to video-stimulated interviewing

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Humor as a Communication Strategy in Provider-Patient Communication in a Chronic Care Setting

Humor is a potential communication strategy to accomplish various and potentially conflicting consultation goals. We investigated humor use and its reception in diabetes consultations by analyzing how and why humor emerges and its impact on the interaction. We did this by using an interactional sociolinguistics approach. We recorded 50 consultations in an Irish diabetes setting. Analysis of the humor events drew on framework analysis and on concepts from Conversation Analysis and pragmatics. The study also comprised interviews using tape-assisted recall. We identified 10 humor functions and two umbrella functions. A key finding is that most humor is relationship-protecting humor initiated by patients, that is, they voice serious messages and deal with emotional issues through humor. Our findings imply that patients' and providers' awareness of indirect communication strategies needs to be increased. We also recommend that researchers employ varied methods to adequately capture the interactive nature of humor.

How to gather information from talkative patients in a respectful and efficient manner: a qualitative study of GPs' communication strategies

BACKGROUND

Gathering information from talkative patients presents a challenge to clinicians. Empirical evidence on how to effectively deal with this challenge is scant.

OBJECTIVE

This study explores communication strategies and their underlying mechanisms that GPs consider effective when gathering information from talkative patients in order to inform the development of best practices.

METHODS

We conducted a qualitative study with experienced GPs. We held individual stimulated-recall interviews (SRIs) with six GPs using their videotaped consultations as a stimulus. The transcripts that ensued were triangulated with data from three focus-group discussions (FGs). We performed a thematic network analysis during an iterative process of data collection and analysis.

RESULTS

To deal with talkative patients during consultations, GPs first try to pinpoint the cause of patients' talkativeness before deciding on the approach to take. Moreover, they resort to the familiar communication strategies, however, in doing so adopt take a more directive attitude. To prevent such attitude from damaging the relationship, GPs take a stepped approach in which they try not to be overly directive, make the patient co-responsible for efficient time management and make use of empathic interrupting.

CONCLUSIONS

In the absence of evidence, this description of GPs' communication strategies can guide clinicians, residents and students in gathering information from talkative patients in an efficient, yet empathic and respectful manner. When developing best practices, heed should be paid to the causes of patients' talkativeness and the tension between taking a directive approach and building a doctor-patient relationship.