Vol. 9, No. 2
Family Practice © Oxfofd University Press 1992
Printed in Groat Britain
Do Physicians Care About Patients With Dysphagia? A Study on Confirming Communication BARBRO GUSTAFSSON, LJTA TIBBUNG* AND TORES THEORELL
INTRODUCTION It has been estimated that slightly more than 15% of the middle-aged population suffer from oesophageal dysphagia.1 A large proportion of these experience difficulty in swallowing as seriously affecting the quality of life.2-3 Benign dysphagia is usually caused by intermittent disturbance in oesophageal muscle function. Oesophagus X-rays are usually normal,4 and oesophageal dysphagia cannot be seen from the outside, especially when difficulty in swallowing has not led to loss in weight3 which may hamper a correct diagnosis. Patients with dysphagia often have chest pain, bronchitis and dyspepsia at the same time, which leads to differential diagnostic problems. It is therefore important for the physician to be able to communicate sensitively about what is really worrying the patient.3-3"7 On one hand there is a physician's delay in diagnosing and treating patients with dysphagia,4'7 on the other hand a patient's denial, unwillingness or inability to describe symptoms and feelings of unNalional Institute for Psychosocial Factors and Health, Karolinska Institute, Stockholm, and •Department of Otorhinolaryngology, University Hospital, LinkOping, Sweden. Address correspondence to: BArbro Gustafsson, University College of Caring Science, Nymarugatan 17, S-302 33 HalmBid, Sweden.
203
worthiness and shame will influence the outcome of the consultation.2'7 A common complaint among patients is that physicians do not listen to their problems, that their medical visit is experienced as stressful, that they are identified as a 'case', and that the consultation is dissatisfying, insulting or degrading, which can be interpreted as poor recognition or confirmation.8"" Confirmation has been regarded as the process through which individuals are recognized, acknowledged and endorsed by others and is connected with humanity, affection and concern.12 Gustafsson and Porn have described confirmation as a relationship which strengthens selfassessment. They interpret four of its components— sympathy, allowing action, understanding and competence—in terms of a theory of human motivation.13 Confirmation is the kind of communication which is growthful and therapeutic and the confirmed patient is shown to feel more relaxed, confident and strong than a non-confirmed patient." We were interested, therefore, in interviewing patients with oesophageal dysphagia in order to explore whether they had considered themselves confirmed when they first visited a physician for their dysphagia, whether patients had special attributes which could explain why they had been confirmed,
Downloaded from http://fampra.oxfordjournals.org/ at University of Birmingham on June 3, 2015
Gustafsson B, Tibbling L and Theorell T. Do physicians care about patients with dysphagia? A study on confirming communication. Family Practice 1992; 9: 203-209. Thirty-nine patients with longstanding oesophageal dysphagia took part in an interview and a questionnaire study to investigate whether they considered themselves met with interest, respect, understanding and knowledge (felt confirmed) when consulting their physician for the first time (mostly general practitioner), whether non-confirmed patients have any distinguishing attributes, and whether confirmation affects the patient's impression of being helped. Twenty-five of these considered themselves as nonconfirmed. There was no difference between the groups as regards sex, age, education, degree of swallowing difficulties and incidence of chest symptoms other than dysphagia. There was a greater fear of cancer (P < 0.05) and a stronger indirect aggression (P < 0.05) among the non-confirmed patients. Patients who felt confirmed reported more often that a correct oesophageal diagnosis had been given (P < 0.05), felt they had received adequate help (P < 0.001) and experienced improvement in swallowing difficulties (P < 0.05). It is concluded that patient attributes seem to slightly influence the patients' possibilities of being confirmed, and that confirmation is of great importance for the patient's feeling of being helped and improved.
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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
and whether confirmation had a positive effect on the patient's swallowing difficulties.
Interview The interview, performed by one of the authors, was based on about 50 pre-designed, open-ended or closed questions compiled in a questionnaire. Issues concerning the patients first medical consultation due to dysphagia which were considered were: confirmationpatient experience of being confirmed; patient characteristics—demographic data (sex, age, education), physical data (length of dysphagia, subjective severity of dysphagia (score 1-5), chest symptoms other than dysphagia), psychological data (fear of cancer because of dysphagia, feelings of shame because of dysphagia, feelings of guilt because of dysphagia, reduced self-esteem because of dysphagia, insecurity in life because of dysphagia), social data (denial of dysphagia), personality data (see questionnaire below), consulting data (decision to visit a physician interpretation of cause of dysphagia, complaints presented to the physician); medical diagnoses (first and final diagnoses); and consequence of consultation (provision of information, advice and help, improvement in swallowing, physical, psychological and social adaptedness).
The anxiety-related scales. The somatic anxiety scale concerns automatic disturbances, restlessness and panic attacks. The muscular tension scale comprises items for muscular tenseness, stiffness and inability to relax. The psychic anxiety scale is related to feelings of worrying, anticipations and lack of self-confidence and sensitiveness. The inhibition of aggression scale represents actions of unexpressed anger, lack of ability to speak up and to assert oneself in social situations. The somatic anxiety scale and the muscular tension scale comprise nervous tension and distress. The psychic anxiety scale, the psychasthenia scale and the inhibition of aggression scale deal with cognitive-social anxiety. The hostility-related scales. The suspicion scale concerns feelings of being suspicious, hostility projected on others, and distrust of people's motives. The guilt scale represents items of being remorseful and ashamed for bad thoughts. The aggressiveness-related scales. The indirect aggression scale is related to actions of sulking and slamming doors when angry—undirected expression of aggression. The verbal aggression scale comprises aggressive feelings, such as getting into arguments and telling people off when annoyed. The irritability scale is about feelings of being irritable and lacking patience. Most of the scales consists of 10 items. There were four alternative answers to each item of the different scales: 'does not apply at all' (1 point), 'does not apply very well' (2 points), 'applies quite well' (3 points), and 'applies completely' (4 points). The higher the sum of points the more prominent is the personality trait which the respective scale aims to explore. The standard value of the different scales is 50. Definitions The patient is regarded confirmed when answering 'Yes' to the following question: "Did you feel that you were confirmed by the physician? Or, in other words, were you met with interest, respect, and understanding, and examined by a physician with knowledge of
Downloaded from http://fampra.oxfordjournals.org/ at University of Birmingham on June 3, 2015
PATIENTS AND METHODS Thirty-nine patients (24 women and 15 men) were invited to participate in an interview and questionnaire study. All patients had a history of oesophageal dysphagia which had caused them to attend a physician. Nineteen of 22 patients investigated at an oesophageal laboratory because of oesophageal dysphagia agreed to take part. Almost all of these patients had first consulted a family physician or GP. Another 20 patients were taken from a quality of life study of 7% pensioners, 62 of whom had oesophageal dysphagia. All pensioners who had consulted a physician because of dysphagia (n = 20) agreed to take part. At the time of interview 18 of 20 pensioners with dysphagia had attended a clinic specialized in oesophageal disorders. The study population was separated into two groups. Group A comprised 25 patients (median age 51.0 years, range 10-66 years) who had not felt confirmed at their first visit to a physician, and group B, 14 patients (median age 60.5 years, range 32-80 years) who had felt confirmed. There was an average time interval of 10.8 years (range 1-29 years) between the first consultation and the time of interview in non-confirmed patients and of 6.3 years (range 1-15 years) in confirmed patients. Age and patient characteristics are from the time of their first medical consultation. The personality data are from the time of interview. The final medical diagnoses in the two groups are shown later, in Table 5. Twenty-seven patients received their final diagnosis from physicians at a special clinic for oesophageal disorders, and two patients from GPs.
Personality Inventory At the interview the patients received a personality inventory questionnaire, the Karolinska Scales of Personality (KSP), consisting of self-report scales for completion at home. The KSP questionnaire is constructed or modified from other published scales by Schalling et al.M Ten of the 14 scales which were used in this study are constructed on theories of biologically based temperament dimensions according to different forms of vulnerability. The scales were validated by factor analysis and by clinical investigations resulting in separate scales of personality traits, which are partly interdependent. The scales of special interest in the present study are related to anxiety, hostility and aggressiveness.
205
PATIENTS WITH DYSPHAGIA
dysphagia?" Dysphagia is defined as a patient's experience of reduced ability to transport food or drink from the upper oesophagus to the stomach expressed as a sensation of obstruction in the chest when eating or drinking. Statistical Analyses The Fisher's exact test was used for comparison between groups in the interview study. The unpaired /-test was used for the personality inventory questionnaire. All tests were performed as two-tailed tests.
Physical, Psychological and Social Characteristics Patient characteristics in group A and group B are shown in Table 1. Sex, age, level of education, duration of dysphagia, subjective severity of dysphagia, feelings of guilt or shame, reduced self-esteem, experiences of insecurity in life because of dysphagia and experiences of advantages of denial did not differ significantly between the two groups. The fear of cancer was significantly more common in nonconfirmed patients than in confirmed patients (P < 0.05). Chest symptoms in group A and group B are shown in Table 2. No significant differences were found between the two groups. All patients had one or more symptoms from the chest other than dysphagia. Eighteen of 25 patients in group A and 11 of 14 patients in group B had two or more symptoms from the chest.
Patient characteristics
Group A (n = 25)
Female/male
15/10
9/5
Median age, years (range)
51.0(10-66)
60.5 (32-80)
Median history of dysphagia, years (range)
2.0 (0-28)
Severity of dysphagia, score M ± SD (range)
Group B (" = 14)
5.0 (0-54)
3.2 ± 1.2(1-5) 3.7 ± 1.0(2-5) 21 (84%)
5 (36%)*
8 (32V.)
4 (29%)
Feelings of guilt
16 (64%)
9(64%)
Advantages of denial
14 (56%)
4 (28%)
Reduced self-esteem
22 (88%)
9(64%)
Feelings of insecurity
23 (92%)
11 (78%)
Fear of cancer Feelings of shame
1
P < 0.05
TABLE 2. Chest symptoms other than dysphagia in group A (non-confirmed patients) and in group B (confirmed patients). Chest symptoms
Group A (n = 25)
Group B (n = 14)
Chest pain
22 (88%)
11 (78%)
Regurgitation
12 (48%)
8 (57%)
Heartburn
12 (48%)
9(64%)
Personality Characteristics Personality traits are given in Table 3. The four scales interpreting anxiety proneness and the two scales showing hostility did not differ significantly between the groups. Indirect aggression, which was one of the three scales interpreting aggressiveness, was more pronounced in the non-confirmed group (P < 0.05).
Choking
7(28%)
1 (7%)
Vomiting
8 (32%)
5 (36%)
Consulting Characteristics Nine non-confirmed patients (32%) and seven confirmed patients (50%) decided on their own to consult a physician due to dysphagia. The patients' own interpretation of cause of their dysphagia and the first complaint presented to the physician are shown in Table 4.
Preliminary and Final Diagnoses The preliminary and final medical diagnoses are shown in Table 5. Thirteen patients in group A and none in group B had been given a diagnosis of mental disorder (P < 0.01). Nine patients in group A (36%) and 12
Downloaded from http://fampra.oxfordjournals.org/ at University of Birmingham on June 3, 2015
RESULTS Twenty-five of 39 patients (64%) did not feel confirmed at their first medical consultation (group A). Six of the 25 patients did not feel confirmed at later consultations either and one patient never consulted a physician again. Fourteen patients (36%) regarded themselves as confirmed at their first visit to a physician (group B). The rate of confirmed patients was the same for the patients recruited from the oesophageal laboratory as for the pensioners recruited from the quality of life study.
TABLE 1. Different patient characteristics in group A (nonconfirmed patients) and group B (confirmedpatients) at their first medical consultation.
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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
TABLE 3. Personality score according to the KSP in group A (non-confirmed patients) and group B (confirmed patients). M ± SD (ranges). Standard value = 50. Personality traits
Group A (n «= 25)
Anxiety proneness Somatic anxiety
Group B (n = 114)
49.0 ± 13.4 (33-79)
Muscular tension
54.0 ± 10.3 (27-64)
50.1 ± 9.7 (38-71)
Psychic anxiety
52.4 ± 11.2(36-80)
47.3 ± 11.7 (32-67)
Psychasthenia
53.6 ± 9.0 (44-84)
46.8 ± 13.9 (19-77)
Inhibition of aggression
52.1 ± 11.5 (40-74)
45.8 ± 11.6(19-56)
53.6 ± 7.8 (40-68)
53.2 ± 14.1 (29-78)
49.5 ± 12.6 (27-71)
49.6 ± 14.1 (30-69)
Aggressiveness Indirect aggression
51.0 ± 6.9 (36-61)
45.3 ± 6.4 (31-58)*
Verbal aggression
49.0 ± 9.3 (35-74)
51.5 ± 7.4 (42-64)
Irritability
50.1 ± 10.9 (32-81)
46.1 ± 11.3 (24-62)
Hostility Suspicion Guilt
* P < 0.05
TABLE 4. First complaint presented to the physician (FCD) and patient interpretation of cause of dysphagia (COD) in group A (non-confirmed patients) and group B (confirmed patients). Group A (" = 2 5 )
Group B (/>= 14)
8 (32%)
9(64%)
Chest symptoms
8 (32%)
4(28%)
Abdominal symptoms
9 (36%)
1 (8%)
11 (44%)
10(71%)
Heart
5 (20%)
3 (21%)
Stomach
2(8%)
1 (8%)
Food allergy
1 (4%)
0(0%)
Unknown
6(24%)
0(0%)
FCD Dysphagia
COD Oesophagus
patients in group B (86%) had received an oesophageal diagnosis only (P < 0.05). Sixteen patients in group A (64%) and two patients in group B (14%) had been given one or two preliminary diagnoses other than oesophageal disease (P < 0.05). Twenty-one patients in group A were afraid they had cancer, 14 of whom were given other preliminary diagnoses than oesophageal disease. All confirmed patients with fear of cancer {n = 5) received an oesophageal diagnosis. One confirmed patient and one non-confirmed patient were directly informed by their physician that the symptoms were not malignant. Consequence of Consultation The patients' opinions of the consequence of consultation are shown in Table 6. Patients in group B felt that they had been helped significantly more often than patients in group A (P < 0.001). Patients in group B who had received information or advice reported a higher rate of improvement in swallowing than the corresponding patients in group A (P < 0.05). None of the six patients in group A who were not even confirmed at later consultations received help or information and none had experienced improvement in swallowing. Poor physical, psychological and social adaptedness was experienced by eight patients in group A (32%) and one patient in group B (7%).
Downloaded from http://fampra.oxfordjournals.org/ at University of Birmingham on June 3, 2015
55.6 ± 10.6 (40-75)
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PATIENTS WITH DYSPHAGIA
TABLE 5. Preliminary and final medical diagnoses in group A (non-confirmed patients) and group B (confirmed patients). Figures in parentheses under 'preliminary medical diagnoses' denote number of patients with one diagnosis only. Figures in brackets under 'final medical diagnoses' denote preliminary medical diagnosis. Diagnoses
Group A (n = 25)
Group B (« = 14)
9(9)
12 (12)"
Preliminary medical diagnoses Oesophageal disease (OD)
0(0) b
Heart disorder (HD)
8(3)
2(2)
Gall bladder disease (GD)
2(0)
0(0)
Food allergy (FA)
1(0)
0(0)
Thyroid lesion (TL)
1(0)
0(0)
5 (OD1; MD2; HD1; TD1)
2 (OD2)
Two or more diseases (TD)
Final medical diagnoses Achalasia Hiatal hernia r
M
12 (OD4; MD4; HD1; TD3)
7 (OD6; HD1)
Oesophageal stricture
3 (MD1; HD1; TD1)
1 (OD1)
Gastro-oesophageal reflux
1 (OD1)
2 (OD2)
Oesophageal dysmotility
2 (OD2)
0(0)
Unknown
2(OD1;TD1)
2(OD1; HD1)
P
Family Practice © Oxfofd University Press 1992
Printed in Groat Britain
Do Physicians Care About Patients With Dysphagia? A Study on Confirming Communication BARBRO GUSTAFSSON, LJTA TIBBUNG* AND TORES THEORELL
INTRODUCTION It has been estimated that slightly more than 15% of the middle-aged population suffer from oesophageal dysphagia.1 A large proportion of these experience difficulty in swallowing as seriously affecting the quality of life.2-3 Benign dysphagia is usually caused by intermittent disturbance in oesophageal muscle function. Oesophagus X-rays are usually normal,4 and oesophageal dysphagia cannot be seen from the outside, especially when difficulty in swallowing has not led to loss in weight3 which may hamper a correct diagnosis. Patients with dysphagia often have chest pain, bronchitis and dyspepsia at the same time, which leads to differential diagnostic problems. It is therefore important for the physician to be able to communicate sensitively about what is really worrying the patient.3-3"7 On one hand there is a physician's delay in diagnosing and treating patients with dysphagia,4'7 on the other hand a patient's denial, unwillingness or inability to describe symptoms and feelings of unNalional Institute for Psychosocial Factors and Health, Karolinska Institute, Stockholm, and •Department of Otorhinolaryngology, University Hospital, LinkOping, Sweden. Address correspondence to: BArbro Gustafsson, University College of Caring Science, Nymarugatan 17, S-302 33 HalmBid, Sweden.
203
worthiness and shame will influence the outcome of the consultation.2'7 A common complaint among patients is that physicians do not listen to their problems, that their medical visit is experienced as stressful, that they are identified as a 'case', and that the consultation is dissatisfying, insulting or degrading, which can be interpreted as poor recognition or confirmation.8"" Confirmation has been regarded as the process through which individuals are recognized, acknowledged and endorsed by others and is connected with humanity, affection and concern.12 Gustafsson and Porn have described confirmation as a relationship which strengthens selfassessment. They interpret four of its components— sympathy, allowing action, understanding and competence—in terms of a theory of human motivation.13 Confirmation is the kind of communication which is growthful and therapeutic and the confirmed patient is shown to feel more relaxed, confident and strong than a non-confirmed patient." We were interested, therefore, in interviewing patients with oesophageal dysphagia in order to explore whether they had considered themselves confirmed when they first visited a physician for their dysphagia, whether patients had special attributes which could explain why they had been confirmed,
Downloaded from http://fampra.oxfordjournals.org/ at University of Birmingham on June 3, 2015
Gustafsson B, Tibbling L and Theorell T. Do physicians care about patients with dysphagia? A study on confirming communication. Family Practice 1992; 9: 203-209. Thirty-nine patients with longstanding oesophageal dysphagia took part in an interview and a questionnaire study to investigate whether they considered themselves met with interest, respect, understanding and knowledge (felt confirmed) when consulting their physician for the first time (mostly general practitioner), whether non-confirmed patients have any distinguishing attributes, and whether confirmation affects the patient's impression of being helped. Twenty-five of these considered themselves as nonconfirmed. There was no difference between the groups as regards sex, age, education, degree of swallowing difficulties and incidence of chest symptoms other than dysphagia. There was a greater fear of cancer (P < 0.05) and a stronger indirect aggression (P < 0.05) among the non-confirmed patients. Patients who felt confirmed reported more often that a correct oesophageal diagnosis had been given (P < 0.05), felt they had received adequate help (P < 0.001) and experienced improvement in swallowing difficulties (P < 0.05). It is concluded that patient attributes seem to slightly influence the patients' possibilities of being confirmed, and that confirmation is of great importance for the patient's feeling of being helped and improved.
204
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
and whether confirmation had a positive effect on the patient's swallowing difficulties.
Interview The interview, performed by one of the authors, was based on about 50 pre-designed, open-ended or closed questions compiled in a questionnaire. Issues concerning the patients first medical consultation due to dysphagia which were considered were: confirmationpatient experience of being confirmed; patient characteristics—demographic data (sex, age, education), physical data (length of dysphagia, subjective severity of dysphagia (score 1-5), chest symptoms other than dysphagia), psychological data (fear of cancer because of dysphagia, feelings of shame because of dysphagia, feelings of guilt because of dysphagia, reduced self-esteem because of dysphagia, insecurity in life because of dysphagia), social data (denial of dysphagia), personality data (see questionnaire below), consulting data (decision to visit a physician interpretation of cause of dysphagia, complaints presented to the physician); medical diagnoses (first and final diagnoses); and consequence of consultation (provision of information, advice and help, improvement in swallowing, physical, psychological and social adaptedness).
The anxiety-related scales. The somatic anxiety scale concerns automatic disturbances, restlessness and panic attacks. The muscular tension scale comprises items for muscular tenseness, stiffness and inability to relax. The psychic anxiety scale is related to feelings of worrying, anticipations and lack of self-confidence and sensitiveness. The inhibition of aggression scale represents actions of unexpressed anger, lack of ability to speak up and to assert oneself in social situations. The somatic anxiety scale and the muscular tension scale comprise nervous tension and distress. The psychic anxiety scale, the psychasthenia scale and the inhibition of aggression scale deal with cognitive-social anxiety. The hostility-related scales. The suspicion scale concerns feelings of being suspicious, hostility projected on others, and distrust of people's motives. The guilt scale represents items of being remorseful and ashamed for bad thoughts. The aggressiveness-related scales. The indirect aggression scale is related to actions of sulking and slamming doors when angry—undirected expression of aggression. The verbal aggression scale comprises aggressive feelings, such as getting into arguments and telling people off when annoyed. The irritability scale is about feelings of being irritable and lacking patience. Most of the scales consists of 10 items. There were four alternative answers to each item of the different scales: 'does not apply at all' (1 point), 'does not apply very well' (2 points), 'applies quite well' (3 points), and 'applies completely' (4 points). The higher the sum of points the more prominent is the personality trait which the respective scale aims to explore. The standard value of the different scales is 50. Definitions The patient is regarded confirmed when answering 'Yes' to the following question: "Did you feel that you were confirmed by the physician? Or, in other words, were you met with interest, respect, and understanding, and examined by a physician with knowledge of
Downloaded from http://fampra.oxfordjournals.org/ at University of Birmingham on June 3, 2015
PATIENTS AND METHODS Thirty-nine patients (24 women and 15 men) were invited to participate in an interview and questionnaire study. All patients had a history of oesophageal dysphagia which had caused them to attend a physician. Nineteen of 22 patients investigated at an oesophageal laboratory because of oesophageal dysphagia agreed to take part. Almost all of these patients had first consulted a family physician or GP. Another 20 patients were taken from a quality of life study of 7% pensioners, 62 of whom had oesophageal dysphagia. All pensioners who had consulted a physician because of dysphagia (n = 20) agreed to take part. At the time of interview 18 of 20 pensioners with dysphagia had attended a clinic specialized in oesophageal disorders. The study population was separated into two groups. Group A comprised 25 patients (median age 51.0 years, range 10-66 years) who had not felt confirmed at their first visit to a physician, and group B, 14 patients (median age 60.5 years, range 32-80 years) who had felt confirmed. There was an average time interval of 10.8 years (range 1-29 years) between the first consultation and the time of interview in non-confirmed patients and of 6.3 years (range 1-15 years) in confirmed patients. Age and patient characteristics are from the time of their first medical consultation. The personality data are from the time of interview. The final medical diagnoses in the two groups are shown later, in Table 5. Twenty-seven patients received their final diagnosis from physicians at a special clinic for oesophageal disorders, and two patients from GPs.
Personality Inventory At the interview the patients received a personality inventory questionnaire, the Karolinska Scales of Personality (KSP), consisting of self-report scales for completion at home. The KSP questionnaire is constructed or modified from other published scales by Schalling et al.M Ten of the 14 scales which were used in this study are constructed on theories of biologically based temperament dimensions according to different forms of vulnerability. The scales were validated by factor analysis and by clinical investigations resulting in separate scales of personality traits, which are partly interdependent. The scales of special interest in the present study are related to anxiety, hostility and aggressiveness.
205
PATIENTS WITH DYSPHAGIA
dysphagia?" Dysphagia is defined as a patient's experience of reduced ability to transport food or drink from the upper oesophagus to the stomach expressed as a sensation of obstruction in the chest when eating or drinking. Statistical Analyses The Fisher's exact test was used for comparison between groups in the interview study. The unpaired /-test was used for the personality inventory questionnaire. All tests were performed as two-tailed tests.
Physical, Psychological and Social Characteristics Patient characteristics in group A and group B are shown in Table 1. Sex, age, level of education, duration of dysphagia, subjective severity of dysphagia, feelings of guilt or shame, reduced self-esteem, experiences of insecurity in life because of dysphagia and experiences of advantages of denial did not differ significantly between the two groups. The fear of cancer was significantly more common in nonconfirmed patients than in confirmed patients (P < 0.05). Chest symptoms in group A and group B are shown in Table 2. No significant differences were found between the two groups. All patients had one or more symptoms from the chest other than dysphagia. Eighteen of 25 patients in group A and 11 of 14 patients in group B had two or more symptoms from the chest.
Patient characteristics
Group A (n = 25)
Female/male
15/10
9/5
Median age, years (range)
51.0(10-66)
60.5 (32-80)
Median history of dysphagia, years (range)
2.0 (0-28)
Severity of dysphagia, score M ± SD (range)
Group B (" = 14)
5.0 (0-54)
3.2 ± 1.2(1-5) 3.7 ± 1.0(2-5) 21 (84%)
5 (36%)*
8 (32V.)
4 (29%)
Feelings of guilt
16 (64%)
9(64%)
Advantages of denial
14 (56%)
4 (28%)
Reduced self-esteem
22 (88%)
9(64%)
Feelings of insecurity
23 (92%)
11 (78%)
Fear of cancer Feelings of shame
1
P < 0.05
TABLE 2. Chest symptoms other than dysphagia in group A (non-confirmed patients) and in group B (confirmed patients). Chest symptoms
Group A (n = 25)
Group B (n = 14)
Chest pain
22 (88%)
11 (78%)
Regurgitation
12 (48%)
8 (57%)
Heartburn
12 (48%)
9(64%)
Personality Characteristics Personality traits are given in Table 3. The four scales interpreting anxiety proneness and the two scales showing hostility did not differ significantly between the groups. Indirect aggression, which was one of the three scales interpreting aggressiveness, was more pronounced in the non-confirmed group (P < 0.05).
Choking
7(28%)
1 (7%)
Vomiting
8 (32%)
5 (36%)
Consulting Characteristics Nine non-confirmed patients (32%) and seven confirmed patients (50%) decided on their own to consult a physician due to dysphagia. The patients' own interpretation of cause of their dysphagia and the first complaint presented to the physician are shown in Table 4.
Preliminary and Final Diagnoses The preliminary and final medical diagnoses are shown in Table 5. Thirteen patients in group A and none in group B had been given a diagnosis of mental disorder (P < 0.01). Nine patients in group A (36%) and 12
Downloaded from http://fampra.oxfordjournals.org/ at University of Birmingham on June 3, 2015
RESULTS Twenty-five of 39 patients (64%) did not feel confirmed at their first medical consultation (group A). Six of the 25 patients did not feel confirmed at later consultations either and one patient never consulted a physician again. Fourteen patients (36%) regarded themselves as confirmed at their first visit to a physician (group B). The rate of confirmed patients was the same for the patients recruited from the oesophageal laboratory as for the pensioners recruited from the quality of life study.
TABLE 1. Different patient characteristics in group A (nonconfirmed patients) and group B (confirmedpatients) at their first medical consultation.
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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
TABLE 3. Personality score according to the KSP in group A (non-confirmed patients) and group B (confirmed patients). M ± SD (ranges). Standard value = 50. Personality traits
Group A (n «= 25)
Anxiety proneness Somatic anxiety
Group B (n = 114)
49.0 ± 13.4 (33-79)
Muscular tension
54.0 ± 10.3 (27-64)
50.1 ± 9.7 (38-71)
Psychic anxiety
52.4 ± 11.2(36-80)
47.3 ± 11.7 (32-67)
Psychasthenia
53.6 ± 9.0 (44-84)
46.8 ± 13.9 (19-77)
Inhibition of aggression
52.1 ± 11.5 (40-74)
45.8 ± 11.6(19-56)
53.6 ± 7.8 (40-68)
53.2 ± 14.1 (29-78)
49.5 ± 12.6 (27-71)
49.6 ± 14.1 (30-69)
Aggressiveness Indirect aggression
51.0 ± 6.9 (36-61)
45.3 ± 6.4 (31-58)*
Verbal aggression
49.0 ± 9.3 (35-74)
51.5 ± 7.4 (42-64)
Irritability
50.1 ± 10.9 (32-81)
46.1 ± 11.3 (24-62)
Hostility Suspicion Guilt
* P < 0.05
TABLE 4. First complaint presented to the physician (FCD) and patient interpretation of cause of dysphagia (COD) in group A (non-confirmed patients) and group B (confirmed patients). Group A (" = 2 5 )
Group B (/>= 14)
8 (32%)
9(64%)
Chest symptoms
8 (32%)
4(28%)
Abdominal symptoms
9 (36%)
1 (8%)
11 (44%)
10(71%)
Heart
5 (20%)
3 (21%)
Stomach
2(8%)
1 (8%)
Food allergy
1 (4%)
0(0%)
Unknown
6(24%)
0(0%)
FCD Dysphagia
COD Oesophagus
patients in group B (86%) had received an oesophageal diagnosis only (P < 0.05). Sixteen patients in group A (64%) and two patients in group B (14%) had been given one or two preliminary diagnoses other than oesophageal disease (P < 0.05). Twenty-one patients in group A were afraid they had cancer, 14 of whom were given other preliminary diagnoses than oesophageal disease. All confirmed patients with fear of cancer {n = 5) received an oesophageal diagnosis. One confirmed patient and one non-confirmed patient were directly informed by their physician that the symptoms were not malignant. Consequence of Consultation The patients' opinions of the consequence of consultation are shown in Table 6. Patients in group B felt that they had been helped significantly more often than patients in group A (P < 0.001). Patients in group B who had received information or advice reported a higher rate of improvement in swallowing than the corresponding patients in group A (P < 0.05). None of the six patients in group A who were not even confirmed at later consultations received help or information and none had experienced improvement in swallowing. Poor physical, psychological and social adaptedness was experienced by eight patients in group A (32%) and one patient in group B (7%).
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55.6 ± 10.6 (40-75)
207
PATIENTS WITH DYSPHAGIA
TABLE 5. Preliminary and final medical diagnoses in group A (non-confirmed patients) and group B (confirmed patients). Figures in parentheses under 'preliminary medical diagnoses' denote number of patients with one diagnosis only. Figures in brackets under 'final medical diagnoses' denote preliminary medical diagnosis. Diagnoses
Group A (n = 25)
Group B (« = 14)
9(9)
12 (12)"
Preliminary medical diagnoses Oesophageal disease (OD)
0(0) b
Heart disorder (HD)
8(3)
2(2)
Gall bladder disease (GD)
2(0)
0(0)
Food allergy (FA)
1(0)
0(0)
Thyroid lesion (TL)
1(0)
0(0)
5 (OD1; MD2; HD1; TD1)
2 (OD2)
Two or more diseases (TD)
Final medical diagnoses Achalasia Hiatal hernia r
M
12 (OD4; MD4; HD1; TD3)
7 (OD6; HD1)
Oesophageal stricture
3 (MD1; HD1; TD1)
1 (OD1)
Gastro-oesophageal reflux
1 (OD1)
2 (OD2)
Oesophageal dysmotility
2 (OD2)
0(0)
Unknown
2(OD1;TD1)
2(OD1; HD1)
P
