BMJ 2015;351:h5831 doi: 10.1136/bmj.h5831 (Published 4 November 2015)
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Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
How to make less more: empathy can fill the gap left by reducing unnecessary care Sometimes no alternative, conservative option exists, writes Edward R Melnick Edward R Melnick assistant professor, Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA “But how can you be sure, doctor?” the patient asked. “Wouldn’t it help to get a CT scan? Just to be sure.”
My heart sank: another patient here for a scan—not for my expertise and recommendations. On the basis of my evaluation, she had sustained a concussion caused by a low risk minor head injury. Good evidence indicates that computed tomography (CT) would be negative for clinically important injury.1 “Could I have a concussion?” she asked.
“You can’t see a concussion on a CT scan,” I explained. We discussed what a concussion is and what to expect after leaving the emergency department. A conversation followed; I listened to her concerns and addressed them. She looked relieved. Would a normal CT scan have given her the same reassurance? In regions of the United States where people receive more healthcare services, some measures of health are worse.2 Less overuse of health services (where potential harm exceeds the potential benefits) could result in better health.3 4 And yet, overuse continues for reasons including “fee for service” reimbursement, patient expectations, a quixotic quest for certainty, the glamour of technology, and defensive practice.4 5
Replacing unnecessary care with necessary care
Referring to a patient with a herniated lumbar disk who was successfully treated conservatively with physical therapy instead of surgery, the surgeon and author Atul Gawande argued, “It isn’t enough to eliminate unnecessary care. It has to be replaced with necessary care.”6 But how can we do this in situations where there is no alternative, conservative option? For instance, the patient with concussion who would not benefit from diagnostic testing was still in need of necessary care in the form of education, counseling, and reassurance. Such situations are particularly relevant given the many constraints and administrative demands clinicians face during a typical patient encounter. Time pressures and incentives that prioritize clinical productivity and patient satisfaction may
prevent clinicians from actually caring for patients by creating a perception that it is “quicker to order a test or write a prescription than explain to a patient why they are not being treated.”4
Such an approach not only contributes to the epidemic of overuse: it does surprisingly little to reassure patients, decrease their anxiety, or resolve their symptoms.7 Furthermore, it jeopardizes the very foundation of the doctor-patient relationship—a relationship predicated on care.8
Regardless of how overuse is curtailed, it must be replaced with empathic care. In our recent qualitative study of non-clinical factors that influence overuse of CT imaging in low risk minor head injury, clinicians and patients alike identified empathic themes—establishing trust, patient engagement, and reassurance—as essential in decreasing the overuse of imaging.9 If the clinician cared for, listened to, and engaged them and attended to their specific situation, patients reported that they were more likely to trust the clinician and the recommendation on whether a scan was medically necessary..
The benefits of empathic engagement A useful definition of empathy in patient care is the “cognitive attribute that involves an understanding of patients’ experiences, concerns, and perspectives combined with a capacity to communicate this understanding.”10 The focus on cognition, understanding, and communication suggests that empathy can be taught and learned (and that it can also decline or be forgotten).10 Our work on head injury identified the importance of patient engagement, including education and reassurance through listening, counseling, and identifying and tackling concerns.9 Importantly, in this and other clinical situations, watchful waiting or active surveillance are not the same as doing nothing; rather, genuine empathic care is fostering an encounter or a relationship in which patients are engaged with, are listened to, and have their concerns attended to. Empathic engagement with patients has many benefits. Patients who are engaged by their clinician feel more informed, more
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BMJ 2015;351:h5831 doi: 10.1136/bmj.h5831 (Published 4 November 2015)
Page 2 of 2
VIEWS & REVIEWS
accurately understand the potential benefits and harms of appropriate clinical options, and reach decisions that are more consistent with their values. Although not its primary purpose, patient engagement and activation may also simultaneously result in more sensible use of healthcare.11
1
I thank Hemal K Kanzaria, assistant professor, Department of Emergency Medicine, University of California, San Francisco, CA, USA; and Erik P Hess, Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.
5
Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: the author has no commercial associations that might pose a conflict of interest. ERM is supported in part by grant number K08HS021271 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the author and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
8
Provenance and peer review: Not commissioned; not externally peer reviewed.
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Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT head rule and the New Orleans criteria in patients with minor head injury. JAMA 2005;294:1511-8. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003;138:288-98. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998;280:1000-5. Grady D, Redberg RF. Less is more: how less health care can result in better health. Arch Intern Med 2010;170:749-50. Hoffman JR, Kanzaria HK. Intolerance of error and culture of blame drive medical excess. BMJ 2014;349:g5702. Gawande A. Overkill: America’s epidemic of unnecessary care. New Yorker 2015 May 11. www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande. Rolfe A, Burton C. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med 2013;173:407-16. Szasz TS, Hollender MH. A contribution to the philosophy of medicine; the basic models of the doctor-patient relationship. AMA Arch Intern Med 1956;97:585-92. Melnick ER, Shafer K, Rodulfo N, et al. Understanding overuse of CT for minor head injury in the ED: a triangulated qualitative study. Acad Emerg Med 2015; in press: AEMJ-15-232.R1. Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med 2009;84:1182-91. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014;1:CD001431.
Cite this as: BMJ 2015;351:h5831 © BMJ Publishing Group Ltd 2015
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