Missed Empathic Opportunities During Hand Surgery Office Visits

Effectiveness of a digital vs face-to-face preoperative assessment: A randomized, noninferiority clinical trial

STUDY OBJECTIVE

Digitalizing the preoperative assessment clinic can be a solution to keep up with the growing demand for surgery. It remains unclear if a digital preoperative assessment clinic is as safe, and effective in terms of patient health outcomes and experience compared to face-to-face consultations. This study aimed to compare quality of recovery and mental state in patients undergoing a digital preoperative assessment versus regular face-to-face consultations.

DESIGN

This was a single centre, randomized (1:1), parallel, open-label, noninferiority trial.

SETTING

The preoperative clinic and preoperative unit of an urban secondary care hospital.

PATIENTS

All adult, Dutch speaking, ASA I-IV patients with access to an online computer who required surgery.

INTERVENTIONS

Digital preoperative screening, consisting of an electronic screening questionnaire and web-based platform with personalized information and recommendations related to the procedure, or face-to-face screening, consisting of two 20-min in-hospital consultations.

MEASUREMENTS

The primary endpoint was quality of recovery, measured 48 h after surgery. The analysis followed a per-protocol principle, and only patients who underwent the intended screening were included in the analysis. The noninferiority margin was set at -6. The trial was registered at ClinicalTrials.gov, NCT05535205, during the study on 09/08/2022, before analysing results.

MAIN RESULTS

Between March 1, 2021 and 30 august 2021, 480 patients were assessed for eligibility. 400 patients were randomly assigned to the digital group (n = 200) or face-to-face group (n = 201), of which respectively 117 and 124 patients were eventually included in the primary analysis. The mean quality of recovery score of patients undergoing digital screening (158) was non-inferior to that of patients undergoing face-to-face screening (155), with a mean difference of 3·2 points and a 97.5% lower confidence limit of -2.1 points. There were no adverse events.

CONCLUSIONS

A digital preoperative screening is not inferior to face-to-face consultations in patients undergoing predominantly low to moderate risk surgery. Given its potential to reduce physician workload, reallocate healthcare resources, and lower healthcare costs, a digital preoperative screening may be a better choice for preoperative assessments.

Does Addressing Mental Health During a Musculoskeletal Specialty Care Visit Affect Patient-rated Clinician Empathy?

BACKGROUND

Unhelpful thoughts and feelings of worry or despair about symptoms account for a notable amount of the variation in musculoskeletal symptom intensity. Specialists may be best positioned to diagnose these treatable aspects of musculoskeletal illness. Musculoskeletal specialists might be concerned that addressing mental health could offend the patient, and avoidance might delay mental health diagnosis and treatment. Evidence that conversations about mental health are not associated with diminished patient experience might increase specialist confidence in the timely diagnosis and initial motivation to treat unhelpful thoughts and feelings of worry or despair.

QUESTIONS/PURPOSES

Using transcripts of videotaped and audiotaped specialty care visits in which at least one instance of patient language indicating an unhelpful thought about symptoms or feelings of worry or despair surfaced, we asked: (1) Is clinician discussion of mental health associated with lower patient-rated clinician empathy, accounting for other factors? (2) Are clinician discussions of mental health associated with patient demographics, patient mental health measures, or specific clinicians?

METHODS

Using a database of transcripts of 212 patients that were audio or video recorded for prior studies, we identified 144 transcripts in which language reflecting either an unhelpful thought or feelings of distress (worry or despair) about symptoms was detected. These were labeled mental health opportunities. Patients were invited on days when the researcher making video or audio records was available, and people were invited based on the researcher's availability, the patient's cognitive ability, and whether the patient spoke English. Exclusions were not tracked in those original studies, but few patients declined. There were 80 women and 64 men, with a mean age of 45 ± 15 years. Participants completed measures of health anxiety, catastrophic thinking, symptoms of depression, and perceived clinician empathy. Factors associated with perceived clinician empathy and clinician discussion of mental health were sought in bivariate and multivariable analyses.

RESULTS

Greater patient-rated clinician empathy was not associated with clinician initiation of a mental health discussion (regression coefficient 0.98 [95% confidence interval 0.89 to 1.1]; p = 0.65). A clinician-initiated mental health discussion was not associated with any factors.

CONCLUSION

The observation that a clinician-initiated mental health discussion was not associated with diminished patient ratings of clinician empathy and was independent from other factors indicates that generally, discussion of mental health does not harm patient-clinician relationship. Musculoskeletal clinicians could be the first to notice disproportionate symptoms or misconceptions and distress about symptoms, and based on the evidence from this study, they can be confident about initiating a discussion about these mental health priorities to avoid delays in diagnosis and treatment. Future studies can address the impact of training clinicians to notice unhelpful thoughts and signs of distress and discuss them with compassion in a specialty care visit; other studies might evaluate the impact of timely diagnosis of opportunities for improvement in mental health on comfort, capability, and optimal stewardship of resources.

Predictors of Physician Compassion, Empathy, and Related Constructs: a Systematic Review

BACKGROUND

Compassion in healthcare provides measurable benefits to patients, physicians, and healthcare systems. However, data regarding the factors that predict care (and a lack of care) are scattered. This study systematically reviews biomedical literature within the Transactional Model of Physician Compassion and synthesizes evidence regarding the predictors of physician empathy, compassion, and related constructs (ECRC).

METHODS

A systematic literature search was conducted in CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, OvidJournals, ProQuest, Web of Science, and Scopus using search terms relating to ECRC and its predictors. Eligible studies included physicians as participants. Methodological quality was assessed based on the Cochrane Handbook, using ROBINS-I risk of bias tool for quantitative and CASP for qualitative studies. Confidence in findings was evaluated according to GRADE-CERQual approach.

RESULTS

One hundred fifty-two included studies (74,866 physicians) highlighted the diversity of influences on compassion in healthcare (54 unique predictors). Physician-related predictors (88%) were gender, experience, values, emotions and coping strategies, quality of life, and burnout. Environmental predictors (38%) were organizational structure, resources, culture, and clinical environment and processes. Patient-related predictors (24%) were communication ease, and physicians' perceptions of patients' motives; compassion was also less forthcoming with lower SES and minority patients. Evidence related to clinical predictors (15%) was scarce; high acuity presentations predicted greater ECRC.

DISCUSSION

The growth of evidence in the recent years reflects ECRC's ongoing importance. However, evidence remains scattered, concentrates on physicians' factors that may not be amenable to interventions, lacks designs permitting causal commentary, and is limited by self-reported outcomes. Inconsistent findings in the direction of the predictors' effects indicate the need to study the relationships among predictors to better understand the mechanisms of ECRCs. The current review can guide future research and interventions.