Article

Emergency physician empathy does not explain variation in admission rates

Correspondence / American Journal of Emergency Medicine 37 (2019) 762793 767

Table 1

Generalized Anxiety Disorder 7-item (GAD-7 scale).

Over the last 2 weeks, how often have you been bothered by the following problems?

0 (not at all)

1 (several days)

2 (over half the days)

3 (nearly every day)

1. Feeling nervous, anxious, or on edge

118 (36.9%)

58 (18.1%)

49 (15.3%)

95 (29.7%)

2. Not being able to stop or control worrying

130 (40.6%)

57 (17.8%)

40 (12.5%)

93 (29.1%)

3. Worrying too much about different things

101 (31.6%)

54 (16.9%)

55 (17.2%)

110 (34.4%)

4. Trouble relaxing

93 (29.1%)

62 (19.4%)

49 (15.3%)

116 (36.3%)

5. Being so restless that it’s hard to sit still

153 (47.8%)

47 (14.7%)

48 (15.0%)

72 (22.5%)

6. Becoming easily annoyed or irritable

97 (30.3%)

74 (23.1%)

57 (17.8%)

92 (28.8%)

7. Feeling afraid as if something awful might happen

186 (58.1%)

54 (16.9%)

22 (6.9%)

58 (18.1%)

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? – n (%)

Not difficult at all

123 (42.4%)

Somewhat difficult

98 (33.8%)

Very difficult

38 (13.1%)

Extremely difficult

31 (10.7%)

Not applicable

30

Acknowledgements

The authors wish to thank Nancy Buderer, MS, for her expertise in statistical analysis, and J. Michael Ballester, MD, and Dennis Mann, MD, PhD, for their assistance with data collection.

Catherine A. Marco Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, United States of America Corresponding author at: Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, 3525 Southern Blvd.,

Kettering, OH 45429, United States of America.

E-mail address: [email protected].

Justin Anderson Mitchell McMurray Matthew Lovell Jaree Naqvi Nicholas Seitz

Wright State University Boonshoft School of Medicine, Dayton, OH, United

States of America

4 August 2018

https://doi.org/10.1016/j.ajem.2018.08.020

References

  1. Downey VA, Zun LS. Identifying undiagnosed pediatric Mental illness in the emer- gency department. Pediatr Emerg Care 2018;34(2):e21-3.
  2. Downey LV, Zun LS, Burke T. Undiagnosed mental illness in the emergency depart- ment. J Emerg Med 2012;43(5):876-82.
  3. American Psychiatric Association: Diagnostic and statistical manual of mental disor- ders (5th Ed.). WDSM-5(TM) diagnostic criteria 2013. Washington DC. Generalized anx- iety disorder [300.02 (F41.1)].
  4. Spitzer RL, Kroenke K, JBW Williams, Lowe B. A brief measure for assessing general- ized anxiety disorder. Arch Intern Med 2006;166:1092-7.
  5. Kertz S, Bigda-Peyton J, Bjorgvinsson T. Validity of the Generalized Anxiety Disorder-7 scale in an acute psychiatric sample. Clin Psychol Psychother 2013;20(5):456-64.
  6. Lowe B, Decker O, Muller S, Brahler E, Schellberg D, Herzog W, et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care 2008;46(3):266-74.
  7. Plummer F, Manea L, Trepel D, Mcmillan D. Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis. Gen Hosp Psy- chiatry 2016;39:24-31.
  8. Seo J, Park S. Validation of the Generalized Anxiety Disorder-7 (GAD-7) and GAD-2 in patients with migraine. J headache pain 2015;16:97.
  9. Dark T, Flynn HA, Rust G, Kinsell H, Harman JS. Epidemiology of emergency depart- ment visits for anxiety in the United States: 2009-2011. Psychiatr Serv 2017;68(3): 238-44.

    Emergency physician empathy does not explain variation in admission rates

    Inpatient hospital care comprises the largest proportion of Healthcare costs and the emergency department (ED) serves as the pri- mary portal to Inpatient hospitalization [1]. Previous research demon- strates profound variation in admission rates between ED physicians seemingly unrelated to severity of illness or associated patient factors [2].

    Less attention has focused on the human factors contributing to an emergency physician’s decision to admit or discharge a patient. Previ- ous qualitative work outside the ED setting suggests physician empathy may play a role in medical decision-making and a positive physician-pa- tient relationship has been linked to improved patient outcomes and satisfaction [3-5].

    Physician empathy is also associated with some improvement in practice and health service use including reduced physician burnout and Medical malpractice risk [6,7]. However, few studies have studied the relationship between emergency physician empathy and resource use decisions of high visibility and importance, namely hospital admis- sion. Based on popular anecdote, we hypothesized that physicians with higher empathy would be more liberal in resource use and in turn admit more patients to the hospital.

    We conducted a cross-sectional sampling of ED attending physicians in a single healthcare system across 2 EDs, one a tertiary, urban aca- demic medical center and the other an urban, community ED. All eligi- ble participants were board certified emergency physicians practicing in either site. Institutional Review Board approval was obtained for this study.

    We used the Jefferson Scale of Empathy (JSE), a validated psycho- metric instrument that yields a quantitative measurement of empathy specifically validated for use with attending physicians, resident physi- cians, and medical students [8-10]. We utilized the attending physician version (HP-Version). Each of 20 items are rated on a Likert scale rang- ing from 1 to 7, with total scores range from 20 to 140 and higher scores indicating greater levels of empathy [11].

    Annual Hospital admission rate of each physician was calculated as the physician specific proportion of ED visits admitted to the hospital. Admissions were attributed to the attending physician assigned to the clinical care team at time of admission order. Both admissions to obser- vation and inpatient status were included as admissions.

    All analyses were performed using SAS 9.4 (SAS Institute, Inc., Cary, NC, USA) and R Version 3.5.0. We report descriptive statistics including Pearson correlations between physician empathy and hospital admis- sion rate.

    768 Correspondence / American Journal of Emergency Medicine 37 (2019) 762793

    Of 91 approached attending physicians, a total of 44 (48%) com- pleted the survey. 25 (38.6%) were female. The mean Jefferson Scale of Physician Empathy (JSE) score was 113.34 (+-12.5), with a range of 91 to 136. There was no significant difference in level of empathy by sex (p = 0.39) (see Fig. 1). Level of empathy was not significantly correlated with annual hospital admission rate (r = -0.11, p = 0.47) (see Fig. 2). Cronbach’s alpha was 0.87 in our sample, but must be interpreted with caution due to sample size.

    Fig. 1. JSE score by gender.

    Fig. 2. Association between admit rate and JSE score.

    Despite evidence suggesting that increased expressed physician em- pathy results in better patient outcomes as well as increased provider satisfaction in non-ED settings [12], our work did not identify a relation- ship between a validated measure of physician empathy and Hospital admission rates. Our findings are consistent with prior work that uti- lized the same survey data and found no relationship between physician JSE scores and Computerized tomography utilization [13]. These findings contradict labels of conventionally “empathic” physicians as “too nice” or “pushovers” resulting in higher resource utilization to ex- plain the positive affective relationships with patients. Instead, we find little to no relationship between physician empathy and costly hos- pital admission decisions, the most resource sensitive consideration in emergency medicine.

    Despite the negative findings of this work, several considerations warrant mention. While no clear relationship to empathy was noted,

    other human factors, such as overall stress level and risk aversion, may mediate the relationship between level of empathy and hospital admission rate. Additionally, it is possible that the self-reported JSE which has been validated in numerous clinical settings is not applicable to the real-time or episodic nature of decision making and relationships in the ED [9,15]. Finally, we utilized observed admission rates within a single healthcare system that are not risk adjusted and may not be gen- eralizable–however, prior work has demonstrates that patient and hos- pital factors do not entirely explain variation between physicians suggesting these findings still warrant mention.

    While physician empathy is likely an important mediator of patient reported outcomes, it does not appear to explain physician decision-making regarding hospitalization. Future work should seek to better explain the complex cognitive and interpersonal factors that drive both patient satisfaction and healthcare resource utilization.

    Vivek Parwani* David Ashkenasi Craig Rothenberg Andrew Ulrich Sharon Chekijian Marc Shapiro Edward Melnick Arjun K. Venkatesh

    Department of Emergency Medicine, Yale University School of Medicine,

    United States of America

    *Corresponding author at: 464 Congress Avenue Suite 260A, New

    Haven, CT 06519, United States of America.

    E-mail address: [email protected] (V. Parwani).

    4 August 2018

    https://doi.org/10.1016/j.ajem.2018.08.025

    References

    Schuur JD, Venkatesh AK. The growing role of emergency departments in hospital admissions. N Engl J Med 2012;367(5):391-3.

  10. Abualenain J, Frohna WJ, Shesser R, Ding R, Smith M, Pines JM. Emergency depart- ment physician-level and hospital-level variation in admission rates. Ann Emerg Med 2013;61(6):638-43.
  11. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for Diabetic patients. Acad Med 2011; 86(3):359-64.
  12. Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient sat-

    isfaction and compliance. Eval Health Prof 2004;27(3):237-51.

    Stewart M, Meredith L, Brown JB, Galajda J. The influence of older patient-physician communication on health and health-related outcomes. Clin Geriatr Med 2000;16 (1):25-36.

  13. Beckman HB. The doctor-patient relationship and malpractice. Arch Intern Med 1994;154(12):1365.
  14. Levinson W. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277(7):553-9.
  15. Hojat M, Gonnella JS, Mangione S, Nasca TJ, Magee M. Physician empathy in medical

    education and practice: experience with the Jefferson scale of physician empathy. Semin Integr Med 2003;1(1):25-41.

    Hojat M, Mangione S, Nasca TJ, et al. The Jefferson scale of physician empathy:

    development and preliminary psychometric data. Educ Psychol Meas 2001;61(2): 349-65.

    Hojat M. Empathy in patient care: antecedents, development, measurement, and outcomes. Springer Publications; 2007.

  16. Di Lillo M, Cicchetti A, Scalzo AL, Taroni F, Hojat M. The Jefferson scale of physician empathy: preliminary psychometrics and group comparisons in Italian physicians. Acad Med 2009;84(9):1198-202.
  17. Canale SD, Louis DZ, Maio V, et al. The relationship between physician empathy and disease complications. Acad Med 2012;87(9):1243-9.
  18. Melnick ER, O’Brien EGJ, Kovalerchik O, Fleischman W, Venkatesh AK, Taylor RA. The association between physician empathy and variation in imaging use. Acad Emerg Med 2016;23(8):895-904.

    [15] Pedersen R. Empirical research on empathy in medicine–a critical review. Patient Educ Couns 2009;76(3):307-22.

Leave a Reply

Your email address will not be published. Required fields are marked *