The patient needed an emergency physician practiced in the ways of deliberate clinical inertia. She was in her late 20s and suffering from an inertia issue herself, one of her lower digestive tract.
She had taken several days' worth of Norco while recovering from a clavicle fixation and had not followed standard opioid bowel care recommendations. Not surprisingly, peristalsis became sluggish, and she said she had tried everything to resolve it: a long walk, fiber, and a Bikram yoga class chased with a dose of MiraLAX.
She came to the ED for help accompanied by her concerned mother, who was a strong patient advocate. The natural course of her condition and treatment options were reviewed at the bedside, and a recommendation was made. The patient's advocate was not happy, and a longer discussion ensued. More on the outcome a bit later.
Rather than review the hard new evidence for this case, we decided to provide a fresh take on a perennial problem in medicine—overdiagnosis and overtreatment. As our anchor to this topic, we chose a new offering called “Don't Just Do Something, Stand There! The Value and Art of Deliberate Clinical Inertia,” the first of a three-part series. (Emerg Med Australas 2018;30:273.)
This article reviews what we know about the existing biases that confound this dynamic—doctors are biased to intervene and patients are biased to overestimate the benefit of interventions—and their unfortunate outcome—too much testing, too many interventions, and low-value care. (Yale J Biol Med 2013;86:271; http://bit.ly/2CYM2YS; JAMA Intern Med 2016;176:1565; http://bit.ly/2t0dpx9.)
Eighty-five percent of surveyed U.S. emergency physicians think too many diagnostic tests are ordered in their EDs, and 97 percent said more than 20 percent of the advanced imaging studies they ordered were not medically necessary. (Acad Emerg Med 2015;22:390; http://bit.ly/2G7MSq6.) Having acknowledged the issue, the authors then provide some possible mitigating solutions that begin with a critical definition: Deliberate clinical inertia is “the art of doing nothing as a positive response.” (See table.)
Let's start with reframing the idea of doing nothing. Every action has an equal and opposite reaction, Newton told us, so doing something may not always translate to doing something worthwhile. But patients prefer action over inaction, so the key is to frame doing nothing as being active; even the patient-doctor interaction can be viewed as active treatment. How do we do this step by step?
First, empathize with the patient's situation and then address symptom management and observation if needed. Next, explain the natural course of the clinical condition at hand and try to manage expectations as a build-up to shared decision-making. We all do this as part of our regular practice, but perhaps not as effectively as we could. How often do we discuss possible Clostridium difficile infection when prescribing antibiotics? How often do we consider that the patient may have difficulty understanding a diagnosis (“Is it fractured or broken?”), and how such uncertainty may result in bias toward doing more than less?
Do we consciously consider the default choice in shared decision-making? Is it the active choice (an x-ray), our choice (no x-ray), or what is in the best interest of the patient (best-interest standard)? Medical ethicists would say it should be the last. (Hastings Cent Rep 2017;47:32.)
The authors took a stepwise approach through the process of deliberate clinical inertia for a 42-year-old with acute pain caused by an exacerbated chronic L2 injury. It worked beautifully; the patient was discharged home on over-the-counter analgesia and without advanced imaging. We have all had dozens of successes like this, but we also have had many failures. Let's see what happens when we apply a stepwise approach to doing nothing in our practice.
Back to our constipated young lady and her familial patient advocate. We practiced deliberate clinical inertia and recommended that she pursue a more aggressive therapy in her own bathroom, which we believed to be in the best interest of the patient, but they wanted more immediate action in the ED. Educating them about the expected clinical course failed, though we noted that enemas in the ED are usually performed for more severe constipation in elderly or debilitated patients and that most patients find home care far more comfortable. The senior member of our dyad peeled off in search of nursing management with an intent to complain, so we provided the treatment that left everyone feeling badly.
We are not deterred, however; deliberate clinical inertia may have lost this round, but no technique will bat a thousand, and we'll try again soon.
Dr. Vinson is an emergency physician at Kaiser Permanente Sacramento Medical Center, a chair of the KP CREST (Clinical Research on Emergency Services and Treatment) Network, and an adjunct investigator at the Kaiser Permanente Division of Research. He also hosts Lit Bits, a blog that follows the medical literature at http://drvinsonlitbits.blogspot.com. Dr. Ballard is an emergency physician at San Rafael Kaiser, a chair of the KP CREST Network, and the medical director for Marin County Emergency Medical Services. He is also the creator of the Medically Clear podcast on iTunes. Read his past articles at http://bit.ly/EMN-MedClear.