Pulmonary Vascular Disease: Pulmonary Vascular Disease - PE/DVT |

Influence of Patient Affect on Physician Recognition of Serious Illness and Need for Computerized Tomographic Pulmonary Angiography Among Patients With Suspected Pulmonary Embolism FREE TO VIEW

Samih Raad, MD; Jacob Capito, MD; Cassandra Hall; Dawn Neumann, PhD; Corlin Jewell; Jeffrey Kline, MD
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Indiana University School of Medicine, Indianapolis, IN

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1188A. doi:10.1016/j.chest.2016.08.1297
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SESSION TITLE: Pulmonary Vascular Disease - PE/DVT

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM

PURPOSE: Previous work showed that patients with serious cardiopulmonary diseases lack facial expression variability in response to emotional cues compared to patients who are less sick. That study raised the hypothesis that patient affect contributes to clinician pretest probability of disease, which in turn influences test-ordering behavior. Here, we report initial results of an experiment designed to measure the effect of patient affect on physician belief in the probability that a patient has a serious illness and their desire to order a CTPA.

METHODS: Subjects included patients and physicians (residents, fellows, and attending physicians) at four teaching hospitals in Indianapolis. We recorded patients’ faces who were undergoing CTPA scanning for suspected PE while the patient watched a standardized visual stimulus. Physicians completed a standardized psychometric assessment of facial affect recognition (Diagnostic Assessment of Nonverbal Accuracy 2-Faces, DANVA) in addition to viewing 73 videos of patients’ faces and answering 2 visual analogue scales (VAS) before and after each video. The sample size of N=50 was estimated to determine a clinically meaningful 10% difference in pretest probability. Disease (CPE+ cardiopulmonary emergencies, including PE, ACS, pneumonia, aortic disasters) was determined by adjudication of outcomes.

RESULTS: 183 clinicians were recruited and 50 completed all 73 patients; mean age of physicians was 32±8.3 years. DANVA mean and SD for all physicians was 18.2±3.2, lower than the 30-40 year old population normative mean of 19.3±2.7 and was weakly, negatively correlated with change in VAS (r=-0.20). For the 50 physicians who completed the study, the mean absolute change in pretest probability after seeing the patient’s face for probability of patient having an emergency was 10.0±3.7% (33% had >10% change) and for need for CTPA scan was 9.4±3.4% (30% had > 10% change) Eleven patients had CPE+ meaning physicians saw 550 faces with CPE and 3100 faces that were disease free. Seeing the patient’s face increased the pretest probability of CPE and desire to order a CT scan (>0 change in VAS) in 35% of patients adjudicated as CPE+ and in 35% of patients adjudicated as CPE-. However, seeing the patient’s face decreased the pretest probability (<0 change in VAS) of CPE in 51% of patients with CPE+ and 45% who were CPE-; similarly, the faces decreased desire for CTPA in 45% with CPE+, and 41% who were CPE-. The mean change in VAS poorly discriminated CPE+ from CPE-; for example, the mean VAS change for CPE estimate was -2.8±4.4% for CPE+ patients compared with -2.4±3.8%.

CONCLUSIONS: Under controlled circumstances, seeing the patients face caused relatively large, and frequently clinically important absolute changes in physician estimate of illness and need for CTPA scanning. However, physicians had highly variable accuracy at discriminating sick from not sick patients based upon affect. These data show a potential “Janus face” of patient affect decision-making.

CLINICAL IMPLICATIONS: The data gained informed us about the current role of affect in decision-making and its contribution to expert intuition and will lay the groundwork for a clinical trial to improve clinician recognition and use of patient affect in decision-making.

DISCLOSURE: The following authors have nothing to disclose: Samih Raad, Jacob Capito, Cassandra Hall, Dawn Neumann, Corlin Jewell, Jeffrey Kline

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