The lost art of reassurance medicine

Jerry and his wife, Pam, were not “medical people” and wouldn’t be considered high achievers. They seemed to be taking life in stride with a “mom and pop” disposition. Jerry had Alzheimer’s disease and was returned to his care facility after having a pacemaker inserted. The staff noticed Jerry slumped in his chair and called 911. Jerry’s blood pressure was low, and EMS transported him to the nearest hospital. He arrived with a happy-go-lucky smile on his face.

Pam freely admitted that she was a “goofball,” after several medical professionals reprimanded her for misplacing the card containing the pacemaker model and serial number. Was the pacemaker malfunctioning? Had Jerry experienced a mini-stroke? Was the dose of his blood pressure medication too high? Was he experiencing a “new normal” with his Alzheimer’s? None of this “medical stuff” mattered to Jerry and Pam as they joked with the ER doctor.

Pam warned the doctor that their daughter, Jean, was a nurse at a nearby hospital and that she was “kinda bossy.” In the meantime, the doctor told Pam that Jerry’s “drop attack” might never be completely explained, but that lowering his blood pressure medication dosage was appropriate. Besides reassurance, was further testing needed?

Once Jean arrived, the doctor had a definitive answer to his open-ended question about how to proceed. Jean was dumbfounded by the suggestion that her father was fine and stated, “This is not what we do at my hospital.” The doctor was properly scolded while Pam smiled, her eyes saying, “I told you.” The idea of engaging a reasonable conversation with shared decision-making was not an option. Jean was the boss. The doctor proceeded with business as usual, ordering all necessary tests for hospital admission and observation.

The following 9 reasons are why “reassurance medicine” has become a lost art:

1. Evidence-based medicine takes precedence. We live in a data-driven society. Jerry may have looked fine, but what were his vital signs? What did the laboratory findings reveal and was a CT scan performed? Physicians are rarely faulted for doing a major workup on Jerry to rule out other potential reasons for his “drop attack.” Yet most evidence would likely be inconclusive. Even if evidence proved otherwise, would it change the fact that most “nonmedical people” prefer to leave well enough alone?

2. Chronic illness requires due diligence. Patients with chronic illness, such as Alzheimer’s and heart disease, die if they’re not treated aggressively. Never mind that these diseases are leading causes of death despite medical treatment. Is this fact reassuring? Unassuming folks like Jerry and Pam often fret about others fussing over them. Most easy-going people truly believe they must die of something and are less concerned about what that something might be.

3. Medical knowledge overrides common sense. Intelligent people are prone to intimidate and bully the less educated. They seem to always be right and make this known to others. When a physician and nurse go toe-to-toe, one often tries to outsmart the other. Nonmedical people often use common sense and pose questions that can challenge and humble medical professionals. Medical knowledge is held in high regard, but it can’t compete with common sense and reassurance.

4. Physicians are not cost-conscious. Physician are not spending their own money on patients — they’re making money from treating patients. Attention has been given to value-based care to curb this practice, but it requires training physicians to order fewer tests and offer more reassurance. Few insurers want to pay for physicians to talk to patients so there’s no incentive for them to practice value-based medicine. And there are legal penalties for not practicing defensive medicine.

5. Defensive medicine protects physicians from litigation. Reassurance and defensive medicine are polar opposites. Reassurance comes from a deeper knowing or mother’s intuition that discourages the need for emergency treatment for every injury or ailment. Physicians who practice defensive medicine advise every patient who experiences something out of the ordinary to seek emergency care. Jean was playing it safe while neglecting her maternal instinct in caring for her parents.

6. People fail to trust themselves and others. It’s too easy to doubt others because we’re human and fallible. Trust is a matter of the proverbial glass being half empty or half full. Jerry and Pam trusted the doctor while Jean was suspicious. Even though the physician trusted his judgment, he responded to how Jean perceived him. Reassurance can only be an effective plan if both parties have the ability to trust.

7. Attention is rarely given to reducing a patient’s stress. The quicker stress becomes downplayed, the sooner a patient can relax. Jerry and Pam knew within minutes that the doctor intended to have them return to assisted living. Once Jean arrived, their stress escalated. Reassurance is the best remedy for stress reduction, but the doctor’s order for “stress management” was overruled. It seemed that Jerry was called to suffer rather than feel at ease.

8. Something is always wrong with patients. Most family caregivers find themselves saying, “If it’s not one thing, it’s another.” Few can simply treat one issue and forget about others. If Jerry’s Alzheimer’s disease was fatal, would it make sense to treat him for heart disease or a stroke? Would Jerry want his life prolonged knowing that his quality of life would suffer over time? Was Jerry given reassurance that Alzheimer’s disease if perfectly normal?

9. Reassurance medicine is a spiritual practice. The art of medicine has a spiritual connotation. The laying on of hands, like a pat on the shoulder, demonstrates both compassion and affirmation. It’s a spiritual blessing that only bestowed on the patients through compassionate individuals, not a machine or medication. The healing power of reassurance can be as effective as a placebo and evidence suggest that placebos work. Spiritual healing that’s good for the soul is good for Jerry’s mind and body.

If physicians want to provide reassurance medicine, they need to understand palliative care better. If patients wish to receive reassurance medicine, they need to enroll in a palliative care program. The ER physician demonstrated the art of “person-centered care” by addressing Jerry and Pam with compassion and understanding. The nonmedical model of palliative care as “reassurance medicine” allows patients to embrace the art of medicine fully.

If Warren Buffett, Jamie Dimon, and Jeff Bezos wish to tackle rising health care costs, they’re going to need Atul Gawande to show how “reassurance medicine” supports patient satisfaction and saves money. Once lost, but now found— the art of medicine (that uses clinical judgment over scientific evidence) needs to become the “saving grace” and new valued-based model for health care delivery in America.

Kevin Haselhorst is an emergency physician and author of Wishes To Die For: Expanding Upon Doing Less in Advance Care Directives.  He can be reached at his self-titled site, Kevin Haselhorst

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