One in every three CT scans performed on patients with minor head injury is not medically necessary. The American College of Emergency Physicians has identified CT overuse as the top priority for minimizing wasteful and unnecessary tests in the emergency department. A Yale-led study has found that among other factors, strengthening the doctor-patient relationship can reduce unwarranted scans and their growing cost.

The study published early online in Academic Emergency Medicine.

Emergency providers have guidelines, such as the Canadian CT Head Rule, to help determine when a patient’s minor head injury should lead to a CT scan and further intervention. While the guidelines have been tested and validated, they are often ignored. For example, CT scans may be performed on patients with signs of concussion — even though CT does not help diagnose concussion but rather other risks such as bleeding.

To understand the disconnect between CT guidelines and practice for minor head injury, assistant professor of emergency medicine Dr. Edward R. Melnick and his co-authors conducted a qualitative study that included focus groups and interviews with patients and providers, as well as clinical observations.

The Yale-led team found that a range of nonclinical factors influenced medical decisions leading to unnecessary scans. For providers, those factors included their own lack of confidence and experience, the influence of others (family members, other providers), and time. For patients, empathic themes such as the doctor’s ability to listen and care for them were significant issues.

To address those factors and reduce CT overuse, the researchers identified several themes involving trust and bedside manner: patient engagement, listening, reassurance, identifying and addressing patient concerns, and managing patient anxiety.

“The doctor-patient relationship weighs heavily on the ability of the doctor and patient to be aligned in terms of whether a patient will understand and agree with the doctor’s recommendation,” said Melnick. “When a doctor takes time to listen and care for a patient, and the patient sees the doctor cares, the patient is more willing to trust the doctor’s recommendation whether CT scan is indicated.”

Other authors included Dr. Katherine Shafer, Dr. Nayeli Rodulfo, Joyce Shi, Dr. Erik P. Hess, Dr. Robert L. Wears, Rija A. Qureshi, and Lori A. Post.

The research project was supported with a grant from the Agency for Healthcare Research and Quality.

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