Levinson W, Gorawara-Bhat R, Lamb J
Section of General Internal Medicine, University of Chicago, 5841 S Maryland Ave, MC 2007, Chicago, IL 60637, USA.
JAMA. 2000;284(8):1021-7. doi: 10.1001/jama.284.8.1021.
Patients often present clues (direct or indirect comments about personal aspects of their lives or their emotions) during conversations with their physicians. These clues represent opportunities for physicians to demonstrate understanding and empathy and thus, to deepen the therapeutic alliance that is at the heart of clinical care. A paucity of information exists regarding how physicians address the psychological and social concerns of patients.
To assess how patients present clues and how physicians respond to these clues in routine primary care and surgical settings.
DESIGN, SETTING, AND PARTICIPANTS: Descriptive, qualitative study of 116 randomly selected routine office visits to 54 primary care physicians and 62 surgeons in community-based practices in Oregon and Colorado, audiotaped and transcribed in 1994.
Frequency of presentation of clues by patients during office visits, nature (emotional vs social) and content of clues, and nature of physician responses to clues, coded as positive or missed opportunity.
Fifty-two percent and 53% of the visits in primary care and surgery, respectively, included 1 or more clues. During visits with clues, the mean number of clues per visit was 2.6 in primary care and 1.9 in surgery. Patients initiated approximately 70% of clues, and physicians initiated 30%. Seventy-six percent of patient-initiated clues in primary care settings and 60% in surgical settings were emotional in nature. In surgery, 70% of emotional clues related to patients' feelings about their biomedical condition, while in primary care, emotional clues more often related to psychological or social concerns (80%) in patients' lives. Physicians responded positively to patient emotions in 38% of cases in surgery and 21% in primary care, but more frequently they missed opportunities to adequately acknowledge patients' feelings. Visits with missed opportunities tended to be longer than visits with a positive response.
This study suggests that physicians in both primary care and surgery can improve their ability to respond to patient clues even in the context of their busy clinical practices. JAMA. 2000;284:1021-1027
患者在与医生交谈时常常会给出线索（对其生活或情感方面的直接或间接评论）。这些线索为医生展示理解和同理心提供了机会，从而加深作为临床医疗核心的治疗联盟。关于医生如何处理患者的心理和社会问题，现有信息匮乏。
评估在常规初级保健和外科环境中患者如何给出线索以及医生如何回应这些线索。
设计、场所和参与者：1994年对俄勒冈州和科罗拉多州社区医疗机构中54名初级保健医生和62名外科医生的116次随机选择的常规门诊进行描述性定性研究，对其进行录音并转录。
患者在门诊期间给出线索的频率、线索的性质（情感性与社会性）和内容，以及医生对线索的回应性质，分为积极回应或错失机会。
初级保健和外科门诊中分别有52%和53%包含1条或更多线索。在有线索的门诊中，初级保健每次门诊的线索平均数为2.6条，外科为1.9条。约70%的线索由患者发起，30%由医生发起。在初级保健环境中，76%由患者发起的线索是情感性的，在外科环境中这一比例为60%。在外科中，70%的情感线索与患者对其生物医学状况的感受有关，而在初级保健中，情感线索更多与患者生活中的心理或社会问题有关（80%）。医生在38%的外科病例和21%的初级保健病例中对患者情感做出了积极回应，但他们更常错失充分认可患者感受的机会。错失机会的门诊往往比有积极回应的门诊时间更长。
这项研究表明，即使在繁忙的临床工作中，初级保健医生和外科医生都可以提高回应患者线索的能力。《美国医学会杂志》。2000年；284:1021 - 1027
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