Gordon Howard S, Street Richard L, Kelly P Adam, Souchek Julianne, Wray Nelda P
Houston Center for Quality of Care and Utilization Studies, Houston, TX, USA.
Soc Sci Med. 2005 Sep;61(5):1015-25. doi: 10.1016/j.socscimed.2004.12.021. Epub 2005 Feb 17.
Although rarely studied, physician-patient interactions immediately following diagnostic tests are significant medical events because during these encounters the physician and patient often make decisions about major and sometimes invasive treatment. This investigation analyzed patterns of physician-patient communication following coronary angiography with particular attention to behaviors important to decision-making: physician information-giving, physician use of partnership-building, and active forms of patient participation (e.g., asking questions, being assertive, expressing concerns). We were particularly interested in effects related to the patient's race in light of documented evidence of racial disparities in cardiac care and outcomes. From audiotape recordings, 93 physician-patient interactions after coronary angiogram in a catheterization laboratory in a large US Veterans Affairs Medical Center were coded to measure the frequency of physicians' information-giving and partnership-building and the frequency of active patient participation. We also stratified these behaviors according to whether the behavior was prompted (e.g., physician information in response to a patient's question; a patient's opinion solicited by the doctor) or self-initiated. Several findings were noteworthy. First, these interactions were very brief and dominated by the physician. Second, although physician information-giving increased with more active patient participation, which in turn was correlated with physicians' use of partnership-building, proportionally little of the physicians' information (8%) and active patient participation (9%) was directly prompted by the other interactant. Finally, there was a tendency for physicians to self-initiate less information giving to black patients and for black patients to self-initiate less active participation than white patients. Although these differences were attenuated when other variables (e.g., the physician's training, disease severity) were included in the analysis, the pattern suggests a potential cycle of passivity where certain patients tend to receive fewer informational resources and these patients in turn do less to prompt the doctor for more.
尽管很少被研究，但诊断测试后医生与患者的互动是重大的医疗事件，因为在这些会面中，医生和患者常常会就重大且有时是侵入性的治疗做出决策。本研究分析了冠状动脉造影术后医生与患者的沟通模式，特别关注对决策至关重要的行为：医生提供信息、医生建立合作关系的方式以及患者积极参与的形式（例如提问、坚持己见、表达担忧）。鉴于有记录表明心脏护理及治疗结果存在种族差异，我们尤其关注与患者种族相关的影响。从美国一家大型退伍军人事务医疗中心导管实验室的冠状动脉造影术后的录音中，对93次医生与患者的互动进行编码，以衡量医生提供信息和建立合作关系的频率以及患者积极参与的频率。我们还根据行为是由对方引发的（例如医生回应患者问题时提供的信息；医生征求患者意见）还是自我发起的对这些行为进行了分层。有几个发现值得注意。首先，这些互动非常简短，且以医生为主导。其次，尽管随着患者更积极的参与，医生提供的信息有所增加，而这又与医生建立合作关系的方式相关，但医生提供的信息中只有8%以及患者的积极参与中只有9%是由对方直接引发的。最后，医生往往会减少向黑人患者主动提供信息，而且黑人患者自我发起的积极参与比白人患者少。尽管在分析中纳入其他变量（例如医生的培训、疾病严重程度）后这些差异有所减弱，但这种模式表明存在一种潜在的被动循环，即某些患者往往获得较少的信息资源，而这些患者反过来促使医生提供更多信息的行为也更少。
