Epstein Ronald M, Shields Cleveland G, Meldrum Sean C, Fiscella Kevin, Carroll Jennifer, Carney Patricia A, Duberstein Paul R
Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA.
Psychosom Med. 2006 Mar-Apr;68(2):269-76. doi: 10.1097/01.psy.0000204652.27246.5b.
To understand how physicians communicate may contribute to the mistrust and poor clinical outcomes observed in patients who present with medically unexplained symptoms (MUS).
After providing informed consent, 100 primary care physicians in greater Rochester, New York, were visited by two unannounced covert standardized patients (actors, or SPs) portraying two chest pain roles: classic symptoms of gastroesophageal reflux disease (GERD) with nausea and insomnia (the GERD role) and poorly characterized chest pain with fatigue and dizziness (the MUS role). The visits were surreptitiously audiorecorded and analyzed using the Measure of Patient-Centered Communication (MPCC), which scores physicians on their exploration of the patients' experience of illness (component 1) and psychosocial context (component 2), and their attempts to find common ground on diagnosis and treatment (component 3).
In multivariate analyses, MUS visits yielded significantly lower scores on MPCC component 1 (p = .01). Subanalysis of component 1 scores showed that patients' symptoms were not explored as fully and that validation was less likely to be used in response to patient concerns in the MUS than in the GERD visits. Component 2 and component 3 were unchanged.
Physicians' inquiry into and validation of symptoms in patients with MUS was less common compared with more medically straightforward patient presentations. Further research should study the relationship between communication variables and poor clinical outcomes, misunderstandings, mutual distrust, and inappropriate healthcare utilization in this population, and test interventions to address this problem.
了解医生的沟通方式如何导致出现医学上无法解释的症状（MUS）的患者产生不信任感和不良临床结局。
在获得知情同意后，两名未事先通知的隐蔽标准化患者（演员，即SP）拜访了纽约大罗切斯特地区的100名初级保健医生，这两名患者分别扮演两种胸痛角色：伴有恶心和失眠的胃食管反流病（GERD）的典型症状（GERD角色）以及伴有疲劳和头晕的特征不明确的胸痛（MUS角色）。就诊过程被秘密录音，并使用以患者为中心的沟通测量工具（MPCC）进行分析，该工具从医生对患者疾病体验（第1部分）和心理社会背景（第2部分）的探索，以及他们在诊断和治疗上寻求共识的尝试（第3部分）等方面对医生进行评分。
在多变量分析中，MUS就诊在MPCC第1部分的得分显著更低（p = 0.01）。对第1部分得分的亚分析表明，与GERD就诊相比，在MUS就诊中，患者的症状未得到充分探究，并且针对患者担忧进行验证的可能性更低。第2部分和第3部分得分未变。
与医学上更明确的患者表现相比，医生对MUS患者症状的询问和验证较少见。进一步的研究应探讨沟通变量与该人群不良临床结局、误解、相互不信任和不适当医疗利用之间的关系，并测试解决这一问题的干预措施。
