Paterniti Debora A, Fancher Tonya L, Cipri Camille S, Timmermans Stefan, Heritage John, Kravitz Richard L
Division of General Medicine, University of California-Davis, 4150 V Street, Sacramento, CA 95817, USA.
Arch Intern Med. 2010 Feb 22;170(4):381-8. doi: 10.1001/archinternmed.2009.533.
Physicians need strategies for addressing patient requests for medically inappropriate tests and treatments. We examined communication processes that physicians use to deal with patient requests of questionable appropriateness.
Data come from audio-recorded visits and postvisit questionnaires of standardized patient visits to primary care offices in Sacramento and San Francisco, California, and Rochester, New York, from May 2003 to May 2004. Investigators performed an iterative review of visit transcripts in which patients requested, but did not receive, an antidepressant prescription. Measurements include qualitative analysis of strategies for communicating request denial. The relationship between strategies and satisfaction reports in postvisit questionnaires was examined using the Fisher exact test.
Standardized patients requested antidepressants in 199 visits; the antidepressants were not prescribed in 88 visits (44%), 84 of which were available for analysis. In 53 of 84 visits (63%), physicians used 1 or more of the following 3 strategies that explicitly incorporated the patient perspective: (1) exploring the context of the request, (2) referring to a mental health professional, and (3) offering an alternative diagnosis. Twenty-six visits (31%) involved emphasis on biomedical approaches: prescribing a sleep aid or ordering a diagnostic workup. In 5 visits (6%), physicians rejected the request outright. Standardized patients reported significantly higher visit satisfaction when approaches relying on the patient perspective were used to deny the request (P = .001).
Strategies for saying no may be used to communicate appropriate care plans, to reduce provision of medically inappropriate services, and to preserve the physician-patient relationship. These findings should be considered in the context of physician education and training in light of increasing health care costs.
医生需要应对患者提出的不适当医学检查和治疗请求的策略。我们研究了医生用于处理患者提出的合理性存疑请求的沟通流程。
数据来自2003年5月至2004年5月在加利福尼亚州萨克拉门托和旧金山以及纽约州罗切斯特的初级保健办公室进行的标准化患者就诊的录音访问和就诊后问卷调查。研究人员对患者请求但未获得抗抑郁药处方的就诊记录进行了反复审查。测量包括对拒绝请求的沟通策略的定性分析。使用Fisher精确检验检查策略与就诊后问卷调查中的满意度报告之间的关系。
标准化患者在199次就诊中请求使用抗抑郁药；88次就诊（44%）未开具抗抑郁药，其中84次可供分析。在84次就诊中的53次（63%），医生使用了以下3种明确纳入患者观点的策略中的1种或更多种：（1）探究请求的背景，（2）转介给心理健康专业人员，（3）提供替代诊断。26次就诊（31%）强调生物医学方法：开具助眠药物或安排诊断性检查。在5次就诊（6%）中，医生直接拒绝了请求。当使用依赖患者观点的方法拒绝请求时，标准化患者报告的就诊满意度显著更高（P = .001）。
拒绝的策略可用于传达适当的护理计划，减少不适当医疗服务的提供，并维护医患关系。鉴于医疗保健成本不断增加，应在医生教育和培训的背景下考虑这些发现。
