Keeley Robert D, West David R, Tutt Brandon, Nutting Paul A
Department of Family Medicine, University of Colorado, Denver, Mail Stop F-496, Academic Office 1, 12631 E, 17th Ave, Aurora, CO 80045, USA.
BMC Fam Pract. 2014 Jan 15;15:13. doi: 10.1186/1471-2296-15-13.
Improving the patient experience of primary care is a stated focus of efforts to transform primary care practices into "Patient-centered Medical Homes" (PCMH) in the United States, yet understanding and promoting what defines a positive experience from the patient's perspective has been de-emphasized relative to the development of technological and communication infrastructure at the PCMH. The objective of this qualitative study was to compare primary care clinicians' and their patients' perceptions of the patients' experiences, expectations and preferences as they try to achieve care for depression.
We interviewed 6 primary care clinicians along with 30 of their patients with a history of depressive disorder attending 4 small to medium-sized primary care practices from rural and urban settings.
Three processes on the way to satisfactory depression care emerged: 1. a journey, often from fractured to connected care; 2. a search for a personal understanding of their depression; 3. creation of unique therapeutic spaces for treating current depression and preventing future episodes. Relative to patients' observations regarding stigma's effects on accepting a depression diagnosis and seeking treatment, clinicians tended to underestimate the presence and effects of stigma. Patients preferred clinicians who were empathetic listeners, while clinicians worried that discussing depression could open "Pandora's box" of lengthy discussions and set them irrecoverably behind in their clinic schedules. Clinicians and patients agreed that somatic manifestations of mental distress impeded the patients' ability to understand their suffering as depression. Clinicians reported supporting several treatment modalities beyond guideline-based approaches for depression, yet also displayed surface-level understanding of the often multifaceted support webs their patient described.
Improving processes and outcomes in primary care may demand heightened ability to understand and measure the patients' experiences, expectations and preferences as they receive primary care. Future research would investigate a potential mismatch between clinicians' and patients' perceptions of the effects of stigma on achieving care for depression, and on whether time spent discussing depression during the clinical visit improves outcomes. Improving care and outcomes for chronic disorders such as depression may require primary care clinicians to understand and support their patients' unique 'therapeutic spaces.'
在美国，将初级医疗实践转变为“以患者为中心的医疗之家”（PCMH）的努力中，改善患者对初级医疗的体验是一个明确的重点。然而，相对于PCMH技术和通信基础设施的发展，从患者角度理解和促进积极体验的定义却被淡化了。这项定性研究的目的是比较初级医疗临床医生及其患者在寻求抑郁症治疗时对患者体验、期望和偏好的看法。
我们采访了6名初级医疗临床医生以及他们的30名患有抑郁症病史的患者，这些患者来自4家农村和城市地区的中小型初级医疗诊所。
在实现满意的抑郁症治疗过程中出现了三个过程：1. 一段旅程，通常是从不连贯的治疗到连贯的治疗；2. 寻求对自己抑郁症的个人理解；3. 为治疗当前抑郁症和预防未来发作创造独特的治疗空间。相对于患者对耻辱感对接受抑郁症诊断和寻求治疗的影响的观察，临床医生往往低估了耻辱感的存在和影响。患者更喜欢富有同情心的倾听者作为临床医生，而临床医生担心讨论抑郁症会打开“潘多拉盒子”，引发冗长的讨论，并使他们在诊所日程中不可挽回地落后。临床医生和患者一致认为，精神痛苦的躯体表现阻碍了患者将自己的痛苦理解为抑郁症。临床医生报告称，除了基于指南的抑郁症治疗方法外，他们还支持多种治疗方式，但对患者描述的往往多方面的支持网络也只是表面理解。
改善初级医疗的过程和结果可能需要提高理解和衡量患者接受初级医疗时的体验、期望和偏好的能力。未来的研究将调查临床医生和患者对耻辱感对实现抑郁症治疗的影响的看法之间是否存在潜在差异，以及临床就诊时讨论抑郁症的时间是否会改善治疗结果。改善抑郁症等慢性疾病的护理和治疗结果可能需要初级医疗临床医生理解并支持患者独特的“治疗空间”。
