Chibnall John T, Tait Raymond C, Jovel Andres
Department of Neurology & Psychiatry, Saint Louis University School of Medicine, St. Louis, Missouri.
Department of Neurology & Psychiatry, Saint Louis University School of Medicine, St. Louis, Missouri.
J Pain. 2014 Sep;15(9):915-24. doi: 10.1016/j.jpain.2014.06.001. Epub 2014 Jun 19.
Accountability has been shown to affect clinical judgments among health care providers in several ways. It may increase a provider's motivation for accuracy, leading to more deliberative judgments, or it may enhance biases that evaluators consistently demonstrate with patients with chronic pain. In this study, medical students read a vignette about a hypothetical patient referred for evaluation of severe low back pain by the Office of Vocational Rehabilitation. Accountability to the patient was either weak (consultative 1-time evaluation) or strong (ongoing primary care provision); societal accountability was either weak (evaluation information as secondary source for disability determination) or strong (evaluation information primary to disability determination). Participants then made judgments regarding validity of the patient's presentation, influence of psychosocial factors on the presentation, and patient's level of pain, distress, and disability, and completed an empathy measure. Results showed that empathy had strong associations with symptom validity and severity judgments. With empathy as a covariate, 3 crossover interactions emerged. Judgments of symptom validity were lower when the 2 forms of accountability were inconsistent (ie, one weak and the other strong) than when they were consistent (ie, both weak or both strong). Likewise, judgments of psychosocial factors and pain/distress/disability were higher under consistent accountability conditions than when accountability conditions were inconsistent. This pattern may imply conflict avoidance or self-protection as a motivation for judgments under inconsistent accountability. This study demonstrated that role demands can affect symptom judgments in complex ways, and that empathy may play both direct and moderating roles. Because physicians are the primary gatekeepers regarding disability determination in both consultative and treating roles, accountability may have significant mediating effects on such determinations.
This study demonstrated that medical student judgments of pain-related symptoms were strongly associated with their levels of empathic concern. Student judgments of symptom validity and psychosocial influences on patient adjustment were differentially affected by their level of accountability to the patient and society in a disability determination process.
已有研究表明，问责制会通过多种方式影响医疗服务提供者的临床判断。它可能会增强提供者对准确性的动机，从而做出更审慎的判断，或者它可能会强化评估者在面对慢性疼痛患者时一贯表现出的偏见。在本研究中，医学生阅读了一篇关于一名由职业康复办公室转介来评估严重腰痛的假设患者的病例 vignette。对患者的问责制要么较弱（咨询性一次性评估），要么较强（持续提供初级护理）；社会问责制要么较弱（评估信息作为残疾判定的次要来源），要么较强（评估信息是残疾判定的主要依据）。参与者随后对患者陈述的有效性、社会心理因素对陈述的影响以及患者的疼痛、痛苦和残疾程度进行判断，并完成一项共情测量。结果表明，共情与症状有效性和严重程度判断密切相关。将共情作为协变量时，出现了 3 种交叉交互作用。当两种问责形式不一致（即一种弱而另一种强）时，症状有效性的判断低于它们一致时（即两者都弱或两者都强）。同样，在一致的问责条件下，对社会心理因素和疼痛/痛苦/残疾的判断高于问责条件不一致时。这种模式可能意味着在不一致的问责情况下，避免冲突或自我保护是判断的动机。本研究表明，角色要求会以复杂的方式影响症状判断，并且共情可能发挥直接和调节作用。由于医生在咨询和治疗角色中都是残疾判定的主要把关人，问责制可能对这种判定产生重大的中介作用。
本研究表明，医学生对疼痛相关症状的判断与其共情关注水平密切相关。在残疾判定过程中，医学生对症状有效性和社会心理因素对患者调整的影响的判断，因其对患者和社会的问责水平不同而受到不同影响。
