Schwartz Carolyn E, Ayandeh Armon, Finkelstein Joel A
DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA.
Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA.
Health Qual Life Outcomes. 2015 Sep 29;13:161. doi: 10.1186/s12955-015-0343-0.
Effective physician-patient communication is a critical component of a clinical practice and in order to achieve optimal patient outcomes. We aimed to investigate indirect effects of physician-patient communication by examining the relationship between a physician-patient mismatch in perceived outcomes and content in the medical record's clinical note. We compared patient records whose perceived subjective assessment of surgery outcomes agreed or disagreed with the surgeon's perception of that outcome (Subjective Disagreement).
This study included 172 spine surgery patients at a teaching hospital. Patient-reported outcomes included the Oswestry Disability Index; the Short-Form 36; and a Visual Analogue Scale items for leg and back pain. We content-analyzed the clinical note in the medical record, and used logistic regression to evaluate predictors of Subjective Disagreement (n = 41 disagreed vs. 131 agreed).
Patient and surgeon agreed in 76% of cases and disagreed in 24% of cases. Patients who assessed their outcome worse than their surgeons tended to be less educated and involved in litigation. They also tended to report worsened mental health and leg pain. Content analysis revealed group differences in surgeon communication patterns in the chart notes related to how symptom change was emphasized, how follow-up was described, and a specific word reference. Specifically, disagreement was predicted by using "much" to emphasize the findings and noting long-term prognosis. Agreement was predicted by use of positive emphasis terms, having an "as-needed" follow-up plan, and using "happy" in the chart note.
The nature of measuring outcomes of surgery is based on patient perception. In surgeon-patient perspective mismatches, patient factors may serve as barriers to improvement. Worsened change on patient-reported mental health may be an independent factor which colors the patient's general perceptions. This aspect of treatment may be missed by the spine surgeon. Chart note communication styles reflect the subjective disagreement. Investigating and/ or treating mental health deterioration may be valuable in resolving this mismatch and for overall outcome.
有效的医患沟通是临床实践的关键组成部分，也是实现最佳患者治疗效果的必要条件。我们旨在通过研究医患在感知结果方面的不匹配与病历临床记录内容之间的关系，来调查医患沟通的间接影响。我们比较了患者对手术结果的主观评估与外科医生对该结果的看法一致或不一致的患者记录（主观不一致）。
本研究纳入了一家教学医院的172例脊柱手术患者。患者报告的结果包括奥斯威斯利残疾指数、简明健康调查问卷36项以及腿部和背部疼痛的视觉模拟量表项目。我们对病历中的临床记录进行了内容分析，并使用逻辑回归来评估主观不一致的预测因素（41例不一致 vs. 131例一致）。
患者和外科医生在76%的病例中意见一致，在24%的病例中意见不一致。那些认为自己的结果比外科医生评估得更差的患者往往受教育程度较低且卷入诉讼。他们还倾向于报告心理健康状况恶化和腿部疼痛。内容分析显示，在图表记录中，外科医生的沟通模式存在群体差异，涉及对症状变化的强调方式、随访的描述方式以及特定的用词参考。具体而言，使用“很多”来强调检查结果并提及长期预后可预测不一致；使用积极强调词、制定“按需”随访计划以及在图表记录中使用“满意”可预测一致。
手术结果的衡量本质上基于患者的感知。在医患观点不匹配的情况下，患者因素可能成为改善的障碍。患者报告的心理健康状况恶化可能是影响患者总体感知的一个独立因素。脊柱外科医生可能会忽略治疗的这一方面。图表记录的沟通方式反映了主观不一致。调查和/或治疗心理健康恶化可能对解决这种不匹配以及改善总体治疗效果具有重要价值。
