基层医疗中慢性疼痛和阿片类药物的沟通：对患者和医生就诊体验的影响。
Communication about chronic pain and opioids in primary care: impact on patient and physician visit experience.
机构信息
Department of Internal Medicine, University of California Davis, Sacramento, CA, USA.
University of California Davis Center for Healthcare Policy and Research, Sacramento, CA, USA.
出版信息
Pain. 2018 Feb;159(2):371-379. doi: 10.1097/j.pain.0000000000001098.
Patients and physicians report that communication about chronic pain and opioids is often challenging, but there is little empirical research on whether patient-physician communication about pain affects patient and physician visit experience. This study video recorded 86 primary care visits involving 49 physicians and 86 patients taking long-term opioids for chronic musculoskeletal pain, systematically coded all pain-related utterances during these visits using a custom-designed coding system, and administered previsit and postvisit questionnaires. Multiple regression was used to identify communication behaviors and patient characteristics associated with patients' ratings of their visit experience, physicians' ratings of visit difficulty, or both. After adjusting for covariates, 2 communication variables-patient-physician disagreement and patient requests for opioid dose increases-were each significantly associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Patient desire for increased pain medicine was also significantly positively associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Greater pain severity and more patient questions were each significantly associated with greater physician-reported visit difficulty, but not with patient experience. The association between patient requests for opioids and patient experience ratings was wholly driven by 2 visits involving intense conflict with patients demanding opioids. Patient-physician communication during visits is associated with patient and physician ratings of visit experience. Training programs focused on imparting communication skills that assist physicians in negotiating disagreements about pain management, including responding to patient requests for more opioids, likely have potential to improve visit experience ratings for both patients and physicians.
患者和医生报告说，关于慢性疼痛和阿片类药物的沟通常常具有挑战性，但关于疼痛方面的医患沟通是否会影响患者和医生就诊体验的实证研究却很少。本研究对 86 次初级保健就诊进行了视频记录，涉及 49 名开处长期阿片类药物治疗慢性肌肉骨骼疼痛的医生和 86 名患者，使用定制设计的编码系统系统地对这些就诊过程中的所有与疼痛相关的话语进行了编码，并在就诊前和就诊后进行了问卷调查。多元回归用于确定与患者对就诊体验的评价、医生对就诊难度的评价或两者均相关的沟通行为和患者特征。在调整了协变量后，有 2 个沟通变量——医患意见分歧和患者要求增加阿片类药物剂量——都与患者对就诊体验的评价更差和医生报告的就诊难度更大显著相关。患者对增加止痛药的渴望也与患者对就诊体验的评价更差和医生报告的就诊难度更大显著正相关。疼痛程度更严重和患者提问更多，都与医生报告的就诊难度更大显著相关，但与患者就诊体验无关。患者要求阿片类药物与患者就诊体验评分之间的关联完全是由 2 次涉及患者强烈要求阿片类药物的冲突性就诊引起的。就诊期间的医患沟通与患者和医生对就诊体验的评价有关。培训项目专注于传授沟通技巧，帮助医生就疼痛管理方面的分歧进行协商，包括对患者要求增加阿片类药物的要求做出回应，可能有潜力改善患者和医生的就诊体验评分。
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