Joshua J. Fenton, Richard L. Kravitz, Guibo Xing, and Daniel J. Tancredi, University of California, Davis, Sacramento, CA; Paul R. Duberstein, Kevin Fiscella, and Ronald M. Epstein, University of Rochester; Supriya Mohile and Ronald M. Epstein, UR Medicine Wilmot Cancer Institute, Rochester, NY.
J Clin Oncol. 2018 Jan 20;36(3):225-230. doi: 10.1200/JCO.2017.75.6288. Epub 2017 Nov 17.
Purpose Some research has suggested that discussion of prognosis can disrupt the patient-physician relationship. This study assessed whether physician discussion of prognosis is associated with detrimental changes in measures of the strength of the patient-physician relationship. Methods This was a longitudinal cohort study of 265 adult patients with advanced cancer who visited 38 oncologists within community- and hospital-based cancer clinics in Western New York and Northern California. Prognostic discussion was assessed by coding transcribed audio-recorded visits using the Prognostic and Treatment Choices (PTCC) scale and by patient survey at 3 months after the clinic visit. Changes in the strength of the patient-physician relationship were computed as differences in patient responses to The Human Connection and the Perceived Efficacy in Patient-Physician Interactions scales from baseline to 2 to 7 days and 3 months after the clinic visit. Results Prognostic discussion was not associated with a temporal decline in either measure. Indeed, a one-unit increase in PTCC during the audio-recorded visit was associated with improvement in The Human Connection scale at 2 to 7 days after the visit (parameter estimate, 0.10; 95% CI, -0.02 to 0.23) and 3 months after the visit (parameter estimate, 0.18; 95% CI, 0.02 to 0.35) relative to baseline. Standardized effect sizes (SES) associated with an increase of two standard deviations in the PTCC at each time point were consistent with small beneficial effects (SES, 0.14 [95% CI, -0.02 to 0.29] at 2 to 7 days; SES, 0.24 [95% CI, 0.02 to 0.45] at 3 months), and lower bounds of CIs indicated that substantial detrimental effects of prognostic discussion were unlikely. Conclusion Prognostic discussion is not intrinsically harmful to the patient-physician relationship and may even strengthen the therapeutic alliance between patients and oncologists.
目的 一些研究表明,讨论预后可能会破坏医患关系。本研究评估了医生讨论预后是否与患者与医生关系的衡量指标的不利变化有关。
方法 这是一项纵向队列研究,纳入了 265 名在纽约西部和加利福尼亚北部的社区和医院癌症诊所就诊的晚期癌症成年患者,共涉及 38 名肿瘤医生。通过使用预后和治疗选择(PTCC)量表对转录的音频记录就诊进行编码以及患者在就诊后 3 个月进行调查来评估预后讨论。患者与医生关系的强度变化是通过基线到就诊后 2 至 7 天和 3 个月时患者对“人与人之间的联系”和“患者与医生互动中的感知效能”的反应差异来计算的。
结果 预后讨论与任何一种衡量标准的时间下降均无关。实际上,音频记录就诊期间 PTCC 增加一个单位与就诊后 2 至 7 天(参数估计值 0.10;95%CI,-0.02 至 0.23)和就诊后 3 个月(参数估计值 0.18;95%CI,0.02 至 0.35)时“人与人之间的联系”量表的改善相关,与基线相比。在每个时间点,PTCC 增加两个标准差相关的标准化效应大小(SES)与较小的有益效应一致(SES,就诊后 2 至 7 天时为 0.14[95%CI,-0.02 至 0.29];SES,就诊后 3 个月时为 0.24[95%CI,0.02 至 0.45]),且 CI 的下限表明预后讨论不太可能产生实质性的有害影响。
结论 讨论预后对医患关系没有内在的伤害,甚至可能增强患者和肿瘤医生之间的治疗联盟。