Bateni Sarah B, Canter Robert J, Meyers Frederick J, Galante Joseph M, Bold Richard J
Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA.
Hematology/Oncology, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, CA.
Surgery. 2018 Apr 27. doi: 10.1016/j.surg.2018.01.021.
Surgical decision-making in patients with advanced cancer requires careful thought and deliberation to balance the high risks with the potential palliative benefits. We sought to compare surgical decision-making and palliative care training among surgeons and medical physicians who commonly treat advanced cancer patients. We hypothesized that surgeons will report less palliative care training compared with medical physicians, and deficits in palliative care training will be associated with more aggressive treatment recommendations in clinical scenarios of advanced cancer patients with symptomatic surgical conditions.
Practicing surgeons, medical oncologists, intensivists, and palliative care physicians from a large urban city and its surrounding areas were surveyed with a 32-item questionnaire consisting of a survey addressing palliative care training and 4 clinical vignettes depicting patients with advanced cancer and symptomatic surgical conditions.
Of the 299 physicians surveyed, 102 responded (response rate 34.1%). Surgeons reported fewer hours of palliative care training during residency, fellowship, and continuing medical education combined (median 10, IQR 2-15) compared with medical oncologists (median 30, IQR 20-80) and medical intensivists (median 50 IQR 30-100), P < .05. Additionally, 20% of surgeons reported no history of any palliative care training. Analysis of physician recommendations for treatment of the 4 clinical vignettes showed minimal consensus regardless of physician specialty. Absence of palliative care training was associated with recommending major operative intervention more frequently compared with physicians with ≥40 hours of palliative care training (0.7 ± 0.7 vs 1.6 ± 0.8, P =.01).
Substantial deficiencies in palliative care training persist among surgeons and are associated with more aggressive recommendations for treatment for the selected scenarios presented in patients with advanced cancer. These findings highlight the need for greater efforts systemwide in palliative care education among surgeons, including incorporation of a structured palliative care training curriculum in graduate and continuing surgical education.
晚期癌症患者的手术决策需要仔细思考和权衡，以平衡高风险与潜在的姑息治疗益处。我们试图比较外科医生和内科医生在治疗晚期癌症患者时的手术决策和姑息治疗培训情况。我们假设，与内科医生相比，外科医生接受的姑息治疗培训较少，并且在晚期癌症合并有症状性手术情况的临床场景中，姑息治疗培训的不足将与更积极的治疗建议相关。
对来自一个大城市及其周边地区的执业外科医生、肿瘤内科医生、重症监护医生和姑息治疗医生进行了一项32项问卷的调查，该问卷包括一份关于姑息治疗培训的调查问卷和4个描述晚期癌症合并有症状性手术情况患者的临床 vignette。
在接受调查的299名医生中，102人做出了回应（回应率34.1%）。与肿瘤内科医生（中位数30，四分位间距20 - 80）和内科重症监护医生（中位数50，四分位间距30 - 100）相比，外科医生报告在住院医师培训、专科培训和继续医学教育期间接受的姑息治疗培训总时长较少（中位数10，四分位间距2 - 15），P <.05。此外，20%的外科医生报告没有任何姑息治疗培训经历。对医生针对4个临床 vignette 的治疗建议分析显示，无论医生专业如何，共识都很少。与接受过≥40小时姑息治疗培训的医生相比，没有接受过姑息治疗培训的医生更频繁地推荐进行重大手术干预（0.7 ± 0.7 对 1.6 ± 0.8，P =.01）。
外科医生在姑息治疗培训方面仍然存在严重不足，并且与对晚期癌症患者所呈现的选定场景更积极的治疗建议相关。这些发现凸显了在全系统范围内加大对外科医生姑息治疗教育力度的必要性，包括在研究生和继续外科教育中纳入结构化的姑息治疗培训课程。
