Zabar Sondra, Hanley Kathleen, Watsula-Morley Amanda, Goldstein Jenna, Altshuler Lisa, Dumorne Heather, Wallach Andrew, Porter Barbara, Kalet Adina, Gillespie Colleen
J Grad Med Educ. 2018 Jun;10(3):285-291. doi: 10.4300/JGME-D-17-00736.1.
Physicians across specialties need to be skilled at diagnosing and treating depression, yet studies show underrecognition and inadequate treatment. Understanding the reasons requires specifying the influence of patient presentation, screening, and physician competence.
We deployed an unannounced standardized patient (SP) case to assess clinic screening and internal medicine (IM) residents' practices in identifying, documenting, and treating depression.
The SP represented a new patient presenting to the outpatient clinic, complaining of fatigue, with positive Patient Health Questionnaire (PHQ) items 2 and 9 and a family history of depression. The SPs assessed clinic screening and IM resident practices; appropriate treatment was assessed through chart review and defined as the resident doing at least 1 of the following: prescribing a selective serotonin reuptake inhibitor (SSRI), making a referral, or scheduling a 2-week follow-up.
Of 129 IM residents, 85 (66%) provided appropriate treatment, 79 (61%) appropriately referred, 59 (46%) prescribed an SSRI, and 49 (38%) scheduled a 2-week follow-up, while 40 (31%) did not add depression to the problem list. The IM residents who used PHQ-2 and PHQ-9 were more likely to appropriately (89%) versus inappropriately (50%) treat ( < .001). Compared with those who did not, residents who treated appropriately assessed depression symptoms more ( < .001) and had better communication (73% versus 50%, = .02), patient centeredness (74% versus 42%, = .03), and patient activation skills (35% versus 11%, < .001).
The use of unannounced SPs helps identify targets for training residents to provide evidence-based treatment of depression.
各专业的医生都需要熟练掌握抑郁症的诊断和治疗，但研究表明，抑郁症存在诊断不足和治疗不充分的情况。要理解其中的原因，需要明确患者表现、筛查以及医生能力的影响。
我们采用了一个未事先通知的标准化患者（SP）病例，以评估门诊筛查情况以及内科（IM）住院医师在识别、记录和治疗抑郁症方面的做法。
该标准化患者代表一名到门诊就诊的新患者，主诉疲劳，患者健康问卷（PHQ）第2项和第9项呈阳性，且有抑郁症家族史。标准化患者评估门诊筛查情况和内科住院医师的做法；通过病历审查评估适当的治疗情况，适当治疗的定义为住院医师至少做到以下其中一项：开具选择性5-羟色胺再摄取抑制剂（SSRI）、进行转诊或安排两周后的随访。
在129名内科住院医师中，85名（66%）提供了适当的治疗，79名（61%）进行了适当的转诊，59名（46%）开具了SSRI，49名（38%）安排了两周后的随访，而40名（31%）未将抑郁症列入问题清单。使用PHQ-2和PHQ-9的内科住院医师更有可能进行适当治疗（89%），而非不适当治疗（50%）（P<0.001）。与未适当治疗的住院医师相比，适当治疗的住院医师对抑郁症状的评估更多（P<0.001），沟通更好（73%对50%，P=0.02），以患者为中心程度更高（74%对42%，P=0.03），患者激活技能更强（35%对11%，P<0.001）。
采用未事先通知的标准化患者有助于确定培训住院医师进行抑郁症循证治疗的目标。
