Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota, USA.
Oncologist. 2019 Nov;24(11):e1180-e1189. doi: 10.1634/theoncologist.2019-0093. Epub 2019 May 17.
Little is known about how complementary and alternative medicine (CAM) is discussed in cancer care across varied settings in the U.S.
In two practices affiliated with one academic medical center in southern California (SoCal), and one in the upper Midwest (UM), we audio-recorded patient-clinician interactions in medical oncology outpatient practices. We counted the frequency and duration of CAM-related conversations. We coded recordings using the Roter Interaction Analysis System. We used chi-square tests for bivariate analysis of categorical variables and generalized linear models for continuous variables to examine associations between dialogue characteristics, practice setting, and population characteristics with the occurrence of CAM discussion in each setting followed by multivariate models adjusting for clinician clustering.
Sixty-one clinicians and 529 patients participated. Sixty-two of 529 (12%) interactions included CAM discussions, with significantly more observed in the SoCal university practice than in the other settings. Visits that included CAM were on average 6 minutes longer, with CAM content lasting an average of 78 seconds. In bivariate tests of association, conversations containing CAM included more psychosocial statements from both clinicians and patients, higher patient-centeredness, more positive patient and clinician affect, and greater patient engagement. In a multivariable model including significant bivariate terms, conversations containing CAM were independently associated with higher patient-centeredness, slightly longer visits, and being at the SoCal university site.
The frequency of CAM-related discussion in oncology varied substantially across sites. Visits that included CAM discussion were longer and more patient centered.
The Institute of Medicine and the American Society of Clinical Oncology have called for more open discussions of complementary and alternative medicine (CAM). But little is known about the role population characteristics and care contexts may play in the frequency and nature of those discussions. The present data characterizing actual conversations in practice complements a much larger literature based on patient and clinician self-report about CAM disclosure and use. It was found that CAM discussions in academic oncology visits varied significantly by practice context, that the majority were initiated by the patient, and that they may occur more when visit time exists for lifestyle, self-care, and psychosocial concerns.
在美国，不同环境下的癌症护理中，补充和替代医学（CAM）的讨论情况鲜为人知。
在加利福尼亚州南部（SoCal）的一家学术医疗中心附属的两家实践机构和中西部地区（UM）的一家实践机构中，我们对医学肿瘤学门诊实践中的医患互动进行了音频记录。我们统计了与 CAM 相关的对话的频率和持续时间。我们使用罗特互动分析系统对录音进行编码。我们使用卡方检验对二分类变量进行了双变量分析，对连续变量使用了广义线性模型，以检查对话特征、实践环境和人群特征与每个环境中 CAM 讨论发生的关联，然后使用多元模型调整临床医生聚类。
61 名临床医生和 529 名患者参与了研究。在 529 次互动中有 62 次（12%）包含 CAM 讨论，SoCal 大学实践中的观察到的次数明显多于其他环境。包含 CAM 的就诊时间平均延长了 6 分钟，CAM 内容平均持续 78 秒。在关联的二项测试中，包含 CAM 的对话中，临床医生和患者都有更多的心理社会陈述，患者中心性更高，患者和临床医生的情绪更积极，患者参与度更高。在包含显著二项变量的多变量模型中，包含 CAM 的对话与患者中心性更高、就诊时间略长以及位于 SoCal 大学地点独立相关。
肿瘤学中与 CAM 相关的讨论频率在不同地点之间差异很大。包含 CAM 讨论的就诊时间更长，且更以患者为中心。
美国医学研究所和美国临床肿瘤学会呼吁更开放地讨论补充和替代医学（CAM）。但对于人口特征和护理环境在这些讨论的频率和性质中可能扮演的角色，人们知之甚少。本研究通过对实际对话的描述，补充了基于患者和临床医生对 CAM 披露和使用的自我报告的大量文献。研究发现，学术肿瘤学就诊中的 CAM 讨论在实践环境中差异显著，大多数是由患者发起的，当有时间关注生活方式、自我保健和心理社会问题时，可能会更频繁地发生。
