From Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, 2nd Brigade, 4th Infantry Division, Fort Collins, Colorado, Uniformed Services University of the Health Sciences, Bethesda, Maryland, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, and 59th Medical Wing, JBSA Lackland, Texas.
South Med J. 2021 Jan;114(1):23-27. doi: 10.14423/SMJ.0000000000001195.
The concept of "historical alternans" (HA), a teaching folklore term referring to different descriptions of patient histories to trainees versus attending clinicians, can cause disjointed care and be a source of frustration for the trainee. Increased focus on the proper evaluation and treatment of pain in the emergency department (ED) setting prompts an evaluation of the HA concept as it relates to pain.
We conducted a prospective observational pilot study comparing pain descriptions given to attending and trainee clinicians in the ED using a five-question pain description survey. Trainees included emergency medicine physician residents, emergency medicine physician assistant residents, off-service residents, and students. Trainees completed the first survey and attending clinicians repeated survey questions after at least a 10-minute washout. Surveys include descriptions of pain as part of patients' primary concern, severity indicated by a verbal numerical rating score (VNRS), and pain location, quality, and duration.
During a 10-day period, surveys were completed for 97 patient encounters. Most trainee clinicians were emergency medicine physician residents (53%), followed by emergency medicine physician assistants (32%), students (13%), and off-service residents (2%). Pain complaints centered on the abdomen (18.5%), chest (12%), and knee (6%). Differences in pain description were found in the majority of cases (55%), with most having one categorical difference. The majority of categorical differences were VNRS (38%), although the difference in scores was not statistically significant ( = 0.20). Medical students had the highest variance in VNRS difference compared with attending clinicians. There was no significant difference in described duration ( = 0.99) or quality of pain ( = 0.99) between trainee and attending clinicians.
Most patient encounters had at least one difference in categorical pain descriptors between trainee and attending clinicians. Although differences in severity of pain were present, they were not significant. HA does occur in the ED setting, but the magnitude of difference may be minimal.
“历史交替”（HA）的概念是一个教学俗语，指的是向受训者和主治临床医生描述患者病史的不同描述，这可能会导致护理脱节，并给受训者带来挫折感。由于越来越关注在急诊室（ED）环境中对疼痛进行适当的评估和治疗，因此需要对 HA 概念进行评估，以了解其与疼痛的关系。
我们进行了一项前瞻性观察性试点研究，使用五问题疼痛描述调查比较了 ED 中主治医生和受训者临床医生的疼痛描述。受训者包括急诊医学住院医师、急诊医学医师助理住院医师、其他科室住院医师和学生。受训者完成了第一次调查，主治医生在至少 10 分钟的洗脱期后重复调查问题。调查包括疼痛作为患者主要关注点的描述、口头数字评分量表（VNRS）表示的严重程度以及疼痛位置、性质和持续时间。
在 10 天的时间里，共完成了 97 例患者就诊的调查。大多数受训者临床医生是急诊医学住院医师（53%），其次是急诊医学医师助理（32%）、学生（13%）和其他科室住院医师（2%）。疼痛主诉集中在腹部（18.5%）、胸部（12%）和膝盖（6%）。在大多数情况下发现疼痛描述存在差异（55%），其中大多数存在一个类别差异。大多数类别差异是 VNRS（38%），尽管分数差异没有统计学意义（=0.20）。与主治医生相比，医学生在 VNRS 差异方面的方差最大。受训者和主治医生之间在描述的疼痛持续时间（=0.99）或质量（=0.99）方面没有显著差异。
大多数患者就诊时，受训者和主治临床医生之间至少有一个疼痛描述的类别差异。尽管存在疼痛严重程度的差异，但这些差异并不显著。HA 确实会在 ED 环境中发生，但差异的幅度可能很小。
