Sharpe M, Mayou R, Seagroatt V, Surawy C, Warwick H, Bulstrode C, Dawber R, Lane D
Department of Psychiatry, University of Oxford, UK.
Q J Med. 1994 Mar;87(3):187-93.
Almost all doctors encounter difficulties in managing some patients. Previous studies have examined the characteristics of such patients: we have additionally studied the reasons why hospital doctors find these patients 'difficult to help'. Three clinics (two medical and one surgical) were studied. The consultants rated 60 (22%) of 293 attenders s severely or extremely difficult to help. Difficulty was associated with greater patient distress (odds ratio 3.9; 95% CI 2.0-7.7), less patient satisfaction (2.6; 1.3-5.0) and chronic attendance (5.0; 1.4-17.3). An interview study of 40 'difficult' patients indicated that doctors considered psycho-social factors more important in difficult patients (3.2; 1.3-7.7). Objective differences between the doctor's and the patient's aims for care also occurred more frequently for difficult patients (2.8; 1.1-7.2). Three common types of difficulty were identified; medically unexplained symptoms; co-existing social problems; and severe untreatable illness. A review of the management aims for patients whom doctors find 'difficult to help', combined with improved access to psycho-social care, could improve both the quality and the cost-effectiveness of hospital out-patient services.
几乎所有医生在管理某些患者时都会遇到困难。以往的研究探讨了这类患者的特征：我们还研究了医院医生认为这些患者“难以治疗”的原因。我们对三家诊所（两家内科和一家外科）进行了研究。会诊医生将293名就诊者中的60名（22%）评定为极难或极其难以治疗。治疗困难与患者更大的痛苦（比值比3.9；95%可信区间2.0 - 7.7）、更低的患者满意度（2.6；1.3 - 5.0）以及长期就诊（5.0；1.4 - 17.3）相关。一项对40名“难治性”患者的访谈研究表明，医生认为心理社会因素在难治性患者中更为重要（3.2；1.3 - 7.7）。在难治性患者中，医生和患者在护理目标上的客观差异也更频繁地出现（2.8；1.1 - 7.2）。确定了三种常见的困难类型；医学上无法解释的症状；并存的社会问题；以及严重的无法治疗的疾病。回顾医生认为“难以治疗”的患者的管理目标，并改善心理社会护理的可及性，可能会提高医院门诊服务的质量和成本效益。
