Wilson I B, Green M L, Goldman L, Tsevat J, Cook E F, Phillips R S
Primary Care Outcomes Research Institute, Boston, MA, USA.
Med Decis Making. 1997 Apr-Jun;17(2):217-27. doi: 10.1177/0272989X9701700213.
Recent studies have shown that physicians do not accurately assess patients' health status or treatment preferences. Little is known, however, about how physicians' levels of training or experience relate to their abilities to assess these preferences. To better understand this phenomenon, the authors compared the abilities of medical interns and attending physicians to predict the choices of their adult patients for end-of-life care.
230 seriously-ill adult inpatients were surveyed about their desires for cardiopulmonary resuscitation, their current quality of life, and their attitudes toward six other common adverse outcomes. The medical intern and attending physician who cared for these patients were asked to estimate the patient's responses for all of the same items. Agreement was assessed using the kappa statistic.
Compared with interns, attending physicians had known patients longer, had talked with patients more frequently about prognosis, and felt they knew more about their patients' preferences (all p < .0001). Despite this, the attending physicians were no more accurate than the interns in assessing patients' preferences. Both interns and attending physicians had only a fair understanding of patients' preferences for cardiopulmonary resuscitation or their quality of life (kappa statistics 0.32 to 0.47), and even less understanding of their willingness to tolerate adverse outcomes (kappa statistics -0.03 to 0.37).
For this cohort of seriously ill patients, neither medical interns nor their attending physicians were consistently accurate in assessing patients' preferences, and attending physicians were not more accurate than medical interns. Attending physicians should not assume that they can infer patients' preferences any better than the interns caring for these hospitalized patients.
近期研究表明，医生无法准确评估患者的健康状况或治疗偏好。然而，关于医生的培训水平或经验如何与其评估这些偏好的能力相关，我们知之甚少。为了更好地理解这一现象，作者比较了医学实习生和主治医生预测成年患者临终护理选择的能力。
对230名病情严重的成年住院患者进行了调查，询问他们对心肺复苏的意愿、当前的生活质量以及对其他六种常见不良后果的态度。照顾这些患者的医学实习生和主治医生被要求估计患者对所有相同项目的回答。使用kappa统计量评估一致性。
与实习生相比，主治医生认识患者的时间更长，与患者更频繁地谈论预后，并且觉得他们更了解患者的偏好（所有p <.0001）。尽管如此，主治医生在评估患者偏好方面并不比实习生更准确。实习生和主治医生对患者心肺复苏的偏好或生活质量的了解都只是一般（kappa统计量为0.32至0.47），对患者耐受不良后果意愿的了解更少（kappa统计量为-0.03至0.37）。
对于这组重症患者，医学实习生和他们的主治医生在评估患者偏好方面都不一致准确，主治医生并不比医学实习生更准确。主治医生不应认为他们比照顾这些住院患者的实习生更能推断患者的偏好。
