Burack J H, Irby D M, Carline J D, Root R K, Larson E B
Division of Health and Medical Sciences, School of Public Health, University of California, Berkeley, Calif., USA.
J Gen Intern Med. 1999 Jan;14(1):49-55. doi: 10.1046/j.1525-1497.1999.00280.x.
To describe how and why attending physicians respond to learner behaviors that indicate negative attitudes toward patients.
Inpatient general internal medicine service of a university-affiliated public hospital.
Four ward teams, each including an attending physician, a senior medicine resident, two interns, and up to three medical students.
Teams were studied using participant observation of rounds (160 hours); in-depth semistructured interviews (n = 23); a structured task involving thinking aloud (n = 4, attending physicians); and patient chart review. Codes, themes, and hypotheses were identified from transcripts and field notes, and iteratively tested by blinded within-case and cross-case comparisons.
Attending physicians identified three categories of potentially problematic behaviors: showing disrespect for patients, cutting corners, and outright hostility or rudeness. Attending physicians were rarely observed to respond to these problematic behaviors. When they did, they favored passive nonverbal gestures such as rigid posture, failing to smile, or remaining silent. Verbal responses included three techniques that avoided blaming learners: humor, referring to learners' self-interest, and medicalizing interpersonal issues. Attending physicians did not explicitly discuss attitudes, refer to moral or professional norms, "lay down the law," or call attention to their modeling, and rarely gave behavior-specific feedback. Reasons for not responding included lack of opportunity to observe interactions, sympathy for learner stress, and the unpleasantness, perceived ineffectiveness, and lack of professional reward for giving negative feedback.
Because of uncertainty about appropriateness and effectiveness, attending physicians were reluctant to respond to perceived disrespect, uncaring, or hostility toward patients by members of their medical team. They tended to avoid, rationalize, or medicalize these behaviors, and to respond in ways that avoided moral language, did not address underlying attitudes, and left room for face-saving reinterpretations. Although these oblique techniques are sympathetically motivated, learners in stressful clinical environments may misinterpret, undervalue, or entirely fail to notice such subtle feedback.
描述主治医生如何以及为何对表明对患者持消极态度的学习者行为做出反应。
一所大学附属医院的住院普通内科服务部门。
四个病房团队，每个团队包括一名主治医生、一名高级内科住院医师、两名实习生以及最多三名医学生。
通过对查房进行参与观察（160小时）、深度半结构化访谈（n = 23）、一项涉及出声思考的结构化任务（n = 4，主治医生）以及患者病历审查对团队进行研究。从转录本和实地记录中识别代码、主题和假设，并通过盲法的个案内和跨案例比较进行迭代测试。
主治医生识别出三类潜在的问题行为：对患者不尊重、走捷径以及公然的敌意或粗鲁。很少观察到主治医生对这些问题行为做出反应。当他们做出反应时，他们倾向于采取被动的非语言姿态，如僵硬的姿势、不微笑或保持沉默。言语反应包括三种避免指责学习者的技巧：幽默、提及学习者的自身利益以及将人际问题医学化。主治医生没有明确讨论态度、提及道德或专业规范、“制定规则”或提及他们的示范作用，并且很少给予针对具体行为的反馈。不做出反应的原因包括缺乏观察互动的机会、对学习者压力的同情以及给予负面反馈会带来不愉快、感觉无效且缺乏职业回报。
由于对适当性和有效性存在不确定性，主治医生不愿对其医疗团队成员对患者的不尊重、冷漠或敌意做出反应。他们倾向于回避、合理化或医学化这些行为，并以避免使用道德语言、不解决潜在态度问题且为保全面子的重新解释留出空间的方式做出反应。尽管这些间接技巧是出于同情，但处于压力较大临床环境中的学习者可能会误解、低估或完全没有注意到这种微妙的反馈。
