Nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology: understanding the gap between guidelines and practice
Nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology: understanding the gap between guidelines and practice
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DOI：
10.1111/j.1365-2133.2010.09868.x
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发表时间：
2010-10-01
影响因子：
10.3
通讯作者：
Finlay, A. Y.
中科院分区：
文献类型：
--
作者：
Hajjaj, F. M.;Salek, M. S.;Finlay, A. Y.
P>背景皮肤科临床决策是一个复杂的过程，可能受到多种非临床因素的影响。目的本研究的目的是探讨诊断和严重程度之外的非临床影响对皮肤科临床决策的作用。方法对威尔士 9 家不同医院皮肤科的 46 名临床医生进行半结构化定性访谈。对访谈进行录音，随后进行转录，并对其内容进行分析。结果影响皮肤科患者管理决策的非临床因素已确定与患者、临床医生和实践特征相关。患者相关因素包括居住地、社会经济环境、教育和智力、种族、年龄、治疗依从性、治疗期望、生活质量、顾虑和忧虑、困难患者以及家人或朋友。临床医生相关因素包括临床时间限制、临床医生的个人情况、与同事的关系以及与制药公司的关系。与实践相关的因素包括在私人诊所工作、国家医疗服务体系 (NHS) 的治疗费用、处方官僚机构以及工作场所治疗服务的可用性。对于制药公司对临床医生处方的影响以及对 NHS 治疗成本的认识，顾问与其他临床医生的观点存在差异。大多数已确定的因素可能会在潜意识中影响临床医生的决策过程。一些临床医生强调，这些因素在医学课程中没有讲授，并且在临床指南中通常被忽略，因此对循证医学实践构成了挑战。结论这项研究描述了超越传统循证指南方法的医疗决策现实的一个方面。正确理解对决策的非临床影响对于获得以患者为中心的最佳治疗结果至关重要。
P>BackgroundClinical decision making in dermatology is a complex process and might be influenced by a wide range of nonclinical factors.ObjectivesThe aim of this study was to explore the role of nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology.MethodsSemi-structured qualitative interviews were conducted with 46 clinicians working in departments of dermatology of nine different hospitals in Wales. Interviews were audio-recorded and later transcribed and their contents analysed.ResultsNonclinical factors influencing patient management decisions in dermatology that were identified related to patients, clinicians and practice characteristics. Patient-related factors included place of residence, socioeconomic circumstances, education and intelligence, ethnicity, age, treatment adherence, expectations from treatment, quality of life, concerns and worries, difficult patients, and family members or friends. Clinician-related factors included time constraints in clinic, clinicians' personal circumstances, relationship with colleagues, and relationship with pharmaceutical companies. Practice-related factors included working in private practice, cost of treatment to the National Health Service (NHS), prescribing bureaucracy, and availability of treatment service in the work place. There was a difference between the consultants' views and those of the other clinicians over the impact of pharmaceutical companies on clinicians' prescribing and the awareness of treatment costs to the NHS. Most of the factors identified could potentially influence the clinicians' decision-making process subconsciously. Some clinicians highlighted that these factors are untaught in the medical curriculum, and are usually ignored in clinical guidelines, and therefore represent a challenge to the practice of evidence-based medicine.ConclusionsThis study has described one aspect of the reality of medical decision making beyond the conventional evidence-based guidelines approach. Proper understanding of nonclinical influences on decision making is of paramount importance for the best patient-centred treatment outcomes.