Getting to "no": strategies primary care physicians use to deny patient requests.
Getting to "no": strategies primary care physicians use to deny patient requests.
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DOI：
10.1001/archinternmed.2009.533
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发表时间：
2010-02-22
影响因子：
--
通讯作者：
Kravitz, Richard L.
中科院分区：
文献类型：
--
作者：
Paterniti, Debora A.;Fancher, Tonya L.;Cipri, Camille S.;Timmermans, Stefan;Heritage, John;Kravitz, Richard L.
医生需要策略来解决患者对医学上不适当的测试和治疗的要求。我们研究了沟通过程中，医生用来处理病人的要求有疑问的适当性。数据来自2003年5月至2004年5月期间，加州的萨克拉门托和弗朗西斯科以及纽约的罗切斯特的标准化患者到初级保健办公室就诊的音频记录访视和访视后问卷。研究者对患者要求但未接受抗抑郁药处方的访视记录进行了反复审查。测量方法包括对通信请求拒绝策略的定性分析。策略和满意度报告的访视后问卷调查之间的关系进行了检查，使用Fisher精确检验。标准化患者在199次访视中要求使用抗抑郁药;在88次访视（44%）中未开具抗抑郁药，其中84次可用于分析。在84次访问中，有53次（63%），医生使用了以下3种策略中的一种或多种，明确纳入了患者的观点：（1）探索请求的背景，（2）参考心理健康专业人员，（3）提供替代诊断。26次访问（31%）涉及强调生物医学方法：处方睡眠援助或订购诊断检查。在5次就诊（6%）中，医生完全拒绝了这一要求。标准化的患者报告显着更高的访问满意度时，依赖于患者的角度的方法被用来拒绝的要求（P=.001）。说不的策略可用于沟通适当的护理计划，以减少提供医疗不适当的服务，并保持医患关系。这些研究结果应考虑在医生的教育和培训的背景下，在不断增加的医疗保健费用。
Physicians need strategies for addressing patient requests for medically inappropriate tests and treatments. We examined communication processes that physicians use to deal with patient requests of questionable appropriateness. Data come from audio-recorded visits and postvisit questionnaires of standardized patient visits to primary care offices in Sacramento and San Francisco, California, and Rochester, New York, from May 2003 to May 2004. Investigators performed an iterative review of visit transcripts in which patients requested, but did not receive, an antidepressant prescription. Measurements include qualitative analysis of strategies for communicating request denial. The relationship between strategies and satisfaction reports in postvisit questionnaires was examined using the Fisher exact test. Standardized patients requested antidepressants in 199 visits; the antidepressants were not prescribed in 88 visits (44%), 84 of which were available for analysis. In 53 of 84 visits (63%), physicians used 1 or more of the following 3 strategies that explicitly incorporated the patient perspective: (1) exploring the context of the request, (2) referring to a mental health professional, and (3) offering an alternative diagnosis. Twenty-six visits (31%) involved emphasis on biomedical approaches: prescribing a sleep aid or ordering a diagnostic workup. In 5 visits (6%), physicians rejected the request outright. Standardized patients reported significantly higher visit satisfaction when approaches relying on the patient perspective were used to deny the request (P=.001). Strategies for saying no may be used to communicate appropriate care plans, to reduce provision of medically inappropriate services, and to preserve the physician-patient relationship. These findings should be considered in the context of physician education and training in light of increasing health care costs.
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