BREAKING BAD NEWS-- LABORATORY MODEL

我们一直在研究压力、免疫和健康之间的关系，特别是在细胞因子失衡方面。最初的研究表明，在正常的医学生中，从1型到2型细胞因子失衡的主要转换是考试压力的作用。实验室工作也会产生短暂的心理和生理变化。本研究的目的是在实验室模型中评估不同任务的心理和生理影响。拟建研究的具体目标是：1。突发坏消息对四年级医学生心理和生理影响的表征。评估情绪、免疫、内分泌和心血管功能的变化。2. 检查与突发坏消息的心理和生理影响有关的变量。将确定公布坏消息的信心、公布坏消息的方法、交感神经系统的觉醒与公布坏消息的心理和免疫效应之间的关系。我们采用三组随机对照设计，评估了四年级医学生在准备和传递坏消息时的心理和生理反应。参与者将被随机分配到：1)一组传递坏消息；2)传递好消息的团体；3)对照组。通过加入一个传递好消息的小组，我们控制了情况中压力评估者的方面，而对照组将控制时间的流逝。任务反应的维度包括情绪和自我效能、免疫、内分泌和心血管功能的测量。我们还评估了音频和视频磁带的一些参数，包括开放式问题的使用，建立融洽关系和移情反应。受试者被要求“角色扮演”一名医生，与一名模拟病人进行15分钟的突发坏消息或突发好消息采访。受试者和模拟病人都有一个脚本来工作。突发的坏消息场景是一个癌症病人即将听到自己的绝症诊断结果。一个突发的好消息是，一个病人即将听到他们的癌症检测结果都是阴性的。然后讨论后续护理和生活方式问题。在这两种情况下，将注意确保参与者的发言时间相同。在这两种情况下的受试者都被告知，他们的评估不是基于他们的医学知识或访谈内容，而是基于他们的沟通技巧。被分配到对照组的参与者被要求在任务期间阅读杂志。压力最好是通过情绪、生理和生化指标的结合来衡量的。拟议中的研究使用这种方法来评估压力，测量情绪和生理唤醒的变化，这些变化是由儿茶酚胺和皮质醇水平以及生命体征所指示的。情绪是用情绪状态表来评估的，这是一个情绪形容词检查表。在整个研究过程中测量血压和心率，以提供在任务期间心血管反应的测量。在实验室中评估的压力引起的内分泌变化比典型的自我报告指标提供了更客观的压力评估。儿茶酚胺和皮质醇测定使用血浆样品进行。患者报告了在抽样期间所吃的食物、吸烟、咖啡和酒精的消费以及药物。这些测量将作为协方差用于分析血压和内分泌数据，以控制可能的误差来源。免疫功能将在上午7点至11点之间进行评估，以控制昼夜变化。外周血单核细胞（PBMC）将从肝素化静脉血中收集，并评估自然杀伤（NK）细胞数量、NK活性和细胞培养中有丝分裂原诱导的细胞因子的产生。细胞因子水平将通过抗体夹心ELISA检测，使用配对的IFN-g、IL-4、IL-10和IL-12抗体。

We have been investigating the relationships between stress, immunity, and health, particularly as applied to cytokine imbalances. Initial studies revealed a primary switch from type 1 to type 2 cytokine imbalances in otherwise normal medical students as a function of exam stress. Laboratory tasks can also produce transient psychological and physical changes. The purpose of this study is to assess the psychological and physical effects of different tasks in a laboratory based model. Specific objectives of the proposed research are: 1. Characterization of the psychological and physiological effects that breaking bad news has on fourth-year medical students. Changes in mood, and immune, endocrine, and cardiovascular function will be assessed. 2. Examination of variables that are associated with the psychological and physiological effects of breaking bad news. The association between confidence in breaking bad news, method of breaking bad news, sympathetic nervous system arousal and the psychological and immunological effects of breaking bad news will be determined. We have assessed the psychological and physiological response of fourth-year medical students while they prepare for and deliver bad news in a simulated physician-patient scenario using a three group randomized controlled design. Participants will be randomly assigned to either: 1) a group delivering bad news; 2) a group delivering good news; or 3) a control group. By including a group that delivers good news we control for the stressful evaluator aspects of the situation, and the control group will control for the passage of time. Dimensions of response to the task include measures of mood and self-efficacy, and immune, endocrine, and cardiovascular function. We also assess the audio and video tapes on a number of parameters including use of open-ended questions, establishment of rapport, and empathic responses. Subjects are asked to ""role-play"" a physician conducting a 15 minute breaking bad or breaking good news interview with a simulated patient. Both the subject and the simulated patient are given a script to work from. The breaking bad news scenario will be one of a cancer patient who is about to hear the diagnosis of their terminal disease. The breaking good news scenario is one of a patient who is about to hear that their tests all came back negative for cancer. The subject then discusses follow-up care and lifestyle issues. Care will be taken to ensure that the participants speak for similar amounts of time in both scenarios. Subjects in both conditions are told that they are not being evaluated on their medical knowledge or the content of the interview, but rather on their communication technique. Participants assigned to the control group are asked to read magazines for the duration of the task period. Stress is best measured with a convergence of mood, physiological, and biochemical measures. The proposed research uses this approach to stress assessment, measuring changes in mood and physiological arousal indexed by catecholamine and cortisol levels and vital signs. Mood is assessed using the Profile of Mood States, a mood adjective check-list. Blood pressure and heart rate are measured throughout the study to provide a measure of cardiovascular reactivity during the task period. Stress-induced endocrine changes assessed in the laboratory provide a more objective assessment of stress than the typical self-report indices. Catecholamine and cortisol assays are conducted using plasma samples. Patients report on foods eaten during the sampling period, smoking, consumption of coffee and alcohol, and medications. These measures will be used as covariances in analysis of BP and endocrine data to control for possible sources of error. Immune function will be assessed between 7 and 11 AM to control for diurnal variation. Peripheral blood mononuclear cells (PBMC) will be harvested from heparinized venous blood and assessed for natural killer (NK) cell numbers, NK activity and mitogen-induced cytokine generation from cell cultures. Cytokine levels will be determined by antibody-sandwich ELISA using paired antibodies for IFN-g, IL-4, IL-10 and IL-12.