Social and behavioral influences on clinical communication and pain management

社会和行为对临床沟通和疼痛管理的影响

• 批准号: 8816046
• 负责人: Ronald M. Epstein
• 金额: $ 48.91万
• 依托单位: PURDUE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2011
• 资助国家: 美国
• 起止时间: 2011-03-01 至 2018-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8816046
• 关键词: Address; Advanced Malignant Neoplasm; Affect; Analgesics; Attenuated; Behavior; Black race; Caring; Clinical; Code; Communication; Consent; Detection; Experimental Designs; Fright; Guidelines; Health; Implicit Association Test; Inferior; Intervention; Knowledge; Label; Learning; Malignant Neoplasms; Measures; Methodology; Methods; Observational Study; Outcome; Outcome Measure; Pain; Pain Measurement; Pain management; Patient Care; Patients; Pharmaceutical Preparations; Physicians; Primary Health Care; Race; Randomized; Recommendation; Recording of previous events; Research; Role; Specialist; Symptoms; Testing; Training; Transcript; Unconscious State; Visit; behavior influence; communication behavior; contextual factors; design; ethnic discrimination; experience; health care delivery; improved; novel; older patient; oncology; outcome forecast; patient oriented; preference; programs; racial difference; racial discrimination; racial disparity; research study; social

DESCRIPTION (provided by applicant): Compared to white patients with advanced cancer, black patients experience inferior pain control and less frequent and less effective discussions about symptoms, prognosis and treatment preferences. It is not clear the degree to which these differences are due to patient factors (e.g. asking fewer questions) or physician factors (e.g. implicit/unconscious racial bias, poor communication). Preliminary studies suggest that activating patients to be more assertive and to ask more questions during the visit can mitigate racial differences in communication and pain management. The proposed study addresses this critical question though a field experiment. Using novel standardized patient methodology, we will randomly assign black or white patients with identical cancer history and symptoms to primary care and oncology physicians to examine whether potentially mutable patient and physician behaviors (activation and patient-centered communication) might mitigate some of these racial differences, including those that are due to implicit biases. Aims: 1. To examine the magnitude of racial differences in physicians' assessment of pain, discussions about prognosis and treatment choices, and use of guideline-concordant pain management. 2. To examine whether patient activation mitigates racial differences in physician communication behaviors and pain management decisions. 3. To explore potential moderators of racial differences in physician communication behaviors and pain management decisions, such as patient-centered communication and implicit unconscious bias. Methods: We will conduct a randomized experiment examining mutable patient and physician behaviors. We will create 4 unannounced standardized patient (SP, "secret shopper") roles portraying identical scenarios - a 70-year old patient with advanced cancer and uncontrolled pain - differing only by patient race (black/white) and level of activation (high/typical). We will randomly assign 120 physicians to see 2 unannounced covert SPs of the same race over a 12-month period, but differing according to activation. Outcome measures: We will transcribe and code audio-recorded physician-SP visits. We will code the depth of physician pain assessment using the Measure of Physician Pain Assessment, developed in our pilot (Cronbach's 1 = .68). We will assess prognosis and treatment choice communication using the Prognosis and Treatment Choices measure, which we developed in our pilot (Cronbach's 1 = 0.80). We found racial differences on both of these outcomes in our pilot. We will assess guideline-concordant pain medication recommendations using chart audit and review of transcripts. We will assess Exploring and Validating Concerns a component of patient-centered communication that has been associated with prescribing behavior, and the Implicit Associations Test, a measure of implicit bias to examine their moderating effects (Aim 3).

描述（由申请人提供）：与晚期癌症白色患者相比，黑人患者的疼痛控制较差，关于症状、预后和治疗偏好的讨论频率较低且效果较差。目前尚不清楚这些差异在多大程度上是由于患者因素（例如，问的问题较少）或医生因素（例如，隐性/无意识的种族偏见，沟通不畅）。初步研究表明，激活患者在访问期间更加自信并提出更多问题可以减轻沟通和疼痛管理中的种族差异。这项研究通过实地实验解决了这一关键问题。使用新的标准化患者方法，我们将随机分配具有相同癌症病史和症状的黑人或白色患者给初级保健和肿瘤学医生，以检查潜在可变的患者和医生行为（激活和以患者为中心的沟通）是否可能减轻其中一些种族差异，包括由于隐性偏见造成的差异。目的：1.检查医生对疼痛的评估、预后和治疗选择的讨论以及使用指南一致的疼痛管理方面的种族差异程度。2.检查患者激活是否减轻了医生沟通行为和疼痛管理决策中的种族差异。3.探讨医生沟通行为和疼痛管理决策中种族差异的潜在调节因素，如以患者为中心的沟通和内隐无意识偏见。方法：我们将进行一项随机实验，检查易变的患者和医生行为。我们将创建4个未公布的标准化患者（SP，“秘密购物者”）角色，描绘相同的场景-一名70岁的晚期癌症患者和不受控制的疼痛-仅在患者种族（黑人/白色）和激活水平（高/典型）方面有所不同。我们将随机分配120名医生，在12个月的时间内观察同一种族的2个未公布的秘密SP，但根据激活情况不同。结果指标：我们将转录和编码医生SP就诊的音频记录。我们将使用在我们的试点中开发的医生疼痛评估的措施（Cronbach的1 = .68）对医生疼痛评估的深度进行编码。我们将使用我们在试点中开发的预后和治疗选择指标（Cronbach's 1 = 0.80）评估预后和治疗选择沟通。我们在试点中发现了这两种结果的种族差异。我们将通过图表审核和成绩单审查评估指南一致的止痛药推荐。我们将评估探索和验证问题，这是以患者为中心的沟通的一个组成部分，与处方行为有关，以及内隐关联测试，这是一种测量内隐偏见的方法，以检查其调节作用（目标3）。

项目成果

Patient activation reduces effects of implicit bias on doctor-patient interactions.

• DOI: 10.1073/pnas.2203915119
• 发表时间: 2022-08-09
• 期刊: Proceedings of the National Academy of Sciences of the United States of America
• 影响因子: 11.1

Is physician implicit bias associated with differences in care by patient race for metastatic cancer-related pain?

• DOI: 10.1371/journal.pone.0257794
• 发表时间: 2021
• 期刊: PloS one
• 影响因子: 3.7
• 作者: Fiscella K;Epstein RM;Griggs JJ;Marshall MM;Shields CG
• 通讯作者: Shields CG