Physician-Patient Communication, Decision Making and Management in Chronic Pain.

项目摘要 慢性疼痛（CP）影响了超过1亿美国人，估计每年花费社会6350亿美元。 慢性下腰痛（cLBP）是其最常见的表现之一。有证据表明，阿片类药物 处方和成像在cLBP的初级护理中被过度使用，与指南相反。患者经常报告说， 他们觉得医生对他们的抱怨持怀疑态度或不屑一顾。他们可能会认为医生 解释说，他们的痛苦没有一个生理机制，如无效或指责;他们是 通常因缺乏治疗益处而沮丧。患者对行为疗法的依从性，例如 运动往往是穷人，因为自然反应的疼痛是保护表面受伤的身体。人士 cLBP可能会经历残疾和社交退缩，但如果他们保持活跃，从长远来看会更好 订婚了因此，医生希望鼓励病人克服对疼痛的自然反应。 与患者的沟通是医生在CP管理中最重要的工具，但医生， 经常发现CP患者在情感上要求很高，或者控制欲很强。现存的医患关系研究 围绕cLBP互动是基于自我报告，很少直接观察。为了改善临床护理， 了解增强共同决策和后续决策的互动特征至关重要。 患者理解、满意度、治疗依从性以及功能和疼痛结果。在当前 根据该提案，我们将首次采用经过验证的方法对通信过程进行分类 cLBP管理我们将对提供者和患者的言语行为进行分类，以测量以下结构： 患者参与，知情和自主选择，以患者为中心和促进沟通， 提供者和患者对健康相关行为的承诺，同时也标记 相互作用，如阿片类药物的使用;以及将行为与结果相匹配。这项研究的长期目标是 制定以提供者和患者为中心的干预措施，以改善慢性疼痛的临床沟通， 并取得更好的结果，同时减少阿片类药物滥用和其他次优临床 实践我们计划招募50名cLBP患者，在2个研究中心接受治疗， 在15个月的时间内记录与每位患者的多次接触， 每次遇到病人后，编码和分析互动。我们假设患者的参与度和 促进提供者的做法，通过我们的方法操作，将与病人的功能， 疼痛结果。这项工作将支持开发有前途的、可测试的干预措施，以改善临床 在cLBP沟通，基于我们的有效和无效的做法新开发的知识。

Project Summary Chronic pain (CP) affects more than 100 million Americans and is estimated to cost society $635 billion a year. Chronic low back pain (cLBP) is one of its most prevalent manifestations. There is evidence that both opioid prescribing and imaging are overused in primary care of cLBP, contrary to guidelines. Patients often report that they feel their physicians are skeptical or dismissive of their complaints. They may perceive physicians' explanations that their pain does not have a physiological mechanism as invalidating or blaming; and they are commonly frustrated by lack of benefit of treatment. Patient adherence to behavioral therapies such as exercise is often poor, as the natural response to pain is to protect the seemingly injured body. Individuals with cLBP may experience disability and social withdrawal, but will fare better in the long run if they remain active and engaged. Hence the physician wants to encourage the patient to overcome the natural response to pain. Communication with the patient is the most important tool for a physician in managemen of CP, but physicians, often find patients with CP to be emotionally demanding, or manipulative. Extant studies of physician-patient interaction around cLBP are based on self-reports, and little direct observation. To improve clinical care, it is essential to understand features of the interaction that enhance shared decision–making and subsequent patient understanding, satisfaction, treatment adherence, and function and pain outcomes. In the current proposal, we will, for the first time, apply validated, proven methods for categorizing communication processes to cLBP management. We will classify provider and patient verbal behaviors to measure such constructs as patient engagement, informed and autonomous choice, patient centered and facilitative communication by the provider, and patient commitment to health related behaviors, while also labeling the subject matter of interaction, such as opioid use; and match behaviors to outcomes. The long term goals of this research are to develop provider and patient-focused interventions that can improve clinical communication in chronic pain, and achieve better outcomes, while reducing harms from opioid misuse and other sub-optimal clinical practices. We propose to recruit a cohort of 50 patients with cLBP receiving care in 2 sites, audio-record and transcribe multiple encounters with each patient over a 15 month period, conduct follow-up interviews with the patient after each encounter, code and analyze the interactions. We hypothesize that patient engagement and facilitative provider practices, as operationalized by our methods, will be associated with patient function and pain outcomes. This work will support the development of promising, testable interventions, to improve clinical communication in cLBP, based on our newly developed knowledge of effective and ineffective practices.