BREAKING BAD NEWS-- LABORATORY MODEL

我们一直在研究压力，免疫力和健康之间的关系，特别是应用于细胞因子失衡。最初的研究显示，在其他正常的医学生中，作为考试压力的函数，主要从1型细胞因子失衡转变为2型细胞因子失衡。实验室任务也可能产生短暂的心理和身体变化。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效应。具体研究目标如下：1.描述坏消息对四年级医学生的心理和生理影响。 将评估情绪、免疫、内分泌和心血管功能的变化。2.检验与突发坏消息的心理和生理影响相关的变量。 将确定在宣布坏消息的信心、宣布坏消息的方法、交感神经系统唤醒和宣布坏消息的心理和免疫影响之间的关联。我们评估了心理和生理反应的四年级医学生，而他们准备和提供坏消息，在一个模拟的医生，病人的情况下，使用三组随机对照设计。 参与者将被随机分配到：1）一组传递坏消息; 2）一组传递好消息;或3）一个控制组。 通过包括一个传递好消息的小组，我们控制了情况中有压力的评估者方面，而控制组将控制时间的推移。 对任务的反应维度包括情绪和自我效能的测量，以及免疫、内分泌和心血管功能。 我们还评估了一些参数，包括使用开放式问题，建立融洽关系，和移情反应的音频和视频磁带。 受试者被要求“角色扮演”一名医生与一名模拟患者进行15分钟的坏消息或好消息采访。 受试者和模拟患者都有一个脚本来工作。 最坏的消息是一个癌症患者即将听到他们的晚期疾病的诊断。 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。 然后讨论后续护理和生活方式问题。 将注意确保参与者在两种情况下的发言时间相似。 在这两种情况下，受试者都被告知，他们不是根据他们的医学知识或访谈内容进行评估，而是根据他们的沟通技巧进行评估。被分配到控制组的参与者被要求在任务期间阅读杂志。压力最好用情绪、生理和生化指标来衡量。拟议中的研究使用这种方法来进行压力评估，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指数化的。情绪是使用情绪状态的轮廓，一个情绪形容词检查表来评估的。在整个研究期间测量血压和心率，以提供任务期间心血管反应性的测量。压力引起的内分泌变化在实验室评估提供了一个更客观的评估压力比典型的自我报告指数。使用血浆样品进行儿茶酚胺和皮质醇测定。患者报告在采样期间吃的食物、吸烟、咖啡和酒精的消耗以及药物。 这些测量值将用作BP和内分泌数据分析的协方差，以控制可能的误差来源。将在上午7点至11点之间评估免疫功能，以控制昼夜变化。 将从肝素化静脉血中收获外周血单核细胞（PBMC），并评估细胞培养物中的自然杀伤（NK）细胞数量、NK活性和有丝分裂原诱导的细胞因子生成。将使用IFN-g、IL-4、IL-10和IL-12的配对抗体通过抗体夹心ELISA测定细胞因子水平。

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.