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。初步研究显示，在其他方面正常的医学生中，由于考试压力的作用，细胞因子失衡主要从1型切换到2型。实验室任务也会产生短暂的心理和生理变化。本研究的目的是在基于实验室的模型中评估不同任务的心理和生理影响。这项研究的具体目标是：1.表征突发坏消息对四年级医学生的心理和生理影响。将评估情绪以及免疫、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相关的变量。对坏消息的信心、坏消息的方法、交感神经系统的唤醒和坏消息的心理和免疫学影响之间的联系将被确定。我们使用三组随机对照设计评估了四年级医学生在模拟医生-病人情景中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)传递坏消息的小组；2)传递好消息的小组；或3)对照组。通过加入一个传递好消息的小组，我们可以控制情况的压力评估者方面，而控制组将控制时间的流逝。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的测量。我们还评估了音频和录像带的一些参数，包括使用开放式问题，建立融洽的关系，以及移情反应。受试者被要求与一名模拟患者进行15分钟的突发坏消息或突发好消息采访，由医生进行角色扮演。受试者和模拟患者都得到了一个脚本来进行操作。突发的坏消息场景将是一名癌症患者即将听到他们晚期疾病的诊断。一个突发的好消息是，一名患者即将听说他们的测试结果都是癌症阴性。然后，主题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同。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面试内容，而是他们的沟通技巧。被分配到控制组的参与者被要求在任务期间阅读杂志。衡量压力的最佳方法是将情绪、生理和生化指标结合起来。这项拟议的研究使用这种方法来评估压力，以儿茶酚胺、皮质醇水平和生命体征为指标来衡量情绪和生理唤醒的变化。使用语气形容词检查表--语气状态简表来评估语气。在整个研究过程中测量血压和心率，以提供任务期间心血管反应性的衡量标准。与典型的自我报告指标相比，在实验室中评估的压力诱导内分泌变化提供了更客观的压力评估。儿茶酚胺和皮质醇检测是使用血浆样本进行的。患者报告了抽样期间吃的食物、吸烟、咖啡和酒精的消费以及药物的使用情况。这些测量将被用作分析BP和内分泌数据的协方差，以控制可能的误差源。免疫功能将在上午7点到11点之间进行评估，以控制昼夜变化。外周血单个核细胞(PBMC)将从肝素化的静脉血中提取，并从细胞培养中评估自然杀伤(NK)细胞数量、NK活性和丝裂原诱导的细胞因子生成。细胞因子水平将通过使用干扰素-g、IL-4、IL-10和IL-12的成对抗体的抗体夹心ELISA法来测定。

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.