台灣癌症病人主觀覺知醫病溝通於情緒壓力、因應、及生活品質之中介效果

Abstract

緒論：醫病溝通為病人就醫行為中相當重要的一部分，醫病溝通不良可能造成病人的情緒困擾與預後不佳。過去研究中多以「滿意度」的角度來詮釋「醫病溝通」，認為醫病溝通的責任主要在醫師身上。本研究試圖以病人的角度來思考，推論醫病溝通狀態可能是癌症病人的壓力，也可能是癌症病人的重要資源；以此探討醫病溝通是否能中介病人罹病後之情緒壓力與後續之疾病相關因應歷程與生活品質。\n研究方法：本研究參與者為來自北部某醫學中心的乳癌與頭頸癌患者，於術前接受情緒壓力評估，並於術後六個月填寫癌症病人醫病溝通量表、短版因應量表、及台灣簡明版世界衛生組織生活品質問卷。本研究將常用於測量醫病溝通狀態的「醫病溝通滿意度量表 (The Medical Interview Satisfaction Scale, MISS-21)」，翻譯後依據壓力概念將題項重新分為「正向醫病溝通」、「醫病溝通關係」、及「負向醫病溝通」等三個因素，再以驗證性因素分析（CFA）檢驗此因素建構是否適用於台灣癌症病人，並進行信度與效度檢驗。醫病溝通之中介效果部份，將以路徑分析探討乳癌與頭頸癌樣本於術前情緒壓力、術後六個月之醫病溝通（正向、關係、負向）、因應（個人、社會、逃避）與生活品質（生理、心理、社會、環境）間之關係。\n研究結果：共有乳癌患者123人(全女性，平均年齡53.342歲)與頭頸癌患者94人(男性76人女性18人，平均年齡52.723歲)，總計217人納入本研究。差異分析上發現乳癌與頭頸癌樣本除了「逃避因應」與「心理生活品質」外，所有研究變項上皆有顯著差異。在醫病溝通之中介效果部份，乳癌病人術前情緒壓力可顯著正向預測負向醫病溝通，負向醫病溝通可顯著正向預測逃避因應，逃避因應可顯著負向預測四個面向之生活品質；術前情緒壓力亦可負向預測四個面向之生活品質。頭頸癌病人之術前情緒壓力可顯著負向預測正向醫病溝通，正向醫病溝通顯著正向預測個人因應，個人因應顯著正向預測心理、社會、及環境生活品質。正向醫病溝通可正向預測四個面向之生活品質，負向醫病溝通則可負向預測心理與環境生活品質。簡而言之，對乳癌患者來說，「負向醫病溝通預測」可能為術前情緒壓力對術後六個月之逃避因應與生活品質之部份中介因子；對頭頸癌患者來說，「正向醫病溝通」可能為術前情緒壓力對術後六個月之個人因應與生活品質之完全中介因子。\n討論：本研究結果顯示台灣中文版「癌症病人醫病溝通量表」可從病人主觀覺知角度分為「正向醫病溝通」、「醫病溝通關係」、及「負向醫病溝通」三個因素且具有良好信效度。乳癌患者之術前情緒壓力對後續適應影響甚鉅，而「負向醫病溝通」為重要中介因子，因此提供心理介入以降低乳癌患者術前情緒壓力與其後續知覺醫病溝通為壓力情境的程度，應為提升乳癌患者後續因應與生活品質之重要方向。在頭頸癌患者中，「正向醫病溝通」有顯著效果，顯示醫病溝通為重要醫療資源，若跨專科醫療團隊能協助頭頸癌患者恰當表達其醫療需求，應可提升照護品質並增進生活品質。

Objective: Doctor-patient communication is an essential part of patients` medical behaviors. Poor doctor-patient communication might cause emotional distress and predict poor prognosis. In past studies, "satisfaction" was used as the central concept to define "doctor-patient communication," and it was assumed that the responsibility of doctor-patient communication quality mainly relied on the doctors. This study attempts to take the patient`s perspective. We proposed that communication with doctors could be a crucial resource for cancer patients, but it could also be detrimental if the communication were unsuccessful. Furthermore, this study aimed to explore whether doctor-patient communication could mediate patients` emotional distress after illness, subsequent coping, and quality of life(QoL).\nMethod: Breast cancer and head and neck cancer patients were recruited from a medical center in northern Taiwan. Participants received an emotional distress assessment one-day before surgery(t1). At six-months post-surgery follow-up(t2), they were asked to fill out the "Medical Interview Satisfaction Scale (MISS-21)," "Brief COPE," and the Taiwan Concise World Health Organization Quality of Life Questionnaire. The items of the MISS-21 was first translated into Traditional Chinese (Taiwan) and then restructured into subscales based on the stress model to reflect the patient`s perspective of doctor-patient communication. Three factors, including "positive communication between doctors and patients," and "rapport," and "negative communication between doctors and patients," were identified. Confirmatory factor analysis (CFA) was used to conclude whether this factor structure was suitable for cancer patients in Taiwan, and the reliability and validity were also tested. Path analysis was used to explore the mediating effect of the "perceived doctor-patient communication (positive, rapport, negative)" between "emotional distress(t1)", "coping (individual, social, avoidance)(t2)," and "the QoL (physical, psychological, social, environmental)(t2)," in both breast cancer and head and neck cancer patients.\nResults: A total of 217 patients were included in this study. In which, 123 were breast cancer patients (all women, average age 53.342 years old), and 94 were head and neck cancer patients (76 males and 18 females, average age 52.723 years). Results showed significant differences in all research variables except for "escape response" and "psychological quality of life" between the two cancer groups. As to the mediating effect of the "perceived doctor-patient communication," the "emotional distress" at t1 can predict the "negative communication(t2)," then the "avoidance coping," and the "avoidance coping" can negatively predict all four aspects of the QoL in breast cancer patients. Furthermore, "emotional distress (t1)" can also negatively predict all four aspects of the QoL. In head and neck cancer patients, "emotional distress" at t1 can negatively predict the "positive communication(t2)," which then can positively predict "individual coping(t2)," and which can predict the psychological, social, and environmental QoL(t2). The "positive communication(t2)" can positively predict all four aspects of the QoL, and the "negative communication(t2)" can negatively predict the psychological and environmental QoL(t2). In short, for breast cancer patients, the "negative communication" could be a partial mediator between pre-operational emotional distress and subsequent quality of life. For patients with head and neck cancer, "positive communication" could be a full mediator between pre-operational emotional distress and subsequent quality of life.\nDiscussion: The results of this study show that the modified Taiwan version of MISS-21 can be restructured into"positive communication between doctors and patients," and "rapport," and "negative communication between doctors and patients," and can serve as a\n"Cancer Patient Medical Communication Scale" with sound reliability and validity. In breast cancer patients, the preoperative emotional distress had significant impacts on subsequent adaptation, and "negative communication between doctors and patients" was an essential mediating factor. Therefore, psychological interventions aimed to diminish preoperative emotional distress and reduce negative communication could improve the succeeding quality of life. For patients with head and neck cancer, "positive communication" had a significant, full mediating effect, showing that positive communication was an indispensable medical resource. Therefore, the multi-disciplinary team needs to assist head and neck cancer patients to express their needs to medical staff to improve the subsequent quality of life.