Machen Hausärzte Unterschiede, wenn sie mit Kopfschmerzpatienten umgehen? Eine Querschnittsstudie mit ängstlich oder neutral gespielten standardisierten Patienten

Zusammenfassung

Einleitung: In der allgemeinmedizinischen Versorgung besteht eine große Behandlungsvariabilität, die komplex determiniert ist. Werden Hausärzte in ihrem Handeln davon beeinflusst, wie ein Patient seine Symptome präsentiert? Hat dies Auswirkungen etwa in Bezug auf mehr kostenintensive Diagnostik, eine größere Zahl von Handlungsschritten oder eine längere Konsultationsdauer? Ist der Einsatz standardisierter Patienten ein praktikables Forschungsinstrument?

Methoden: Standardisierte Patientinnen stellen sich in Hausarztpraxen vor mit Kopfschmerzen. Typ A: ängstlich-besorgt; Typ B: neutral akzeptierend.

Untersuchungseinheit: 53 männliche Hausärzte aus Düsseldorf und Umgebung. Jeder Hausarzt wird 2002 jeweils im Abstand von ca. 3 Wochen von einer Typ A- und einer Typ B-Patientin aufgesucht. Ausgewertet werden standardisierte Protokolle der Konsultation (n=92), verdeckte Tonträgeraufzeichnungen (Zustimmungsquote: 79%) (n=58) und anschließende halbstrukturierte Interviews mit jedem Hausarzt zur Frage der Entscheidungsfindung (n=47).

Ergebnisse: Die Methodenqualität ist hoch, die Aufdeckungsrate mit 2% sehr niedrig. Die Behandlervariabilität in 92 Konsultationen ist groß. Bei den ängstlich-besorgten Patientinnen kommt es in 39%, bei den neutral-akzeptierenden in 7% zu Schritten zu einer kostenintensiven Diagnostik. Die Anzahl von Handlungsschritten in der Konsultation (Anamnese, Untersuchungen) ist aber in beiden Gruppen gleich bei großer Variabilität. Die Konsultationsdauer ist in beiden Gruppen etwa gleich lang.

Schlussfolgerungen: Die emotionale Färbung der Symptompräsentation von Patientinnen mit Kopfschmerz hat deutliche wirtschaftliche und qualitative Auswirkungen. Dabei spielen komplex verwobene patientenseitige und arztseitige Faktoren eine Rolle.

Abstract

Background: There is broad variation in performance in general practice. Little is known about how affective components influence decisions of general practitioners (GPs).

Objective: To determine whether GPs’ performance is influenced in quantitative, qualitative or economic respects by anxiety shown by a patient presenting with headache.

Methods: Cross sectional study. Male GPs from 53 general practices in urban regions around Duesseldorf, Germany were consulted during normal surgery hours by two different types of female incognito standardised patients (SPs) complaining of identical severe headache with an interval of around three weeks between the visits. One type of SPs presented the symptom in an anxious, the other in a neutral way. SPs covertly audio-recorded the consultations (with doctors’ prior agreement) and completed a standardised checklist. After the second consultation GPs were interviewed about their impression of the patients.

Main outcome measures: Number of steps towards further investigations (referral rate, X-rays etc.); number of items explored in history taking and procedures performed during physical examinations during the consultations; duration of consultations.

Results:The quality of acting and documentation was high. Only 2% of the SPs were uncovered by the GPs. The interindividual variation in doctoring seen in 92 completely documented consultations was broad. Steps towards costly further investigations were taken in 39% of anxious patients, but only in 7% of neutral patients (n=92; Mc Nemar (binomial) probability value 0.00013). The number of items and procedures during the consultation (history taking, physical examination) was similar in both groups of patients with a broad variation. The average consultation length in both groups was about the same (9.8 min; range 1.5–26 min).

Conclusions: The affective components of female patients’ presentation of their headache to male general practitioners show clear quantitative, economic and qualitative effects.

Schlüsselwörter

Allgemeinmedizin - standardisierte Patienten - Arzt-Patient-Beziehung - Kopfschmerz

Key words

family practice - patient simulation - physician-patient relations - headache

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