教育與臨床實務對醫師與醫學生使用止痛藥治療癌症疼痛的知識與態度之影響

The Effect of Education and Clinical Practice on Knowledge Enlightenment to and Attitudes toward the Use of Analgesics for Cancer Pain Among Physicians and Medical Students

背景：醫師的癌症疼痛教育不足與臨床經驗不夠是台灣癌症疼痛治療不足的重要原因。本研究調查某教學醫院的醫師與在該院見習的五年級醫學生，以瞭解醫學教育與臨床經驗對醫師與醫學生在癌症疼痛處理的知識態度之影響。方法：以問卷調查某教學醫院的醫師97名與在該醫院見習的五年級醫學生78名，以瞭解與比較〝疼痛知識豐富的醫師〞、〝其他醫師〞、〝五年級見習醫學生〞處理癌症疼痛時，合理使用止痛藥的態度與其開嗎啡類止痛藥處方的知識與態度。此外，並給予五年級見習醫學生4個小時的疼痛處理基本原則與臨床藥理課程，以評量醫學生教育的效果。結果：不論疼痛知識豐富的醫師、其他醫師與五年級見習醫學生在合理使用止痛藥方面的態度是相似且負向的(24-92％，33-89％，23-94％)。在開嗎啡類止痛藥處方的知識方面，其他醫師（2.61分）與五年級見習醫學生（2.54分）皆較疼痛知識豐富的醫師（3.60分）具顯著低的平均分數。在開嗎啡類止痛藥處方的態度方面，所有的醫師（疼痛知識豐富的醫師3.52分，其他醫師2.91分）皆比五年級見習醫學生（2.68分）具顯著高的平均分數。然而，臨床經驗中的年資深淺並不影響醫師們對癌症疼痛處理的知識與態度。此外，五年級見習醫學生經4小時的癌症疼痛教育後，他們對癌症疼痛處理的知識與態度上改進很多，甚至超越疼痛知識豐富的醫師，當然這仍需較長期的觀察才知其長期成效。結論：任由醫師完全靠臨床經驗的累積來改進疼痛處理的知識與態度，其效果有限，但麻醉科、血液腫瘤科或放射腫瘤科的醫師例外。本研究建議：癌症疼痛處理的知識與態度應積極地經由醫學生教育與在職教育兩者來加強，以期改善台灣今天癌症疼痛處理嚴重不足的現象。

Background: Insufficient education and limited clinical practice on the part of physicians may contribute to the undertreatment of cancer pain in Taiwan. To address these concerns, a survey among physicians and fifth-year medical students relevant to cancer pain management (CPM) was carried out in a medical school and its principal teaching hospital. Methods: A questionnaire on CPM was sent to 97 physicians and 78 fifth-year medical students (equivalent to the third-year medical students in the United States). The same questionnaire was delivered again to these 78 fifth-year medical students after they had completed a modified curriculum of anesthesiology with a 4-hour course on introduction to clinical pharmacology of CPM. Results: The physicians knowledgeable on pain (physicians of anesthesiology, hematology-oncology, or radiation oncology), physicians unfamiliar with pain (outside of anesthesiology, hematology-oncology, or radiation oncology), and the 5th-yr medical students took similar negative attitudes (24-92%, 33-89%, and 23-94%) toward the optimal use of analgesics for CPM. As compared, the mean score on knowledge of prescribing opioids of pain- knowledgeable physicians was 3.60, the highest of all as against 2.61 of other physicians and 2.54 of 5th-yr medical students. On attitudes toward prescribing opioids, both pain-knowledgeable physicians and other physicians scored a higher means, respectively of 3.52 and 2.91 as opposed to 2.68 of 5th-yr medical students, the lowest of all. However, seniority or length of clinical practice did not improve knowledge or affect attitudes toward CPM. In addition, this 4-hour course did enable the 5th-yr medical students to take a more positive attitude toward and become more knowledgeable on CPM than pain-knowledgeable physicians, as a comparison was made. Conclusions: The effect of accumulation of clinical experience and seniority of clinical practice on CPM was limited among general physicians, except for clinical specialty on anesthesiology, hematology-oncology, or radiation oncology. In Taiwan, the knowledge of and positive attitude toward CPM could only be conveyed to physicians through undergraduate, post graduate or on-job education.