【目的】

随着医学技术的进步和人类对健康要求的不断提高，人们健康管理的主动意识也不断增强，患者参与治疗决策不仅是患者的基本权利，更是改善医疗服务质量，提高患者满意度的重要途径，是以患者为中心的体现，是促进医疗机构高质量发展的必要条件。作为医疗决策的参与主体，医生在医学知识和技能方面相较于患者拥有绝对优势，所以医生在患者参与治疗决策过程中发挥着重要的引导和促进作用。

本研究的目的是了解我国136家三级公立医院的医生对患者参与治疗决策的认知、实践及影响因素，为提高患者治疗参与度提供科学依据和政策建议。

【方法】

2021年1月-3月，选取全国31个省（自治区、直辖市）及新疆生产建设兵团共136家三级公立医院（93家地方医院和43家委属委管医院）一线临床医生为调查对象。按照初级、中级和高级职称比例进行分层抽样，最终确定每家样本医院至少150名医生参与线上问卷调查。调查问卷一般资料包括医生年龄、性别、婚姻状况、地区、学历、职称、工作年限、聘用形式、所在医院和科室等信息，医生执业环境/执业状况资料包括医患关系、门诊沟通时间、工作负荷、薪酬情况、职业认同、工作满意度等维度。测量医生对患者参与治疗决策的认知和实践情况包括3个条目：“让患者参与治疗决策的必要性”条目用来评估医生对患者参与治疗决策必要性的认知情况，从“非常没必要”“没必要”“一般”“有必要”“非常有必要”5个选项进行评估，将回答“有必要”和“非常有必要”定义为“认同有必要让患者参与治疗决策”；“会鼓励患者说出对于治疗方案的意见”条目用来评估医生鼓励患者参与治疗情况，从“非常不鼓励”“不鼓励”“一般”“鼓励”“非常鼓励”5个选项进行评估，将回答“鼓励”和“非常鼓励”定义为“医生鼓励患者说出对于治疗方案的意见”；“当出现A、B两种治疗方案时，患者充分了解后倾向于A方案，医生倾向于B方案，最终医生采取A方案的可能性”条目来反映医生面对不同治疗方案时选择尊重患者意愿的倾向，以百分值进行评估，将“>50%”定义为“倾向于尊重患者意愿”。

将原始数据录入Excel表格，采用SPSS 22.0软件对数据进行统计分析。采用频数和率对数据进行描述性分析，医生对患者参与治疗决策认知和实践的单因素分析采用卡方检验，P值<0.05视为差异显著，多因素分析采用二分类多因素logistic回归。

【结果】

136家样本医院中，有效参与调查的22836名医生认同患者有必要参与治疗决策的比例为80.6%，鼓励患者说出对于治疗方案意见的比例为80.4%，面对不同治疗方案倾向于尊重患者意愿的比例为52.7%。

影响医生认同患者有必要参与治疗决策的因素有性别、年龄、医院类型、地区、是否承担教学任务、是否承担科研任务、科室、感知沟通时间、感知医患关系、感知工作负荷和工作满意度（P<0.05）。

影响医生鼓励患者说出对于治疗方案意见的因素有性别、年龄、医院类型、是否承担教学任务、是否承担科研任务、科室、感知沟通时间、实际单次门诊沟通时间、感知医患关系、感知工作负荷和工作满意度（P<0.05）。

影响医生尊重患者治疗意愿的因素有性别、年龄、医院类型、学历、科室、感知沟通时间、感知医患关系、平均每周工作时间和工作满意度（P<0.05）。

【结论】

多数医生对患者参与治疗决策持认可和鼓励态度，但在实际诊疗过程中有待进一步落实。性别、年龄、医院类型、科室、感知沟通时间、感知医患关系和工作满意度可能是医生促进患者参与治疗决策认知和实践的影响因素。

Objective: With the improvement of medical technology and the continuous improvement of human health requirements, people's awareness of active health management has also been continuously enhanced. Patient participation in treatment decision-making is not only a basic right of patients, but also an important way to improve the quality of medical services and improve patient satisfaction which is a necessary condition to promote the high-quality development of medical institutions as the embodiment of the patient-centered. As the important element of medical decision-making, doctors have absolute advantages over patients in terms of medical knowledge and skills, so doctors play an important role in guiding and promoting patients' participation in treatment decision-making.

The research aims to understand the perception, practice and influencing factors of patients' participation in treatment decision-making among doctors in 136 tertiary public hospitals in China, and to provide scientific basis and policy recommendations for improving patient participation.

Method: From January to March 2021, clinical doctors in 136 tertiary public hospitals (93 local hospitals and 43 affiliated and commissioned hospitals) in 31 provinces (autonomous regions and municipalities) and Xinjiang Production and Construction Corps were selected as the survey subjects. Stratified sampling was carried out according to the proportion of junior, intermediate and senior professional titles and at least 150 doctors in each sample hospital were finally determined to participate in the online questionnaire survey. The general information of the questionnaire includes the doctor's age, gender, marital status, region, education background, professional title, working years, employment form, hospital type, department and other information. The doctor's occupational environment and status includes dimensions such as doctor-patient relationship, outpatient communication time, workload, salary, occupational identity, job satisfaction, etc. The measurement of doctors' perception and practice of patients' participation in treatment decision-making includes 3 items. The item "Necessity of involving patients in treatment decision-making" was used to evaluate physicians' perception of the necessity of patients' participation in treatment decision-making, ranging from "very unnecessary", "unnecessary", "generally", "necessary" and "very necessary". The answers "necessary" and "very necessary" were defined as "agree that it is necessary to involve patients in treatment decision-making"; The item "Encourage patients to express their opinions on the treatment plan" was used to evaluate the practice of doctors to promote patients' participation in treatment, ranging from "very discouraged", "discouraged", "generally", "encouraged", and "very encouraged". The answers "encouraged" and "very encouraged" were defined as "the doctor encourages patients to express their opinions on the treatment plan"; The item "when there are two treatment plans A and B, the patient prefers plan A after full understanding, and the doctor prefers plan B, the possibility for the doctor of adopting plan A" was used to reflect the doctor’s tendency to respect the patient’s wishes when faced with different treatment plans, ranging from 0 to 100. The answer">50%" was defined as "tend to respect the patient’s wishes".

The original data were entered into the Excel and SPSS 22.0 software was used for statistical analysis of the data. The data were descriptively analyzed by frequency and rate. The univariate analysis of doctors' perception and practice of patients' participation in treatment decision-making was performed by Chi-square test. P<0.05 was considered statistically significant. The multivariate analysis was performed by binary multivariate logistic regression.

【Results】

Among the 136 sample hospitals, 80.6% of the 22,836 doctors who effectively participated in the survey agreed that it was necessary for patients to participate in treatment decision-making, while 80.4% encouraged patients to express their opinions on the treatment plan. When faced with different treatment plans, 52.7% of doctors tended to respect the patient's wishes.

Factors that influence doctors' perception of the necessity for patients to participate in treatment decisions include gender, age, hospital type, region, whether to undertake teaching tasks, whether to undertake scientific research tasks, departments, perceived communication time, perceived doctor-patient relationship, perceived workload and job satisfaction (P<0.05).

Factors that influence doctors to encourage patients to express their opinions on treatment plans include gender, age, hospital type, whether to undertake teaching tasks， whether to undertake scientific research tasks, departments, perceived communication time, average single outpatient communication time, perceived doctor-patient relationship, perceived work load and job satisfaction (P<0.05).

Factors that influence doctors' tendency to respect patients' wishes to treat included gender, age, hospital type, education, department, perceived communication time, perceived doctor-patient relationship, average weekly working time and job satisfaction (P<0.05).

Conclusion: Most doctors agree and encourage patients to participate in treatment decision-making, but more practice needs to be implemented during the treatment process. The common factors that influence doctors' perception and practice of patient participation in treatment decision-making include gender, age, hospital type, department, perceived communication time, perceived doctor-patient relationship and job satisfaction.