消化内镜操作中存在诸多不确定性和风险，可能会对内镜医师的诊疗决策产生影响。结直肠息肉切除术是内镜操作中广泛使用的技术，对于结直肠癌的防治有重要意义。本研究旨在设计量表为评估消化内镜医师的不确定性容忍度和风险偏好提供新的临床工具，并探究医师风险偏好特征对切除≤19mm无蒂结直肠息肉的影响，为优化医师综合素质、提高医疗质量提供方向。
本研究分为以下两个部分：
第一部分 内镜医师风险偏好评估量表的设计及信效度分析                
目的
开发中文版内镜医师不确定性反应量表（PRU-E）并验证量表的信效度，以评估医师不确定性容忍度和风险偏好。
方法
本研究混合使用了多种定性和定量方法。2024年1月至3月，通过焦点小组访谈和德尔菲法完善PRU-E量表的题项。2024年4月至5月以线上问卷形式招募了来自国内204家三甲医院的360名消化内镜医师参与问卷调查，以评估PRU-E量表的信度和效度。采用离散趋势法、临界比值法和相关系数法进行条目筛选。效度分析包括内容效度和结构效度，结构效度使用探索性因子分析（EFA）和验证性因子分析（CFA），信度包括内部一致性信度和分半信度。
结果
最终的PRU-E量表包括16个条目并确定了四个主成分，即对不确定性和不良结果的担忧、向患者告知不确定性、向其他医生袒露自己的错误和对内镜场景中不确定性的担忧。量表的总体Cronbach's alpha系数为0.818，各主成分的Cronbach's alpha系数为0.801-0.932，内部一致性信度较好。量表的分半信度为0.919。EFA和CFA均表现出良好的结构效度。内容效度中I-CVI为0.86-1.00，S-CVI为0.96。
结论
本研究开发的PRU-E量表是一个可靠且有效的工具，可以用于评估消化内镜医师在内镜场景下的不确定性容忍度和风险偏好。
第二部分 内镜医师风险偏好对结直肠息肉切除方式的影响
目的 
本研究旨在通过PRU-E量表评估内镜医师不确定性容忍度及风险偏好，分析其与结直肠息肉切除方式选择的关系，以探究医师的风险偏好特征如何影响他们的临床决策。
方法
本研究为单中心回顾性研究，纳入2022年1月1日至2023年12月31日北京协和医院30名内镜医师完成的12,290例≤19 mm无蒂结直肠息肉切除术，切除方式包括冷活检钳息肉切除术（CFP）、冷圈套器息肉切除术（CSP）和内镜黏膜切除术（EMR）。息肉按长径分为1~5 mm、>5~10 mm和>10~19 mm三组。通过PRU-E量表评估医师对不确定性的反应及风险偏好，分析医师风险偏好特征与切除方式选择、是否使用止血夹等临床决策及切除单个息肉增加的治疗费用的相关性。
结果
PRU-E量表得分较高（≥50分）的内镜医师在1~5 mm息肉中更倾向选择CFP（中位使用率89.4 vs 87.4%，P=0.013），在>5~10 mm息肉中CSP中位使用率更低（38.4 vs 58.4%，P=0.003），而EMR使用率更高（中位使用率57.1 vs 21.8%，P=0.006）；在>10~19 mm组切除方式以EMR为主，与PRU-E得分无明显相关性。PRU-E得分较高（≥50分）的医师在1~5 mm组（中位数422.1 vs 390.3元，P=0.009）和>5~10 mm组（中位数1962.7 vs 1544.2元，P=0.013）中切除单个息肉增加的费用更高。亚组分析显示，>5~10 mm组中PRU-E高分医师CSP中止血夹使用率更高（66.7% vs 29.4%，P=0.004）。
结论
内镜医师的不确定性容忍度和风险偏好特征能影响其结直肠息肉切除方式的选择及费用。不确定性容忍程度低即风险回避的医师切除单个息肉的平均费用更高，且更多使用金属夹预防迟发出血，这可能与医师对技术安全性、操作复杂性和并发症的担忧有关。

Digestive endoscopy is a vital medical procedure used for both diagnosing and treating various gastrointestinal conditions. The operation of digestive endoscopy involves numerous uncertainties and risks that can influence the diagnostic and therapeutic decisions of endoscopists. Recognizing these challenges, the study presents a novel clinical tool designed to assess endoscopists' tolerance for uncertainty and their risk preferences. The study also seeks to establish a correlation between the endoscopists' risk preferences and their decision-making processes surrounding polyp removal.  

Part 1  Development and Validation of a Physicians' Reactions to Uncertainty Scale for Endoscopy (PRU-E)
Objective: Uncertainty in medical practice significantly impacts physicians' decision-making and patient outcomes, particularly in specialized fields like gastroenterology endoscopy. This study aimed to develop and validate a Chinese version of the Physicians’ Reactions to Uncertainty Scale for Endoscopy (PRU-E).
Methods: A mixed-methods approach was employed. We translated the original PRU scale and used qualitative interviews and Delphi methods to refine the PRU-E. From January to March 2024, and online recruited a total of 360 digestive endoscopists from 204 hospitals across China to assess reliability and validity from April to May 2024. The validity analysis contains content validity and construct validity, including the exploratory factor analysis (EFA) and the confirmatory factor analysis (CFA), while the reliability analysis includes internal consistency and split-half reliability. 
Results: The final PRU-E includes 16 items and identified four key dimensions, namely concerns about uncertainty and bad outcomes, disclosing uncertainty to patients, disclosing mistakes to physicians, and concerns about uncertainty in endoscopic scenarios. Internal consistency reliability is good since the Cronbach’s alpha coefficient for the overall scale was 0.818, while the coefficients for the individual dimensions were 0.801-0.932. The scale demonstrated a split-half reliability of 0.919, with all four dimensions surpassing the reliability threshold of 0.7. Both EFA and CFA showed good construct validity. For the content validity, the I-CVI scores varied from 0.86 to 1.00, while the S-CVI was determined to be 0.96, indicating a strong degree of content validity.
Conclusion: This newly developed PRU-E scale for gastroenterology endoscopy is a reliable and valid tool for measuring physicians’ responses to uncertainty in this clinical domain.  

Part 2  Effect of Endoscopists' Risk Preferences on Colorectal Polypectomy
Objective: This study aimed to assess endoscopists' tolerance of uncertainty and risk preferences using the PRU-E scale and analyze their relationship with the choice of resection methods and costs for colorectal polyps.
Methods: This single-center retrospective study included 12,290 cases of non-pedunculated colorectal polyps (≤ 19mm) resected by 30 endoscopists at Peking Union Medical College Hospital between January 2022 and December 2023. Resection methods included cold forceps polypectomy (CFP), cold snare polypectomy (CSP), and endoscopic mucosal resection (EMR). Polyps were categorized by size into three groups: 1~5 mm, > 5~10 mm, and >10~19 mm. 
Results: Endoscopists with higher PRU-E scores (≥ 50) were more likely to choose CFP for 1~5 mm polyps (median usage rate: 89.4% vs. 87.4%, P=0.013), less likely to use CSP for >5~10 mm polyps (median usage rate: 38.4% vs. 58.4%, P=0.003), and more likely to use EMR (median usage rate: 57.1% vs. 21.8%, P=0.006). Physicians with higher PRU-E scores (≥50) were related to higher incremental costs per polyp in the 1~5 mm group (median: ¥422.1 vs. ¥390.3, P=0.009) and in the >5~10 mm group (median: ¥1962.7 vs. ¥1544.2, P=0.013). Subgroup analysis revealed that in the >5~10 mm group, endoscopists with higher PRU-E scores used hemostatic clips more frequently during CSP (median usage rate: 66.7% vs. 29.4%, P=0.004). 
Conclusion: Endoscopists' uncertainty tolerance and risk preferences could significantly influence their choice of resection methods and costs for colorectal polyps. Physicians with lower uncertainty tolerance tend to create greater average costs per polyp and utilize prophylactic clips more frequently to prevent delayed bleeding.