醫(yī)患交流課件

1、醫(yī)患交流Why, What , Howwww中國特色的醫(yī)患關(guān)系令人堪憂矛盾升級(jí)暴力殘酷2001年7月13日湖南中醫(yī)學(xué)院附屬第一醫(yī)院王萬林醫(yī)生慘遭他曾醫(yī)治的病人殺害2003年8月24日武漢市同濟(jì)來福門診部2名醫(yī)務(wù)人員被刺死、4名被刺傷2004年2月11日四川大學(xué)華西醫(yī)院李寧醫(yī)生被砍傷，致粉碎性開放性顱骨骨折、失血性休克2005年8月12日福建中醫(yī)學(xué)院戴春福醫(yī)生在該院附屬“國醫(yī)堂”醫(yī)院出診時(shí)被患者用刀捅死 2010年6月12日和13日山東齊魯醫(yī)院患者家屬兩天在同一地點(diǎn)（辦公司）殺死一名醫(yī)生（6刀）和一名護(hù)士（20刀）醫(yī)患關(guān)系惡化到如此血腥的地步，在人類歷史上是罕見的!醫(yī)患關(guān)系的基本要素六個(gè) “ C

2、”選擇 ( choice) 稱職 ( competence)交流( communication)同情 ( compassion) 連貫性( continuity)利益不沖突( no conflict of interest) 醫(yī)生與患者：I-you, not I-It交流貫穿整個(gè)醫(yī)療過程Doctor-patient communication 從病史采集到完成治療醫(yī)生與患者建立關(guān)系 在有效的交流基礎(chǔ)之上Is there a problem? Evidence suggests that problems with physician-patient communication are comm

3、on:54% of problems & 45% of concerns neither elicited by the physician nor disclosed by the patient50% of psychosocial and psychiatric problems missed by physicians50% of visits ：the patient & physician no agreement on the nature of the main presenting problemBeckman研究：醫(yī)生打斷患者為18sKurt研究：醫(yī)生打斷患者為23s 8%

4、患者認(rèn)為已完成影響依從性(compliance)“Youre paid to do what I tell you!” Training in patient-physician communication is also now objectively evaluated as a core competency in various accreditation settingsComprehensive Osteopathic Medical Licensing ExaminationUSAPerformance EvaluationThe United States Medical Li

5、censing ExaminationThe American Board of Medical Specialties certification1995年，WHO提出“五星級(jí)醫(yī)生”“保健提供者、交際家、決策者、健康教育家、社區(qū)領(lǐng)導(dǎo)者、服務(wù)管理者”Can Communication Skills Be Taught?Physicians often assume that communication skills are something that one is born with A variety of intervention studies show that these skil

6、ls are indeed teachable.Kurtz提出：Two primary factors have been responsible for this major shift in attitude and practice兩個(gè)原因促使醫(yī)患交流的重視和訓(xùn)練研究的證據(jù)迅速增加（exponential growth）錄像技術(shù)有利研究和教學(xué) Aspergren回顧180篇醫(yī)患交流教育的文獻(xiàn)179篇文獻(xiàn)支持可以教育和學(xué)習(xí)學(xué)生和不同級(jí)別的醫(yī)生接受能力相似 專業(yè)醫(yī)師（specialist）也同樣受益 Aspergren (Association for Medical Education i

7、n Europe)Fallow field報(bào)道3天workshop訓(xùn)練用錄像觀察Physicians improvedExpressions of empathyAppropriate responses to patients cuesUsed fewer leading questions單純經(jīng)驗(yàn)對提高交流技能作用有限 Peter Maguire長期研究在醫(yī)生執(zhí)業(yè)過程交流技能的變化無再訓(xùn)練：許多有經(jīng)驗(yàn)醫(yī)生的交流停留在住院醫(yī)師的水平住院醫(yī)師訓(xùn)練時(shí)間短、有限認(rèn)為已經(jīng)達(dá)到很高的水平影響以后的交流技能的學(xué)習(xí)單純依靠經(jīng)驗(yàn)Experience alone is not a good teacher難以

8、準(zhǔn)確評估交流技能錄音和錄像技術(shù)顯示詢問醫(yī)生在20分鐘談話中患者教育所用的時(shí)間醫(yī)生認(rèn)為910min實(shí)際應(yīng)用不到2min談話時(shí)間的問題掌握技巧，所需時(shí)間更少 7.8min（Doctor-centered) 8.5min（Patient-centered) 11min（Learned skills）有效的談話 準(zhǔn)確 質(zhì)量 結(jié)果 不是用時(shí)間來衡量 Engaging in patient-centred care does take more time while mastering the skills. When learning to ski, It took me 45 min to get d

9、own a hill that I can now easily ski in 3 min.The hill has not changed. My skill level has.談話時(shí)間的問題45 min to go3 min to goMiller提出目標(biāo)： Improving communication in practice to a professional level of competence!?重要的是：Knowledge （Do you know it？）Competence（Can you do it？）Performance（Do you do it?）知識(shí)的本身不能直

10、接轉(zhuǎn)化為行為網(wǎng)球與游泳：雖然大量閱讀對提高技能有限明白道理能夠做到醫(yī)患交流的第一原則FIRST PRINCIPLES OF COMMUNICATIONThe shot-put approachThe Frisbee approach4060年代相互交流雙方均重要Common ground-mutually understoodKurtz ：Doctor-patient communication: principles and practices. Can. J. Neurol. Sci. 2002;29:suppl.2-S23-S29有效交流的五個(gè)原則（Effective communica

11、tion）Ensures interaction not just transmissionReduces unnecessary uncertaintyRequires planning, thinking in terms of outcomesDemonstrates dynamismFollows a helical rather than a linear model交流技能包括內(nèi)容交流技能（content skills）What doctors do?過程交流技能（process skills）How do you do?感知交流技能（perceptual skills）What

12、they are thinking & feeling? Stewart reviewed literature (1983-1998) analyzing patient outcomes relative to physician-patient communication (either randomized controlled trials or analytic studies.) In 22 articles, 16 indicated positive effects on patient health.Good physician-patient communication

13、improves patient healthEmotional healthSymptom resolutionFunctionPain controlPhysiologic measures, such as blood pressure, blood sugar levelBeck回顧了1975年2000年初診患者與醫(yī)生交流的文獻(xiàn)評價(jià)語言和非語言行為對治療結(jié)果影響14 studies of verbal communication8 studies of nonverbal communication“If Ive told you once I told you 1,000 times

14、, stop smoking!”Verbal Behaviors Having Significant Associations with Clinical Outcomes22種語言行為對臨床結(jié)果有正面的影響相互欣賞 intellectual appreciation表示同情 empathy 支持 reassurance or support鼓勵(lì)提問 encouragement of patients questions 患者的觀點(diǎn) patients point of view to guide the conversation 討論治療效果discussion of treatment e

15、ffects友好 friendliness；courtesy接受能力 receptivity to patient questions and statements總結(jié) summarization驗(yàn)證清晰 clarifying statements增加談話時(shí)間 increased encounter length微笑與幽默Laughing and joking14種語言行為對臨床結(jié)果有負(fù)面影響被動(dòng)接受 passive acceptance消極反應(yīng) negative social-emotional interactions,程序化行為 formal behavior對抗或排斥, antagon

16、ism and passive rejection專業(yè)問題比例高 high rates of biomedical questioning打斷談話 interruptions單向交流 one-way焦慮anxiety or tension查體表達(dá)意見expression of opinion during PE緊張 nervousnessVerbal Behaviors Having Significant Associations with Clinical OutcomesNonverbal Behaviors Showing Statistically SignificantAssoci

17、ations with Patient Outcomes16種非語言行為影響臨床結(jié)果正面對視 mutual gaze點(diǎn)頭 head nodding前傾 forward lean身體正面朝向 more direct body orientation,腿、臂不交叉 uncrossed legs and arms 手臂對稱 arm symmetryNonverbal Behaviors Showing Statistically SignificantAssociations with Patient Outcomes16種非語言行為影響臨床結(jié)果負(fù)面過多凝視 more patient gaze身體偏

18、離患者4590 body orientation側(cè)身 indirect body orientation后傾身體 backward lean上肢交叉 crossed arms軀干扭曲 task touch頻繁觸摸 frequent touch無關(guān)行為側(cè)傾 sideways leaning腿的位置 leg position上臂不對稱放置 arm position asymmetry醫(yī)生與患者的距離 physician-patient distance如果要提高技能，以下五個(gè)因素是必須的Systematic delineation and definition of skills to be le

19、arnedObservation of learners performing the skills (live or on videotape)Well-intentioned, detailed, descriptive feedback (preferably with videotape)Practice and rehearsal of skillsRepetition (i.e. a helical, reiterative model rather than a linear, once and done model)The AAPP suggests the mnemonic

20、PEARLS for this relationship-building aspect of the medical interview:Partnership: acknowledges that the physician and the patient are in this togetherEmpathy: expresses understanding to the patientApology: acknowledges that the physician is sorry the patient had to wait, that a laboratory test had

21、to be repeatedRespect: acknowledges the patients suffering, difficulties Legitimization: acknowledges that many patients are angry, frustrated, depressedSupport: acknowledges that the physician will not abandon the patient.以病人為中心的醫(yī)療模式（patient-centered）Treating patients as partnersInviting them in de

22、cision-makingEnlisting their sense of responsibilitiesRespecting their individual value and concerns AAOS communication skills mentors programs(4Es+2Fs)AAOS建議患者介紹完病情及來診原因平均需要2min 初診：How are you today?距離：0.61.2m著裝步速提問方式：Tell me all about it醫(yī)療糾紛與醫(yī)患溝通Malpractice & Communication醫(yī)患交流的必要性國內(nèi)醫(yī)療糾紛的現(xiàn)狀2006年上海市

23、衛(wèi)生局的調(diào)查醫(yī)療糾紛以11%的速度遞增全國家114家醫(yī)院近3 年平均每家醫(yī)院發(fā)生醫(yī)療糾紛66 起衛(wèi)生部2006 年對北京地區(qū)12 家三甲醫(yī)院50.6%醫(yī)務(wù)人員認(rèn)為醫(yī)患溝通不夠是產(chǎn)生醫(yī)療糾紛的原因48.8%患者認(rèn)為醫(yī)師沒有進(jìn)行足夠的醫(yī)患溝通醫(yī)療糾紛原因分析顯示80%以上的醫(yī)療糾紛是由于醫(yī)患溝通不當(dāng)所致15%技術(shù)有關(guān)3%真正的醫(yī)療事故115例醫(yī)療事故鑒定分析（唐婭娜，重慶醫(yī)學(xué)會(huì)醫(yī)療事故技術(shù)鑒定工作辦公室）高發(fā)學(xué)科：骨科婦產(chǎn)科普外科事故率：40.9%（47/155例）原因分析管理制度不健全，違反醫(yī)療常規(guī)醫(yī)療文件書寫不規(guī)范醫(yī)患溝通不夠知識(shí)老化，信息不暢患者的期望值過高醫(yī)生、保險(xiǎn)公司、醫(yī)院為避免起訴：提

24、供最高水平的醫(yī)療服務(wù)減少責(zé)任風(fēng)險(xiǎn)Enteman研究表明在有和無起訴醫(yī)生，無差異醫(yī)療質(zhì)量病歷文件記錄Localio (Harvard medical practice study,1994)1%醫(yī)療失誤造成損害不足2%會(huì)起訴治療效果與起訴的研究98000人/年unnecessary death (IOM: To err is human)并不是治療效果不好均會(huì)糾紛、訴訟并不是所有起訴者效果均不好表明：醫(yī)療質(zhì)量、醫(yī)療失誤、病歷文件不是起訴的關(guān)鍵因素 Hickson比較有與無糾紛醫(yī)生患者的調(diào)查有醫(yī)療糾紛醫(yī)生Feeling rushedFeeling ignoredReceiving inadequa

25、te explanationsSpending less time醫(yī)生（無醫(yī)療糾紛者）provided more information about the visitallowed patients to express all concerns and tell their storychecked their understanding of patients concernsasked patients what they thoughtexpressed warmth, friendliness, and humor.Levinson identified differences i

26、n communication between primary care physicians with and without malpractice claims.Beckman報(bào)道(lessons from plaintiff deposition)醫(yī)療糾紛：來自患者對預(yù)期結(jié)果以往差異良好的交流有利于醫(yī)生了解患者的期望值減少糾紛（liability exposure）67例起訴案例回顧性分析Patient mentioning poor communication as reason for claim71%Desertion32%Devaluing patients or family

27、 views29%Dysfunctional delivery of information26%A lack of understanding by the clinician 13%Contribution of communication breakdowns to malpractice risksThe decision to litigate is most often associated with perceived lack of caring and/or collaboration in health care deliveryBeckman報(bào)道：醫(yī)療糾紛的訴訟案件中原告

28、信息傳遞不足占26%傾聽占8%13%（poor listening）結(jié)論醫(yī)患交流不良是最主要的起訴因素治療效果不滿意是其次Sutddent報(bào)道：36.7%醫(yī)療糾紛無醫(yī)療過錯(cuò)27.4%（non-erroneons）賠償72.6%無過錯(cuò)最終無賠償Aoki（Japan）Medical accident investigating committee8名醫(yī)生+2名律師確認(rèn)：background, type of error, liability, preventability to events決定合理賠償Lawsuit：機(jī)構(gòu)內(nèi)無法解決Aoki（Japan）155例糾紛(Malpractice cla

29、im)醫(yī)院分布19.9%（100 beds）30.3%（100299 beds）27.7%（300 beds）賠償情況87.1%（135/155例）賠償58.1%1萬9.7%10萬平均3.89萬AokiAoki的155例糾紛中（impact of miscommunication)交流不良的比例64.4%交流不良（無醫(yī)療過錯(cuò)組）21.9%交流不良（有醫(yī)療過錯(cuò)組）多因素分析顯示：醫(yī)療過錯(cuò)和交流不良是兩個(gè)獨(dú)立的高危因素Travaline提出Assess What the Patient Already KnowsAssess What the Patient Wants to KnowBe Emp

30、athicSlow DownKeep it SimpleTell the TruthBe HopefulWatch the Patients Body and FaceBe Prepared for a ReactionHow to Communicate with PatientsReminders for the Busy Physician骨科醫(yī)生自我評價(jià)好Physicians perception: I believe patients views me as:Patients perceptionHighly trained70%64%Having successful result

31、s64%53%Being caring and compassionate71%37%Spending time with patients71%36%Providing valuable service65%35%Discrepancies between AAOS members self-assessment and patients perceptions of orthopaedic careThe American academy of orthopaedic surgeons commissioned a survey of consumers in 1998骨科醫(yī)生溝通能力不高

32、錄音帶證明Barrett DS. Are orthopaedic surgeons gorillas? Br Med J 1998;297:1638-9Greenhalgh P. Old bones. Br Med J 1999;318：1361學(xué)術(shù)會(huì)議證明Prof. J, Spencer, university of Newcastle骨科醫(yī)生溝通能力風(fēng)濕病22例，骨科疾病26例，骨折22例4名風(fēng)濕病醫(yī)生，5名骨科醫(yī)生時(shí)間：23min（風(fēng)濕）vs 10.3min（骨科）vs 4min（骨折）滿意度：17分（風(fēng)濕）vs 15分（骨科）vs 14分（骨折）J.ONeill，J.R.Willams

33、 Doctor-patients communication in a musculoskeletal unit: relationship between an observer-rated structured scoring system and patient opinion. Rheumatology 2003;42:1512-1522Adamson評價(jià)醫(yī)療糾紛量與患者評價(jià)醫(yī)生的交流技能的關(guān)系107名醫(yī)生，2030名患者，62項(xiàng)指標(biāo)Adamson研究患者評價(jià)醫(yī)生交流技能Communication A basic clinical skillA series of learned sk

34、ills A set of procedures for improving outcomes of careThere is no achievement ceiling you can never “arrive” ， and then just forget about maintaining mastered skills or learning even better ones.Learning, maintaining, and enhancing them is a life-long task.Suzanne M. Kurtz謝謝Formal training programs

35、 have been created to enhance and measure specific communication skills. Many of these efforts, however, focus on medical schools and early postgraduate years and, therefore, remain isolated in academic settings. Thus, the communication skills of the busy physician often remain poorly developed, and the need for established physicians to become better communi