医患交流课件

1、医患交流Why, What , Howwww中国特色的医患关系令人堪忧矛盾升级暴力残酷2001年7月13日湖南中医学院附属第一医院王万林医生惨遭他曾医治的病人杀害2003年8月24日武汉市同济来福门诊部2名医务人员被刺死、4名被刺伤2004年2月11日四川大学华西医院李宁医生被砍伤，致粉碎性开放性颅骨骨折、失血性休克2005年8月12日福建中医学院戴春福医生在该院附属“国医堂”医院出诊时被患者用刀捅死 2010年6月12日和13日山东齐鲁医院患者家属两天在同一地点（办公司）杀死一名医生（6刀）和一名护士（20刀）医患关系恶化到如此血腥的地步，在人类历史上是罕见的!医患关系的基本要素六个 “ C

2、”选择 ( choice) 称职 ( competence)交流( communication)同情 ( compassion) 连贯性( continuity)利益不冲突( no conflict of interest) 医生与患者：I-you, not I-It交流贯穿整个医疗过程Doctor-patient communication 从病史采集到完成治疗医生与患者建立关系 在有效的交流基础之上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：医生打断患者为18sKurt研究：医生打断患者为23s 8%

4、患者认为已完成影响依从性(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“五星级医生”“保健提供者、交际家、决策者、健康教育家、社区领导者、服务管理者”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两个原因促使医患交流的重视和训练研究的证据迅速增加（exponential growth）录像技术有利研究和教学 Aspergren回顾180篇医患交流教育的文献179篇文献支持可以教育和学习学生和不同级别的医生接受能力相似 专业医师（specialist）也同样受益 Aspergren (Association for Medical Education i

7、n Europe)Fallow field报道3天workshop训练用录像观察Physicians improvedExpressions of empathyAppropriate responses to patients cuesUsed fewer leading questions单纯经验对提高交流技能作用有限 Peter Maguire长期研究在医生执业过程交流技能的变化无再训练：许多有经验医生的交流停留在住院医师的水平住院医师训练时间短、有限认为已经达到很高的水平影响以后的交流技能的学习单纯依靠经验Experience alone is not a good teacher难以

8、准确评估交流技能录音和录像技术显示询问医生在20分钟谈话中患者教育所用的时间医生认为910min实际应用不到2min谈话时间的问题掌握技巧，所需时间更少 7.8min（Doctor-centered) 8.5min（Patient-centered) 11min（Learned skills）有效的谈话 准确 质量 结果 不是用时间来衡量 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.谈话时间的问题45 min to go3 min to goMiller提出目标： 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?）知识的本身不能直

10、接转化为行为网球与游泳：虽然大量阅读对提高技能有限明白道理能够做到医患交流的第一原则FIRST PRINCIPLES OF COMMUNICATIONThe shot-put approachThe Frisbee approach4060年代相互交流双方均重要Common ground-mutually understoodKurtz ：Doctor-patient communication: principles and practices. Can. J. Neurol. Sci. 2002;29:suppl.2-S23-S29有效交流的五个原则（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交流技能包括内容交流技能（content skills）What doctors do?过程交流技能（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回顾了1975年2000年初诊患者与医生交流的文献评价语言和非语言行为对治疗结果影响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种语言行为对临床结果有正面的影响相互欣赏 intellectual appreciation表示同情 empathy 支持 reassurance or support鼓励提问 encouragement of patients questions 患者的观点 patients point of view to guide the conversation 讨论治疗效果discussion of treatment e

15、ffects友好 friendliness；courtesy接受能力 receptivity to patient questions and statements总结 summarization验证清晰 clarifying statements增加谈话时间 increased encounter length微笑与幽默Laughing and joking14种语言行为对临床结果有负面影响被动接受 passive acceptance消极反应 negative social-emotional interactions,程序化行为 formal behavior对抗或排斥, antagon

16、ism and passive rejection专业问题比例高 high rates of biomedical questioning打断谈话 interruptions单向交流 one-way焦虑anxiety or tension查体表达意见expression of opinion during PE紧张 nervousnessVerbal Behaviors Having Significant Associations with Clinical OutcomesNonverbal Behaviors Showing Statistically SignificantAssoci

17、ations with Patient Outcomes16种非语言行为影响临床结果正面对视 mutual gaze点头 head nodding前倾 forward lean身体正面朝向 more direct body orientation,腿、臂不交叉 uncrossed legs and arms 手臂对称 arm symmetryNonverbal Behaviors Showing Statistically SignificantAssociations with Patient Outcomes16种非语言行为影响临床结果负面过多凝视 more patient gaze身体偏

18、离患者4590 body orientation侧身 indirect body orientation后倾身体 backward lean上肢交叉 crossed arms躯干扭曲 task touch频繁触摸 frequent touch无关行为侧倾 sideways leaning腿的位置 leg position上臂不对称放置 arm position asymmetry医生与患者的距离 physician-patient distance如果要提高技能，以下五个因素是必须的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.以病人为中心的医疗模式（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建议患者介绍完病情及来诊原因平均需要2min 初诊：How are you today?距离：0.61.2m着装步速提问方式：Tell me all about it医疗纠纷与医患沟通Malpractice & Communication医患交流的必要性国内医疗纠纷的现状2006年上海市

23、卫生局的调查医疗纠纷以11%的速度递增全国家114家医院近3 年平均每家医院发生医疗纠纷66 起卫生部2006 年对北京地区12 家三甲医院50.6%医务人员认为医患沟通不够是产生医疗纠纷的原因48.8%患者认为医师没有进行足够的医患沟通医疗纠纷原因分析显示80%以上的医疗纠纷是由于医患沟通不当所致15%技术有关3%真正的医疗事故115例医疗事故鉴定分析（唐娅娜，重庆医学会医疗事故技术鉴定工作办公室）高发学科：骨科妇产科普外科事故率：40.9%（47/155例）原因分析管理制度不健全，违反医疗常规医疗文件书写不规范医患沟通不够知识老化，信息不畅患者的期望值过高医生、保险公司、医院为避免起诉：提

24、供最高水平的医疗服务减少责任风险Enteman研究表明在有和无起诉医生，无差异医疗质量病历文件记录Localio (Harvard medical practice study,1994)1%医疗失误造成损害不足2%会起诉治疗效果与起诉的研究98000人/年unnecessary death (IOM: To err is human)并不是治疗效果不好均会纠纷、诉讼并不是所有起诉者效果均不好表明：医疗质量、医疗失误、病历文件不是起诉的关键因素 Hickson比较有与无纠纷医生患者的调查有医疗纠纷医生Feeling rushedFeeling ignoredReceiving inadequa

25、te explanationsSpending less time医生（无医疗纠纷者）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报道(lessons from plaintiff deposition)医疗纠纷：来自患者对预期结果以往差异良好的交流有利于医生了解患者的期望值减少纠纷（liability exposure）67例起诉案例回顾性分析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报道：医疗纠纷的诉讼案件中原告

28、信息传递不足占26%倾听占8%13%（poor listening）结论医患交流不良是最主要的起诉因素治疗效果不满意是其次Sutddent报道：36.7%医疗纠纷无医疗过错27.4%（non-erroneons）赔偿72.6%无过错最终无赔偿Aoki（Japan）Medical accident investigating committee8名医生+2名律师确认：background, type of error, liability, preventability to events决定合理赔偿Lawsuit：机构内无法解决Aoki（Japan）155例纠纷(Malpractice cla

29、im)医院分布19.9%（100 beds）30.3%（100299 beds）27.7%（300 beds）赔偿情况87.1%（135/155例）赔偿58.1%1万9.7%10万平均3.89万AokiAoki的155例纠纷中（impact of miscommunication)交流不良的比例64.4%交流不良（无医疗过错组）21.9%交流不良（有医疗过错组）多因素分析显示：医疗过错和交流不良是两个独立的高危因素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骨科医生自我评价好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骨科医生沟通能力不高

32、录音带证明Barrett DS. Are orthopaedic surgeons gorillas? Br Med J 1998;297:1638-9Greenhalgh P. Old bones. Br Med J 1999;318：1361学术会议证明Prof. J, Spencer, university of Newcastle骨科医生沟通能力风湿病22例，骨科疾病26例，骨折22例4名风湿病医生，5名骨科医生时间：23min（风湿）vs 10.3min（骨科）vs 4min（骨折）满意度：17分（风湿）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评价医疗纠纷量与患者评价医生的交流技能的关系107名医生，2030名患者，62项指标Adamson研究患者评价医生交流技能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谢谢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