大三上课件-心理9relationship

Thepatient/practitionerrelationshipRanran

Song

(

)

Ph.DraDepartment

of

Child

&

woman

healthSchool

of

Public

Health,

Tongji

Medical

UniversityPractitionerPatient2Factors

influencepatient/practitioner

relationship1.

The

patient/practitioner

relationshipdepends

on

the

ability

of

the

twoparticipants

to

communicate

with

eachother.–

MedicaljargonMedical

terms’

meanings→Antibiotic→Breech→Enamel→Glucose→Mucus→Protein→Suture→umbilicusTherump

orbackpartThenavelSubstancethatmakes

upplant

and

animaltissueSugarSecretion

of

body

tissuesJoining

separated

tissueorboneAgenttotreatbacteriaA

hard

glossy

coating3456http:

/s?

biz=MzA3Nzc4MjAzOA==&mid=200596235&idx=1&sn=e5a266d70a782c37f961cd40b8bff852&scene=2&from=timeline&isappinstalled=0#rd7Factorsinfluencepatient/practitioner

relationship

This

relationship

dependsto

some

extentonthe

compatibility

between

what

thepatientwants

and

whatthepractitionerprovides.When

people

visit

physicians

about

health

problemsDo

they

just

want

to

be

cured?Do

they

also

want

to

know

about

the

illnesses

andhow

to

treat

them?How

involved

do

they

want

to

be

in

decisions

andactivities

in

their

treatment?8Factorsinfluencepatient/practitioner

relationshipPatient/practitioner

preferences

forparticipation

in

medical

carePatients

differ

in

the

participation

they

want

inthemedical

care.(Elderly/younger;

amountandtype)Practitioners

differ

in

the

participation

they

areinclined

toprovide.Conclusions

from

a large-scalesurveyAlthough

both

the

patients

and

the

physiciansexpressed

theattitude

that

clients

should

participate

inactivities

and

decisions

pertaining

to

their

health,

neitherthe

patients

nor

the

physicians

behaved

in

this

way

varyoften.When

the wants

a

high

level

of

participationbut

the

practitioner

wants

to

take

total

responsibility,can

be

expected.When

a

patient

wants

the

doctor

to

take

charge

but

thephysician

wants

the to

participate,

both

may

feelfortable.9Conclusion:

a

mismatch

between

thepatient’s

and

practitioner’s

ideasabout

participation

can

impair

theirrelationship.10The

practitioner

behavior

and

styleThe

practitioner’s

interview

styleDoctor-centered

modelRequired

only

brief

answersFocused

mainly

on

the problem

the

mentioned.Ignore

the

attempts

by

a

patient

to

discuss

other

problemshe

or

she

might

have

had.Ask

close-ended

questionPatient-centered

model:Take

less

controlling

rolesAsk

open-ended

questions.Allow

client

to

participate

in

some

of

the

decision

making11A

good

doctorThe

practitioner

whom

patients

preferto

have

and

foremost,people

prefertohaveapractitionerthey

thinkis

competent.Patientstendto

prefera

physician

whogives

clear

explanations

about

illnessesand

treatments,

encourages

them

to

askquestions,and

conveys

a

feeling

ofconcern

for

them.Patientopinion1213The

patient’s

behavior

and

stylePatient’s

behaviorthat

troublepractitionersExpressing

criticism

or

anger

toward the

physicianIgnoring

or

not

listening

what

the

doctor

is

trying

to

sayInsisting

on

laboratory

tests,

and

medications

the

physicianthinks

are

unnecessaryRequesting

that

the

doctor

certify

somethingThe

way

thatpatients

describetheirsymptomsDifferent

patient

describe

the

same

symptoms

differentlyUsing

the

word

the

practitioner

can

not

understandMode

ofpatient/practitionerrelationship萨斯(T.

Sxas)和

(M.

de)1956年提出：–active-passive

mode（主动—型模式）–guidance-cooperation

mode（指导—合作型模式）–mutual

participation

mode（共同参与型模式）14医患关系模式模式指导—合作型共同参与型医生的地位主动—

型

为做什么做什么帮助自疗的地位接受合作（>进入伙伴关系临床模式应用麻醉、危险性或急性慢性疾病疗法生活原型父母与婴儿父母与青少年成人之间discussionTo

my

opinion,thepatient/practitioner

relationship

is16100年前的医患关系17更：“好的医生应该具有三个“H”：Head是知识，Hand是技能，Heart就是良心。”1881年，26岁的更被英国圣公会派往中国时，刚结束二十年，医疗传教的随战后条约进入中国，国人在心理上本能抗拒，加上此时杭州还是一个

“城门上悬挂着人头”的中世纪城市。人们对外科手术，构造都不熟悉，民间对 医院有种种传言“医师以媚药亵妇女，医院被怀疑挖眼剖心用以做药”，西医解剖尸体或制作标本，被认为，信徒临终圣事，被认为教士挖死人眼睛“以为炼银之药”。阅读：---100年前的医患关系/article/652131819The

current

situation20•/i=mobile_

&utm_8/?tt_fromn=client_share&app=news_article&utm_source=mobile_

&iid=3078860531&utm_medium=toutiao_android24什么造成了紧张的医患关系？医疗机构和医务服务态度、医德医风医疗行业风险性高，医疗事故和医疗差错医患沟通不够，信任度下降患者方面需要没有得到满足医疗费用大幅度上涨，求医——就医心理反应、个性特征25什么造成了紧张的医患关系？（续）医疗保障体系三纵，即城镇职工医保、城镇居民医保和新农合，分别覆盖不同群体，是国家组织实施的社会保险制度。三横，即主体层、保底层和补充层。三项基本医疗保险制度构成了主体层，充分体现原则；城乡医疗救助和社会慈善捐助等制度构成保底层，对群众参保和减轻个人负担给予帮助；对于群众更高的、多样化的医疗需求，通过补充医疗保险和商业健康保

险来满足。社会–

部分

的片面……近年来我国卫生 与发展情况我国基本医疗保障体系由城镇职工基本医疗保险、城镇居民基本医疗保险、新型农村合作医疗和城乡医疗救助共同组成，分别覆盖城镇就业人口、城镇非就业人口、农村人口和城乡人群。城镇居民基本医疗保险制度试点和城镇职工基本医疗保险制度覆盖面逐步扩大。2007年，城镇居民基本医疗保险试点城市79个，参保人数达4291万人，2008年试点城市新增229个，参保人数也大大增加。2011年，基本医保已覆盖95%的人口，构建起世界上最大的基本医保网，保障水平也在逐步提高。26基本医疗保障制度覆盖城乡居民。截至2011年，城镇职工基本医疗保险、城镇居民基本医疗保险、新型农村合作医疗参保人数超过13亿，覆盖面从2008年的87％提高到2011年的95％以上，中国已构建起世界上规模最大的基本医疗保障网。筹资水平和报销比例不断提高，新型农村合作医疗 标准从最初的人均20元 ，提高到2011年的200元

，受益人次数从2008年的5.85亿人次提高到2011年的13.15亿人次，政策范围内住院费用报销比例提高到70％左右，保障范围由住院延伸到门诊。《中国的医疗卫生事业》白皮书201227How

to

do？“Patient-center

”誓言2829“I

swear

by

Apollo

Physician

and

Asclepius

and

Hygieia

andPanaceia

and

all

the

gods

and

goddesses,

making

them

mywitnesses,

that

I

will

fulfil

according

to

my

ability

and

judgment

thisoath

and

this

covenant:To

hold

him

who

has

taught

me

this

art

as

equal

to

my

parents

andto

live

my

life

in

partnership

with

him,

and

if

he

is

in

need

of

moneyto

give

him

a

share

of

mine,

and

to

regard

his

offspring

as

equal

tomy

brothers

in

male

lineage

and

to

teach

them

this

art

-

if

theydesire

to

learn

it

-

without

fee

and

covenant;

to

give

a

share

ofprecepts

and

oral

instruction

and

all

the

other

learning

to

my

sonsand

to

the

sons

of

him

who

has

instructed

me

and

to

pupilswhohave

signed

the

covenant

and

have

taken

an

oath

according

to

themedical

law,

but

no

one

else.30I

willapply

dieteticmeasuresfor

the

benefitof

the

sickaccording

to

my

ability

and

judgment;

I

will

keepthemfrom

harm

and

injustice.

I

will

neither

give

a

deadlydrugto

anybody

who

asked

for

it,

nor

willI

make

asuggestionto

this

effect.

Similarly

I

willnot

give

to

a

woman

anabortive

remedy.

In

purity

and

holiness

I

will

guard

mylife

and

my

art.

I

willnot

use

the

knife,

not

evenonsufferers

from

stone,

but

willwithdrawin

favor

of

suchmen

as

are

engaged

in

this

work.Whatever

housesI

may

visit,

I

will

come

for

the

benefitofthe

sick,

remaining

free

of

all

intentional

injustice,

of

allmischief

and

in

particular

of

sexual

relations

with

bothfemale

and

male s,

be

they

free

or

slaves.What

Imay

see

or

hear

in

the

course

of

the

treatment

or

evenoutside

of

the

treatment

in

regard

to

the

life

of

men,which

on

no

account

one

must

spread

abroad,

I

will

keepto

myself,

holding

such

things

shameful

to

bespokenabout.If

I

fulfil

this

oathand

do

not

violateit,

may

it

begrantedto

me

to

enjoy

life

and

art,

being

honoredwith

fameamongallmen

for

all

time

to

come;

if

I

transgress

it

andswear

falsely,

maythe

opposite

of

all

this

bemy

lot.”31我保证履行由于专业我自愿承担的治疗和帮助 的义务。 义务是基于所处的软弱不利的地位，以及他必然给予我和专业能力完全信任。所以，我保证把病人多方面的利益作为专业的第一原则。由于承认这种约束，我接受下列义务，只有或的合法人才能解除我这些义务：①将于的利益置于我专业实践的中心，并在情况需要时置的自我利益上。②拥有和保持 专业要求的知识和技能的能力。③承认 能力的局限,只要 病情需要,我应向各种卫生专业的同事求助。④尊重其他卫生专业同事的价值和信念，并承认他们作为个人的道德责任。32⑤用同等的关切和献身精神 所有需要我帮助的人，不管他们有没有能力付酬。⑥主要为了

的最佳利益，而不是主要为了推行社会的、政治的或财政的政策或⑦尊重 的参与影响他或的利益而行动。决策的道德权利，明确地、清楚地、用 理解的语言说明他或 疾病的性质，以及我建议采用的治疗的好处和

。⑧帮助迫，不作出与他们的价值和信念一致的选择，不强，不口是心非。的一的⑨对我听到、知道和看到的保守

，作为我个必要部分，除非对别人有明确的、严重的、直接。⑩即使我不能治愈时，要帮助，也总要帮助他们，当按照他或她自己的打算不可避免。34ExpressiveReceptiveExpressiveReceptive39Two

levels

of

Patient/practitionercommunicationprofessionaltreatmentcompetenceInteralcommunicationskilleffectCommunicating

withpatients4041Communicating

with

patientsNonverbal

communicatingFacialexpressionsEyecontactTouchBody

positionsInter al

distanceintimate

distance

<0.5mal

distance0.5~1.2msocial

distancepublic

distance1.2~3.5m3.5~7m近日，2015

年

胸科（ATS）国际会议发布了关于解决重症患者治疗医旨在预防重症患者治疗时的医患

，确保医患

的新指南。这项政策护和患者家属和谐的医患关系43What

should

the

practitioner

dowhen

he

faces

the

different

kindof

patients?Patients

forsurgeryBehavioral

control

–

being

able

to

reduce fort

orpromote

recovery

during

or

after

the

medical

procedurebyperforming

certain

actions,

such

as

specialbreathing,coughing

exercises

and

ways

to

turn

inbed.Cognitive

control

–

knowing

how

to

focus

on

the

benefits

ofthe

medical

procedureand

not

its

unpleasant

aspects.(focus

on

the

positive

aspects

of

thesurgery)Informational

control

–

gaining

knowledge

about

theeventsand

sensations

to

expect

duringor

after

surgery,

such

aswatching

a tape

(interviews

with

recovered

patients)and

giving

a

audiotape

(describing

sensations

they

mightexperience)4445Adapting

toterminal

illnessA

terminal

illness

entails

a

slow

deathProgressive

deteriorationin

thefeelingofwell-being

and

abilityfunctionChronic

painThe

patient’s

age

anillness– A

terminal

illchildpting

to

terminalA

terminal

ill

adolescentoryoungadultA

terminal

illmiddle-age

and

older

adults46<=5

years,

deathis

like

living

in

an

otherplaceThere

is

little

need

to

discuss

death

withthemThe

important

thing

is

to

allaytheirconcernsabout

separationfrom

theirparents.About

8

years

of

ages,

death

happenstoeveryone,

and

is

final,

and

involves

theabsenceofbodilyfunctions.An

open

,

honest,

and

sensitive

approachseems

to

reduce

their

anxietyand

maintain

atrusting

relationship

with

their

parents.–

Children

should

know

as

much

abouttheir

illness

as

they

can

co4m7

prehend.–

A

terminal

ill

child48A

terminal

ill

adolescent

or

youngadultMoreangry

about

the“senselessness”

and“injustice“

of their

lives

thanolder

individuals

do.A

terminal

ill

middle-age

and

older

adultsDeath e

less

difficult

as

people

progressfrom

middle

age

toold

age.They

realize

they

will

probably

die

of

chronicillnessThey

think

and

talk

about

poorhealth

anddeathThey

have

made

financial

preparations.They

have

longerpasts

than

youngerpeople,whichhave

allowed

them

the

time

to

achieve

more.Co

stagesDenial–

refuse

to

believe

it

is

trueAnger–whymeBargaining–

trytochange

their

circumstancesby

offering

to

make

adealDepression–

feel

hopelessness

and

grieve

forthings

they

had

in

thepast

andfor

thingstheywill

miss

in

thefuture.Acceptance–