全科醫(yī)學(xué)英文課件：第3講 Doctor- Patient Communication

1、 Doctor- Patient Communication P104-128 Hot discussion In October 25, 2013, Zhejiang Wenling First Peoples Hospital occurred in intentional injury cases, 3 doctors in the outpatient when serving the patients were stabbed by a man. Among them, the deputy director of outpatient management department,

2、director of the department of ENT Wang Yunjie, only 47 years old, was death after invalid rescue. Another 2 people were injured. At present, the suspected XXX has been under criminal detention, the case is still under investigation. In 2012, a nations total of 11 cases of malignant wound medicine, c

3、ausing 35 casualties, which killed 7 people, injured 28 people (including patients and nursing staff 11, 16 medical staff, 1 security), involving Beijing, Heilongjiang and other 8 provinces and cities. Which have attracted a great social extensive concern, and exposed many prominent problems and wea

4、k links in hospital security work. A patient stabbed a doctor to death, and 3 to injured in Harbin Medical University 2012年3月23日，哈爾濱醫(yī)科大學(xué)附屬第一醫(yī)院發(fā)生一 起惡性傷害案件，致1人死亡、3人受傷。 據(jù)介紹，犯罪嫌疑人李夢南為男性，18歲，漢族，戶 籍所在地為內(nèi)蒙古自治區(qū)，患強直性脊柱炎，23日9時 許到哈醫(yī)大一院住院處治療。因其同時患有肺結(jié)核， 治療強直性脊柱炎會對肺部造成影響，醫(yī)生建議他先 治好肺結(jié)核后再治療強直性脊柱炎。李夢南對此心生 不滿，于案發(fā)當日16時

5、許，購買一把水果刀，來到醫(yī) 生辦公室將王浩、鄭一寧、王宇、于惠銘4名醫(yī)務(wù)人員 捅傷。 Minister of Health to respond to Harbin kill Medical Records to punish the murderers According to the Ministry of Health website reported March 26, for The First Affiliated Hospital of Harbin Medical University, doctors were killing event, the Minister of H

6、ealth Chen Zhu requirements of the General Office of the Ministry of Health to the Health Department of Heilongjiang Province to understand the situation and demanded stern punishment for the murderer to crack down on crime, harm the medical staff and Heilongjiang Provincial Health Department on beh

7、alf express deep condolences and sympathy to the family members of killed and injured staff Thinking about the doctor-patient relationship What have changed in the doctor-patient relationship? What have changed in the influence factors of doctor-patient relationship? Objective: Resources Subjective:

8、 System, policy, doctors, patients, management, intermediary agency? Different “doctors” and “patients”in times of changing -Bad relationship comes from the comparative gaps DoctorsInfluencesPatients Service：System：Body： Income：Policy：Require： Occupation：Management：Result： Position：Intermediary：Psyc

9、hology ： Coordination ： Consciousness ： Others： L i g h t n e s s depends on electricity Better result should value my pay 新農(nóng)合 8.4億 居民醫(yī)保 1.9億 職工醫(yī)保 2.2億 管理保健 求醫(yī)： 距離遠了 關(guān)系疏了 成本高了 衛(wèi)生體制 （公平、經(jīng)濟、有效） 三級醫(yī)療 二級醫(yī)療 一級醫(yī)療 Doctorpatient relationship The doctor-patient relationship is central to the practice of heal

10、thcare and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. The doctor-patient relationship forms one of the foundations of contemporary medical ethics. Errors in medical practice Many of the errors in medical practice have their origins in a failu

11、re of communication. The doctor either fails to understand the patients meaning or fails to convey his or her own meaning. These misunderstandings cause frustration for doctors and patients, with all that follows in lowered morale, patients dissatisfaction, ineffective medicine, conflict, and litiga

12、tion. Effective communication is fundamental If we have not understood the patients problem as the very first step, everything that follows in investigation and treatment may be wrong. Even when diagnosis and therapy are technically correct, the way they are communicated to patients has important im

13、plications for their response. Moreover, communication is the essence of a therapeutic relationship. Features of Communication in FM Most of these can be summed up in one word: context. Communication usually takes place between a doctor and patient who know each other, who have shared previous exper

14、iences, and have other relationships in common, for example with other family members. It takes place, very often, over extended periods of time, and in the different environments of office, home, and hospital. It is important, therefore, for us to understand how context influences and enhances comm

15、unication. Understanding of the patients symptoms Most consultations begin with the patients account of his or her symptoms. A very high proportion of patients have symptoms without physical signs or abnormal investigations. Even when signs and abnormal tests are found, the correct diagnosis is more

16、 likely to depend on the history than on the examination and investigation. This is particularly so in general practice. An understanding of the patients symptoms is, therefore, fundamental. What are symptoms? Symptoms are the patients description of what he or she perceives to be abnormal sensation

17、s. By definition, they are subjective and not open to verification by empirical methods. There is no objective test by which we can verify that a patient is actually feeling a pain. This is not to say, however, that we cannot apply rigorous methods to understanding the meaning of a patients symptoms

18、. The methods are those of attentive listening, clarification of meaning through dialogue, and avoidance of selection bias. Symptoms are communication and information Symptoms are a form of communication a patient conveys feelings of illness, distress, or discomfort. Symptoms are the information on

19、which we base our understanding of the patients problem. The starting point is the information received by the patient in the form of messages transmitted from his or her nervous system. Signals Under usual circumstances, we are unaware of these messages. Nor are we normally aware of bodily function

20、s The signals that lead to an adjustment in heart rate, blood pressure, or posture are, received and acted on below the level of consciousness, like digestion and respiration. In unusual circumstances, signals reach consciousness and have to be interpreted or decoded. How the signals are de-coded de

21、pends on a number of factors, including the persons past experience and culture. These all form the context within which the messages are transmitted and interpreted. Interpretation is both cognitive and affective Let us suppose that the constancy of the background feeling is broken by a sensation o

22、f chest pain on waking one morning. At first there is a moment of anxiety; then a fall the day before, when a blow was received on that part of the chest, is remembered. This explanation is accompanied by a feeling of relief. On the other hand, no such explanation may be available. Perhaps the memor

23、y instead is of a colleague who had a severe heart attack accompanied by chest pain. The anxiety results in a visit to the doctor. The presenting complaint is probably the pain, not the anxiety. But things can be even more complicated. Even though the anxiety is not expressed in words, it may be exp

24、ressed in bodily waysfacial expression, gestures, heart rate and so on. An observant physician may recognize the emotion from these signs. To complicate things even more the original change in body state may itself be the bodily expression of an emotion., the patient suddenly became short of breath

25、after her fathers funeral (P283). This distress signal was interpreted as the approach of death . The extreme fear would probably generate more bodily changes: tachycardia, sweating, and pallor, thus adding to her anxiety. A doctors explanation of her symptoms as an expression of grief would have be

26、en processed both cognitively and emotionally, with increased understanding and lessening of fear. As it happened, she encountered a physician who was dismissive and provoked an angry reaction that was anti-therapeutic. Information level of a signal is directly related to its capacity The informatio

27、n level of a signal is directly related to its capacity to surprise the receiver. A person who usually coughs up some mucoid sputum in the morning gets no information by looking at his sputum. If one morning it is bloodstained, he does get information. Information depend on the context The informati

28、on conveyed by the bloodstained sputum will depend on the context within which the message is received. A person who believes that blood in the sputum always means cancer will decode the message differently from the person who does not connect the blood with cancer. A person who coughs up blood for

29、the first time will decode it differently from a person who has coughed up blood before. Information is a daily occurrence We know that information arising from differences in our inner state is a daily occurrence. We all experience minor aches, pains and discomforts of various kinds: headaches, mus

30、cle pains, dyspepsia, fatigue, itching, insomnia, irregularity of bowels or menses, and so on. The fact that a person consults a physician means that he has interpreted the information as a departure from his usual pattern, or as a signal that is outside his frame of reference. Interpretation varies

31、 enormously from one person to another There is no clear relationship between the severity of the symptoms and the decision to consult. A common defense against unwelcome information is denial. People have a great capacity for self-deception. On the other hand, there are those whose tolerance is low

32、 and who consult for very minor ailments. There may, of course, be a very good reason for consulting, as with the person who comes with vague chest pain after a friend has died of a myocardial infarction. How information be treated? Initial decoding of information the first gate: the gate where info

33、rmation from bodily feelings is interpreted and acted on in illness behavior. Symptoms admitted through this gate may be acted on in different ways. For some, self-care will be triedat least for a time; for others, advice from family, friends, or members of the persons lay referral system. The decis

34、ion to consult a physician may be an individual one or may be made with the assistance of family and friends. Decision - the second gate Having decided to see a doctor, the person must then decide how to code his or her symptoms for transmission to the physician, including what language to use and w

35、hich symptom or problem to mention first. The decision is influenced by many factors. Very seldom is there a single symptom or problem; more usually there are many. Often there are also emotions related to the symptoms: anxieties, fantasies, fears. Complexities and difficulties of communication at s

36、econd gate How can the patient convey how he or she feels? At this gate we encounter the complexities and difficulties of doctor-patient communication. First the patient has to code the information in verbal form. How well he or she can do this depends on the availability of a language and his or he

37、r own familiarity with it. For some symptoms a well- understood language is quite readily available. The message is coded in words that have a direct causal relationship with the sensation the patient is trying to communicate. There may also be a clear and direct relationship between the symptom and

38、 a diseased state, such as the one between anginal pain and ischemic heart disease. Other sensations and feelings are much more difficult to put into words: vague illness and distress, changes of mood, unhappiness, anxiety, grief, self-doubt, guilt, remorse. These difficulties are so great that some

39、 very sick people do not consult physicians. In his population survey in Glasgow, Hannay (1979) found severely depressed people who had never consulted a doctor. It seems that disorders that threaten the integrity of the personality are particularly difficult to find expression for. Burack and Carpe

40、nter (1983) studied the relationship between the presenting complaint and the principal problem identified during new patient visits. The problems were classified as somatic, psychosocial, or health maintenance. The presenting complaint correctly identified the category in 76 percent of somatic prob

41、lems, but only 6 percent of psychosocial problems. If, however, the presenting complaint was psychosocial, the principal problem was psychosocial in all cases. If the presenting complaint was somatic, only 53 percent of the identified problems were somatic. How patient overcome these difficulties of

42、 expression To overcome these difficulties of expression, patients find other ways of coding their message. This means using an indirect, rather than a direct, form of communication. When patients express personal distress through bodily symptoms, they are not inventing the symptoms, or imagining th

43、e sensations. They are simply selecting the aspect of the illness experience which they can most easily put into words. Patient may express the problem in terms of a familiar symptom A patient who cannot find words for his or her feeling of despair may express the problem in terms of a familiar symp

44、tom like headaches, which may be an effect of the problem but are not the core of it. It is much easier to talk about headaches than about despair. Patient may express the problem by using metaphors or nonverbal forms In indirect communication, the patient may express meaning by using metaphors or n

45、onverbal forms. Metaphors, according to Jeremy Campbell (1982), “place the familiar in the context of the strange” or, one might add, the strange in the context of the familiar. The message is in the context. A patient with a chronic disease, who is also in personal distress, may communicate this di

46、stress in the form of a visit for the disease. Case 7.1 A patient with multiple sclerosis came with the usual symptoms of her disease. The distress she was trying to communicate was caused by her husbands refusal to countenance birth control. This problem was related to the disease, in that she felt

47、 unfit to manage another child, but only indirectly. Indirect communication is common in family practice It is a universal experience that words are inadequate to express feeling: “words, like nature half reveal and half conceal the soul within,” wrote Tennyson in In Memoriam. In all cultures, the d

48、eepest feelings are expressed in dance, drama, poetry, and other forms of symbolism. Many patients who come to see us are in the grip of powerful emotions, so it is not surprising that indirect communication is common in family practice. Somatization This is defined as the process by which emotions

49、are transduced to bodily symptoms, for which medical aid is sought. The symptoms of conversion were therefore forms of communication rather than the experience of physiological disturbances. The concept has now been expanded to embrace any bodily manifestation of distress. Context “All communication

50、 necessitates context. without context there is no meaning,” One of the most difficult things for a physician is knowing what context to use in decoding the patients message. If the physician decodes the message using the context of physical pathology, the result may be a spurious diagnosis and all

51、its consequences. If the patient is also misreading the context, as is sometimes the case, the possibilities of misdiagnosis are even greater. Difficult Relationships Weston defines a difficult patient as one with whom the physician has trouble forming an effective working relationship. The long-ter

52、m relationships with patients in general practice make this a particular problem for family physicians. Because therapeutic success depends so much on the relationship between doctor and patient, the inability to form a therapeutic relationship is usually a source of much frustration for the doctor.

53、 Interviewing Interviewing is a process by which one person, usually a professional, reaches an understanding of another, usually a patient or client. Medical interviewing provides the context for history takingthe collection of information about the patients problem. Interviewing is a process of co

54、mmunication, both verbal and nonverbal. It is much more than asking questions and receiving answers. Listening The greatest single fault in interviewing is probably the failure to let the patient tell his or her story. So often the talk is dried up by questions that divert the flow of conversation,

55、by changes of subject, or by behavior in the physician that expresses lack of interest (thumbing through the records or glancing at a wrist-watch). At the beginning of an interview, the physician should try, by every means possible, to encourage patients to tell their own story in their own way. Empathy Empathy is the capacity to enter into another per