醫(yī)生要學(xué)習(xí)與患者溝通

Doctor, Shut Up and Listen

醫(yī)生要學(xué)習(xí)與患者溝通

BETSY came to Dr. Martin for a second — or rather, a sixth — opinion. Over a year, she had seen five other physicians for a “rapid heartbeat” and “feeling stressed.” After extensive testing, she had finally been referred for psychological counseling for an anxiety disorder.

貝蒂來找馬丁醫(yī)生是想問問第二個(gè)大夫的意見——實(shí)際上是第六個(gè)。在過去一年里，因?yàn)?ldquo;心動(dòng)過速”和“受迫感”的問題，她咨詢過五位醫(yī)生。在經(jīng)過大量的檢查后，醫(yī)生最終建議她去做焦慮癥方面的心理咨詢。

The careful history Dr. Martin took revealed that Betsy was taking an over-the-counter weight loss product that contained ephedrine. (I have changed their names for privacy’s sake.) When she stopped taking the remedy, her symptoms also stopped. Asked why she hadn’t mentioned this information before, she said she’d “never been asked.” Until then, her providers would sooner order tests than take the time to talk with her about the problem.

馬丁醫(yī)生仔細(xì)地詢問病史，終于得知貝蒂當(dāng)時(shí)正在服用一種減肥用的非處方藥，其中含有麻黃堿。(為了保護(hù)隱私，文中用了化名。)停止服用這種藥物后，她的癥狀也就消失了。在被問到過去為什么沒有提過這件事時(shí)，她說，“從來沒人問過。”在那以前，她的醫(yī)生都會(huì)很快讓她去做檢查，而不是花時(shí)間和她談病情。

Betsy’s case was fortunate; poor communication often has much worse consequences. A review of reports by the Joint Commission, a nonprofit that provides accreditation to health care organizations, found that communication failure (rather than a provider’s lack of technical skill) was at the root of over 70 percent of serious adverse health outcomes in hospitals.

貝蒂的情況還算幸運(yùn)，溝通不暢常常會(huì)導(dǎo)致更惡劣的后果。非營利組織“醫(yī)療機(jī)構(gòu)認(rèn)證聯(lián)合委員會(huì)”(Joint Commission)發(fā)布的一份報(bào)告指出，醫(yī)院中發(fā)生的嚴(yán)重不良健康后果中，有逾70%的根源在于溝通不暢(而不是醫(yī)護(hù)人員欠缺專業(yè)技能)。

A doctor’s ability to explain, listen and empathize has a profound impact on a patient’s care. Yet, as one survey found, two out of every three patients are discharged from the hospital without even knowing their diagnosis. Another study discovered that in over 60 percent of cases, patients misunderstood directions after a visit to their doctor’s office. And on average, physicians wait just 18 seconds before interrupting patients’ narratives of their symptoms. Evidently, we have a long way to go.

醫(yī)生能否解釋、傾聽、與患者產(chǎn)生共鳴，對(duì)于病人的診療有著深遠(yuǎn)的影響。然而一項(xiàng)調(diào)查發(fā)現(xiàn)，有三分之二的病人在不知道診斷結(jié)果的情況下，就被要求出院了。另一項(xiàng)研究發(fā)現(xiàn)，在超過60%的病例中，患者在問診后誤解了醫(yī)生的指示。醫(yī)生平均只會(huì)等18秒，就會(huì)打斷患者對(duì)癥狀的陳述。顯然，我們有很長(zhǎng)的路要走。

Three years ago, my colleagues and I started a program in Harrisburg designed to improve doctors’ communication with their patients. This large urban hospital system serves a city with a population of about 50,000, together with the surrounding metropolitan area of more than 550,000 people.

三年前，我和同事在賓夕法尼亞州哈里斯堡啟動(dòng)了一個(gè)旨在改善醫(yī)患溝通的項(xiàng)目。這個(gè)規(guī)模龐大的城市醫(yī)院系統(tǒng)，為本市大約5萬人口提供服務(wù)，同時(shí)也面向周邊城市群共計(jì)超過55萬的居民。

The hospital faces particular challenges: The city has a high poverty rate (32 percent, compared with the state average of 13 percent), and the metro area has a high rate of childhood obesity. Over all, nearly a third of people around Harrisburg are uninsured, compared with about one in 10 for the rest of Pennsylvania.

醫(yī)院面臨著一些特殊的挑戰(zhàn)：這座城市貧困率極高(達(dá)32%，與之相對(duì)比，全州平均水平為13%)，所在城區(qū)的兒童肥胖率也很高。總體而言，哈里斯堡及周邊人口中，有近三分之一沒有醫(yī)療保險(xiǎn)，而賓夕法尼亞州其他地區(qū)的這一比例則約為十分之一。

Our project started with a simple baseline assessment of how we as doctors communicated with our patients. Observation soon revealed that physicians introduced themselves on only about one in four occasions. And without an introduction, it’s no surprise that patients could correctly identify their physician only about a quarter of the time.

項(xiàng)目開始時(shí)，我們對(duì)醫(yī)生與患者的溝通狀況做了一個(gè)簡(jiǎn)單的基準(zhǔn)評(píng)估。通過觀察，我們很快就發(fā)現(xiàn)，只有大約四分之一的情況，醫(yī)生會(huì)向患者做自我介紹。既然沒有做自我介紹，另一個(gè)現(xiàn)象也就不奇怪了：僅有大約四分之一的情況，患者能正確指出給自己診斷的醫(yī)生是誰。

Brief, rushed physician encounters were common, with limited opportunity for questions. A lack of empathy was often apparent: In one instance, after a tearful patient had related the recent death of a loved one, the physician’s next sentence was: “How is your abdominal pain?”

與醫(yī)生會(huì)面時(shí)簡(jiǎn)短、倉促的情況十分普遍，提問的機(jī)會(huì)也很有限。對(duì)患者缺乏理解的情況往往很明顯：在一個(gè)案例中，患者痛哭流涕地傾訴，最近一位親人去世了，但醫(yī)生接下來問的卻是，“你的腹痛是什么情況?”

We developed a physician-training program, which involved mock patient interviews and assessment from the actor role-playing the patient. Over 250 physicians were trained using this technique. We also arranged for a “physician coach” to sit in on real patient interviews and provide feedback.

我們推出了一項(xiàng)醫(yī)生培訓(xùn)計(jì)劃，其中包括由演員扮演的患者參與的模擬問診和評(píng)估。有超過250名醫(yī)生接受了運(yùn)用這個(gè)技巧進(jìn)行的培訓(xùn)。我們還安排了“醫(yī)生輔導(dǎo)員”在實(shí)際接診時(shí)坐在旁邊，進(jìn)而提供反饋。

Over the next two years, patient satisfaction with doctors, as measured by a standard questionnaire, moved the hospital’s predicted score up in national rankings by a remarkable 40 percentile points. Several studies have found a correlation between higher patient satisfaction scores and better health outcomes. In one, published in The New England Journal of Medicine, Harvard health policy researchers reported that higher patient satisfaction was associated with improved outcomes for several diseases, including heart attacks, heart failure and pneumonia.

在接下來的兩年里，通過一項(xiàng)標(biāo)準(zhǔn)化問卷的衡量，患者對(duì)醫(yī)生的滿意度提高了，而這所醫(yī)院的預(yù)期得分，在全美排名中也出現(xiàn)了40個(gè)百分點(diǎn)的可觀提升。有若干項(xiàng)研究發(fā)現(xiàn)，患者滿意度指標(biāo)的提高，與治療效果的改善存在正相關(guān)性。在一篇發(fā)表在《新英格蘭醫(yī)學(xué)雜志》(The New England Journal of Medicine)上的研究論文中，哈佛大學(xué)的醫(yī)療政策研究人員寫道，患者滿意度提高，與若干種疾病治療效果的改善存在相關(guān)性，包括心肌梗死、心臟衰竭和肺炎。

The need to train and test physicians in “interpersonal and communication skills” was formally recognized only relatively recently, in 1999, when the American Board of Medical Specialties made them one of physicians’ key competencies. Although medical schools and residency programs then began to train and test students on these skills, once physicians have completed training, they are seldom evaluated on them. And doctors trained before the mid-1990s have rarely, if ever, been evaluated at all.

對(duì)醫(yī)生在“人際關(guān)系和溝通技巧”方面進(jìn)行培訓(xùn)和檢驗(yàn)的需求，直到近年來才正式得到承認(rèn)。在1999年，美國醫(yī)療?？莆瘑T會(huì)(American Board of Medical Specialties)將這些技巧列為醫(yī)生的關(guān)鍵能力之一。盡管醫(yī)學(xué)院和住院醫(yī)項(xiàng)目從那時(shí)就開始對(duì)學(xué)生的這些技巧進(jìn)行培訓(xùn)和測(cè)試，但是醫(yī)生在完成學(xué)業(yè)后，極少還會(huì)受到這方面的評(píng)估。所有在上世紀(jì)90年代中期之前接受醫(yī)學(xué)教育的醫(yī)生，則極少甚至完全沒有得到過評(píng)估。

I realize that many colleagues may see methods like ours as too intrusive on their clinical practice and may say that they don’t have the time. But we need to move away from the perception that social skills and better communication are a kind of optional extra for doctors. A good bedside manner is simply good medicine.

我明白很多同行可能會(huì)認(rèn)為，我們這樣的方法對(duì)臨床實(shí)踐的干擾太強(qiáng)，也可能會(huì)說他們沒時(shí)間。不過，我們需要摒棄那種認(rèn)為社交技巧和改善溝通對(duì)醫(yī)生來說是一種可有可無的額外素質(zhì)的念頭，因?yàn)樵谂R床實(shí)踐中，良好的態(tài)度本身就是一劑良藥。

A passionate diabetes specialist told me how she sat down with a patient to understand why he was not using his diabetes medications regularly, despite numerous hospital admissions for complications.

一位充滿熱情的糖尿病專科醫(yī)師給我講述了她與一名患者坐下來聊天的情形。盡管那名患者因?yàn)椴l(fā)癥而多次入院治療，但是他還是不肯規(guī)律地?cái)z入糖尿病藥物，她想弄明白這是為什么。

“I can’t continue to do this anymore,” he told her, on the verge of tears. “I’ve just given up.”

“我不能再這樣活了，”他強(qiáng)忍著淚水告訴她。“我干脆放棄了。”