Khoa học trong giao tiếp thầy thuốc và bệnh nhận

KHOA HỌC TRONG GIAO TIẾP THẦY THUỐC VÀ BỆNH NHẬNGS TS BS LÊ HOÀNG NINHTẠI SAO PHẢI HỌC GIAO TiẾP VỚI BỆNH NHÂN?To:Enhance the therapeutic nature of the medical encounterManage problems in doctor-patient communications Improve outcomes of care through: Mastering a Model of CommunicationsFunction of the medical interviewStructure of the medical interview Knowing how to improve ones skills over timeGiao tiếp có hiệu quả giữa thầy thuốc –và bệnh nhân. Lý do ?Most time spent between practitioner and patientThe most prevalent behavior in a clinician’s lifetimeDiagnose and treat diseaseFacilitate healingEstablish and maintain a therapeutic relationshipOffer information and educateTherapeutic Nature of theMedical Encounter: CAREHelp patients cope with stress and illness or with bad newsActivate patients’ participation in self care and well beingIncrease patients’ sense of accountability,Responsibility, self esteem and confidenceEmpower patients’ own decision making about their healthCác vấn đề phổ biến trong giao tiếp giữa thầy thuốc và bệnh nhân45% of patients’ concerns are not elicited50% of psychosocial and psychiatric problems are missedIn 50% of visits, patient and physician do not agree on the main presenting problemPatients’ most common complaint is the lack of information provided by physiciansMajority of malpractice suits arise from communication errors; not incompetenceẢnh hưởng, tác động của một giao tiếp tốt của thầy thuốc lên bệnh nhânInterview-related factors have documented impact on outcomes of care such as– Symptom resolution (e.g., BP, sugar)– Pain control– Physiological responses– Daily functioning– Emotional health (e.g., decreased distress, anxiety)– Treatment adherence– Patient and provider satisfaction with the encounter and with overall careAllow Patients to Express theirMajor ConcernsSatisfaction and treatment adherenceof patients with children in ER were greater, when parents could express concernsKorsch et al, 1968; Freemon et al, 1971Adults with headaches who were able to fully discuss problem, were more likely to improveHeadache StudyGroup, 1989.Allow Patients to Express theirMajor ConcernsBlood pressure control correlated with patients’ ability to talk about concerns in their own wordsOrth et al., 1987.Satisfaction of adults in medical walk-in cliniccorrelated with abilityto talk about illness intheir own wordsStiles et al., 1979;Putnam et al, 1988.Elicit Patients’ Explanations of Their IllnessesCongruence between patients in pediatric clinic and physicians, about patients’ problems, correlated with improvementStarfield et al., 1981.Congruence between patients in general medicine clinic and physicians, aboutpatients’ problems, correlated with ImprovementFreidin et al., 1980.Involve Patients in Developing aTreatment PlanAdults with hypertension, diabetes, peptic ulcer disease who were trained to ask questions and given explanations of their diagnoses and treatments were more likely to improve than were control patientsGreenfield, et al., 1985Kaplan et al., 1989.Guidelines for EffectiveDoctor-Patient Communication1991 Toronto Consensus Statement Kalamazoo Consensus Statements (2001,2004)Macy Initiative in Health Communication (2003)Chức năng của một phỏng vấn y họcIdentify the Problem– Elicit complete and accurate information– Observe essential data– Form and test hypotheses– Identify psychosocial and other contextual variables Develop and Maintain Relationships– Elicit the patient’s perspective– Respond with empathy to patient’s concerns– Demonstrate professionalism and respect– Recognize and respond to conflictChức năng của một phỏng vấn y học (tt)Education and Counseling– Assess the patient’s understanding of current problems– Explain recommended course of action– Negotiate a mutually agreeable treatment planThe Macy Model of Doctor–Patient CommunicationRepresents a complete set of core skills and vital communication elementsProvides an overall framework for each visit– Acute visit– Follow-up visit– Obtaining informed consent– Delivering bad news– Counseling about lifestyle– Communicating with anxious or depressed patient– Communicating with adolescentsStructure of the Medical InterviewThe Macy ModelFundamental Skills to Maintain During the Interview1. Relationship building2. Managing flowPrepareOpenGather information1. Survey patient’s reason for visit2. Determine patient’s chief concern3. Complete patient’s medical databaseNegotiate and agree on planElicit and understandpatient’s perspectiveClosePatienteducationCommunicate during the exam or procedureCấu trúc một phỏng vấn y khoa Các kỹ năng cần có trong suốt cuộc phỏng vấnUse Relationship Building Skills– Allow patient to express self– Be attentive and empathic non-verbally– Use appropriate language– Communicate in a non-judgmental and supportive way– Recognize emotion and feelings– Use PEARLS Statements—Partnership, Empathy, Apology, Respect, Legitimization, Support Manage Flow– Be organized and logical– Manage time effectivelyCấu trúc một phỏng vấn y khoa: Chuẩn bịReview the patient's chart and other dataAssess and prepare the physical environment– Optimize comfort and privacy– Minimize interruptions and distractionsAssess ones own personal issues, values, biases, and assumptions going into the encounterCấu trúc một phỏng vấn y khoa:MởGreet and welcome patient and family memberIntroduce yourselfExplain role and orient patient to the flow of the visitIndicate time available and other constraintsIdentify and minimize barriers to communicationCalibrate your language and vocabulary to the patient’sAccommodate patient comfort and privacyCấu trúc một phỏng vấn y khoa:Thu thập thông tinSurvey Patient’s Reasons for the Visit– Start with open-ended questions– Invite patient to tell the story chronologically– Allow the patient to talk without interrupting– Actively listen– Use verbal and non-verbal encouragement– Define symptoms completely to determine main concern– Summarize and check for understanding Complete the Patient’s Medical Database– Obtain past medical, family and psychosocial history– Summarize what you heard and check for accuracyCấu trúc một phỏng vấn y khoa: Elicit and Understand Patient’s PerspectiveAsk patient about ideas about illness or problemAsk patient about expectationsExplore beliefs, concerns and expectationsAsk about family, community, and religious or spiritual contextAcknowledge and respond to patient’s concerns, feelings and non verbal cuesAcknowledge frustrations/challenges/progress (waiting time, uncertainty)Cấu trúc một phỏng vấn y khoa: Communicate During the Exam/ProcedurePrepare patient Consider commenting on aspects and findings of the physical exam or procedure as it is performedListen for previously unexpressed data about the patient's illness or concernsCấu trúc một phỏng vấn y khoa:Giáo dục bệnh nhânUse ‘Ask-Tell-Ask’, to giving information meaningfully– Ask about knowledge, feelings, emotions, reactions, beliefs and expectations– Tell the information clearly and concisely, in small chunks, avoid "doctor babble“– Ask repeatedly for patient’s understandingUse aids to enhance understanding (diagrams, models, printed material, community resources)Encourage questionsCấu trúc một phỏng vấn y khoa: Negotiate and Agree on PlanEncourage shared decision making to the extent patient desiresSurvey problems and delineate optionsElicit patient’s understanding, concerns, and preferencesArrive at mutually acceptable solutionCheck patient’s willingness and ability to follow planIdentify and enlist resources and supportsCấu trúc một phỏng vấn y khoa: Đóng Signal closureInquire about any other issues or concernsAllow opportunity for final disclosuresSummarize and verify assessment and planClarify future expectationsAssure plan for unexpected outcomes and follow- upAppropriate parting statementKết LuậnThe Medical InterviewCore clinical skillMost time spent between practitioner and patientImportant contribution to clinical reasoning, diagnosis, and outcomes of careMost prevalent behavior in a clinician’s lifetimeWell established guidelines describe core communication elements essential for every clinical encounter