医患沟通在医学教育中的地位与实现方式
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摘要
医患沟通作为一种核心的临床能力,以病人中心是其基本价值取向。医患沟通应该在医学教育,特别在医学伦理学教育中占有基础地位,其实现方式应表现为以技能为导向的,结构化的教学与评估。中国在此领域尚处于起步阶段,美国的经验值得借鉴。
医患不睦是当下的现实,医患沟通是医学界与社会的共识。医患沟通是医学人文属性和艺术性的体现,是医学实践性和道德性的必然要求。提高与患者的沟通能力,是作为临床医生的道德要求,是医学伦理的实践,是医学专业精神的展现。传统的生物医学模式下,医患沟通侧重对生物医学病史的采集,在学习上主要依靠临床模仿和个人经验的积累;在生物-心理-社会医学模式下,医患沟通更应该侧重对患者全面的关怀。
医患沟通,是作为社会人与专业人双重角色中的医疗专业人士,与作为人的病人之间的信息交换的过程,主要表现为临床医生与患者之间直接的信息交流技能。医患沟通,可以划分为临床实践、教育与研究三个分支。本文主要探讨医患沟通的教育问题。
第一章,列举了医患沟通在临床实践中所涉及的一系列具体问题,对所探讨的核心问题进行了界定,即医患沟通在医学教育中地位与实现方式,并分析了本文的视角、进路、方法、资源等。
第二章主要关注医患沟通在医学教育中的地位。以“李丽云案件”为引子,提出目前临床医生的沟通能力的不足的问题,说明医患沟通教育的必要性,并描述一次利用案例教学法进行临床伦理与沟通的教学实验过程和收获,分析传统的教学方法与沟通教学目标存在的龃龉。最后,述评了医患沟通教育在国际特别是北美地区的研究进展和医患沟通教学的基本理念和共识。
第三章,探讨医患沟通在医学教育中的实现方式。首先实地调查分析了美国乔治华盛顿大学医学中心医患沟通教育的开展情况,并重点关注了其特色鲜明的POM医学人才培养模式;接着,从微观上描述了一次对住院医师的伦理与沟通研习课的设计和实施过程,并亲身设计与参与了该研习课中标准化病人的教学环节。最后,对这种美国式的沟通教育模式在中国移植与开展过程中可能要面对的问题进行简要分析,探讨了教学的技术与文化问题。
第四章,论证了医患沟通的本质,在于理解、信任和帮助,对医患沟通教育进行伦理学的辩护,指出医患沟通教育的内在价值维度和外在价值维度;提出了应将以病人为中心作为医患沟通教学的基本价值取向,在介评了美国医学会以病人为中心的沟通模式后,阐述了以病人为中心的沟通在中国实践的展望。
在本文附录部分将提出沟通教学模块设计作为本研究的一项初步结果。
Patient-centered communication is one of the core clinical skills. Skill-based, structured communication teaching and assessing should play a foundational role in modern medical education. American methods could provide us some new perspectives and useful experiences to promote medical communication education in China.
With current doctor-patient relationships in tension, communication is becoming one of the social consensuses inside and outside of medical professional community. Medicine not only as a science but also an art, effective and efficient communication is an element of modern medical professionalism. Within traditional biomedical model, doctors always focus on taking biomedical history from patients by interview skills; in biopsychosocial model, providing care should be the main goal of communication.
Doctor-patient communication as an information exchanging process in patient care should be skill-based. Medical communication as an academic medical field could be divided into clinical practice, education and research three sections. This research mainly pays attention to communication education.
In the first chapter, we define the core research objective and discus the perspectives, methods and academic resources. In Chapter 2, based on the "L.L.Y case" , we clarify the importance of clinical communication competence training to medical professionals. By describing a case-based ethics teaching, we get a conclusion that traditional teaching and assessing methods are insufficient to communication training. At this point, international especially American educational progress is a good model to develop Chinese communication education. In Chapter 3, we explore the rational ways to implement communication in medical education. After observing the POM model at George Washington University Medical Center (GWUMC), and describing the design and implementing of a workshop concerning about how to teach residents clinical ethics and communication skills using standardized patients by American medical educators, we summarize some highlights about the American learner-centered experiential communication learning methods, and rethink how to improve our working in Chinese context. As a primary conclusion in Chapter 4, we explore the philosophy of doctor-patient communication that is understanding, trust and healing.
In the appendix, we submit a communication teaching module design as the primary outcome of this research.
医患不睦是当下的现实,医患沟通是医学界与社会的共识。医患沟通是医学人文属性和艺术性的体现,是医学实践性和道德性的必然要求。提高与患者的沟通能力,是作为临床医生的道德要求,是医学伦理的实践,是医学专业精神的展现。传统的生物医学模式下,医患沟通侧重对生物医学病史的采集,在学习上主要依靠临床模仿和个人经验的积累;在生物-心理-社会医学模式下,医患沟通更应该侧重对患者全面的关怀。
医患沟通,是作为社会人与专业人双重角色中的医疗专业人士,与作为人的病人之间的信息交换的过程,主要表现为临床医生与患者之间直接的信息交流技能。医患沟通,可以划分为临床实践、教育与研究三个分支。本文主要探讨医患沟通的教育问题。
第一章,列举了医患沟通在临床实践中所涉及的一系列具体问题,对所探讨的核心问题进行了界定,即医患沟通在医学教育中地位与实现方式,并分析了本文的视角、进路、方法、资源等。
第二章主要关注医患沟通在医学教育中的地位。以“李丽云案件”为引子,提出目前临床医生的沟通能力的不足的问题,说明医患沟通教育的必要性,并描述一次利用案例教学法进行临床伦理与沟通的教学实验过程和收获,分析传统的教学方法与沟通教学目标存在的龃龉。最后,述评了医患沟通教育在国际特别是北美地区的研究进展和医患沟通教学的基本理念和共识。
第三章,探讨医患沟通在医学教育中的实现方式。首先实地调查分析了美国乔治华盛顿大学医学中心医患沟通教育的开展情况,并重点关注了其特色鲜明的POM医学人才培养模式;接着,从微观上描述了一次对住院医师的伦理与沟通研习课的设计和实施过程,并亲身设计与参与了该研习课中标准化病人的教学环节。最后,对这种美国式的沟通教育模式在中国移植与开展过程中可能要面对的问题进行简要分析,探讨了教学的技术与文化问题。
第四章,论证了医患沟通的本质,在于理解、信任和帮助,对医患沟通教育进行伦理学的辩护,指出医患沟通教育的内在价值维度和外在价值维度;提出了应将以病人为中心作为医患沟通教学的基本价值取向,在介评了美国医学会以病人为中心的沟通模式后,阐述了以病人为中心的沟通在中国实践的展望。
在本文附录部分将提出沟通教学模块设计作为本研究的一项初步结果。
Patient-centered communication is one of the core clinical skills. Skill-based, structured communication teaching and assessing should play a foundational role in modern medical education. American methods could provide us some new perspectives and useful experiences to promote medical communication education in China.
With current doctor-patient relationships in tension, communication is becoming one of the social consensuses inside and outside of medical professional community. Medicine not only as a science but also an art, effective and efficient communication is an element of modern medical professionalism. Within traditional biomedical model, doctors always focus on taking biomedical history from patients by interview skills; in biopsychosocial model, providing care should be the main goal of communication.
Doctor-patient communication as an information exchanging process in patient care should be skill-based. Medical communication as an academic medical field could be divided into clinical practice, education and research three sections. This research mainly pays attention to communication education.
In the first chapter, we define the core research objective and discus the perspectives, methods and academic resources. In Chapter 2, based on the "L.L.Y case" , we clarify the importance of clinical communication competence training to medical professionals. By describing a case-based ethics teaching, we get a conclusion that traditional teaching and assessing methods are insufficient to communication training. At this point, international especially American educational progress is a good model to develop Chinese communication education. In Chapter 3, we explore the rational ways to implement communication in medical education. After observing the POM model at George Washington University Medical Center (GWUMC), and describing the design and implementing of a workshop concerning about how to teach residents clinical ethics and communication skills using standardized patients by American medical educators, we summarize some highlights about the American learner-centered experiential communication learning methods, and rethink how to improve our working in Chinese context. As a primary conclusion in Chapter 4, we explore the philosophy of doctor-patient communication that is understanding, trust and healing.
In the appendix, we submit a communication teaching module design as the primary outcome of this research.
引文
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1 在美期间,我利用访谈方法,向数名留美多年的华裔人士请教,请他们就自己经历谈谈对美国医生的印象,普遍反映美国医生专业化、态度好,愿意花时间听病人倾诉等等;有意思的是,何人也表达了不适感,即有的时候医生的沟通行为显得有点“假”和“过”,这种观点可能不很具代表性,但也可能是由于文化差异造成的对医生态度认知差异的反映,也可能是美国行为主义对医学教育的影响,值得研究。
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3 Cong Yali.Doctor-Family-Patient Relationship:The Chinese Paradigm of Informed Consent,J of Medicine and Philosophy,2004,29(2):149-178.
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3 我曾利用一星期的时间在一所著名的妇产专科医院门诊观察并体验过医忠沟通的实际情况。在第一天门诊时,我即向老师表达了对自己性别(男性)的担心,老师也要求我沣意控制自己的表情,看到有意思的病例即使很高兴表情也不要表现出兴奋,尤其注意眼神,妇科患者往往很敏感,不要让患者误解对她们有歧视和轻视。另外,强调问诊时候千万不要让患者“牵着走”。但面对女性患者,尤其问及性生活史的时候,还是经常感觉非常不安和尴尬。例如,在病史采集过程中,如何有效率的询问患者性生活史,同时又避免让患者感到不适,这给我出了很大的难题,特别是患者比我年龄大时和有家属陪伴时。妇科门诊量非常大,医生问诊往往非常简略,并经常打断患者表述,与每名患者接触时间也就是2～3分钟,病人没有自由表达的时间,医患之间没有肢体接触,更没有互称姓名。患者有时会跟医生提及与医生的亲属、朋友、同事等具有某种私人或社会关系,希望赢得医生的好感与关注,但忙碌的医生好像对诊断之外的信息没有什么反应。狭小的诊室挤满了患者,往往问诊一个患者的同时,其他病人仿佛都在“饶有兴致地分享”着她的病情和“故事”,病人因此也不愿意讲得太多。病人的背景也非常复杂,当医生判断出患者可能是“小姐”,或初步诊断为性病时,表情和语气往往都有明显变化。在体格检查过程中,指导医生表示,尽管是教学医院,很多患者已经开始明确拒绝学生见习,特别是男学生。于是,我和指导医生达成了默契,在做妇科检查时,由她先选择合适的患者,然后点头暗示是否可以到床边见习。这时,医生往往选择年龄偏大的患者,没有家属陪伴的忠者,另外是很多通过口音判断为农村的患者。
1 冯友兰.中国哲学史.华东师范大学出版社,2000.
2 比如,周国平.妞妞——一个父亲的札记.上海人民出版,1996;傅伟勋.死亡的尊严与生命的尊严.北京大学出版社,2006.
3 参见范瑞平.中美生命伦理学:幼稚与无聊.中外医学哲学.第四卷第一期,2002年5月.
4 参见杜治政.序二.引自孙慕义主编.医学伦理学.高等教育出版社,2004.
1 Introduction.参见Post S G.,Editor in Chief.Encyclopedia of Bioethics(3rd Edition).Macmillan Reference,2004:1737.
1 Jonsen AR.The birth of bioethics.Oxford university press.1998.
2 指由改编自日本小说家芥川龙之介同名小说,并由黑泽明的导演的电影《罗生门》(1950)。
1 Charles C,Gafni A,Whelan T.How to improve communication between doctors and patients.BMJ.2000,320:1220-1221.
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3 我曾经向部分中国医学生针对该案例询问过“你是否愿意冒着被诉的风险去救治患者”,多数人很诚恳地向我表示他们不愿患冒这个风险;该案例发生时正值我在美学习,遂将该案例翻译介绍给与我同班的美国医学生和几名医生,询问同样的问题,多数人却表示会救治患者。这种随机访谈可能不具代表性,但也可能确实因为中美医生对法律和伦理确实有不同的理解。从亚丽教授曾经同样发现过该问题,参见从亚丽.北京大学和芝加哥大学医学伦理学教育和实践机制比较研究.中外医学哲学,2002:第Ⅳ卷1期。
1 比如吴阶平先生对医疗差错的处理,很难想象如果在目前的临床工作中直接承认医疗差错,患者是会不予追究的。见吴阶平.医生是要重视医德的——在安徽就医务工作的讲话.安徽卫生职业技术学院学报,2002.1:1-3.
2 讴歌对老协和人物的描述反映了这一点,特别是杨秀玉医生的一句话,“假如态度好能治好病,我态度能比谁都好”,参见讴歌.协和医事.三联书店,2007:214-223.
3 Kurtz SM,Silverman J,Draper J.Teaching And Learning Communication Skills In Medicine(2nd edition).Radcliffe Publishing,2005:21-22
1 张金钟 主编.医学伦理学.北京大学医学出版社.2005.
1 Williams,John R.Medical ethics manual.World Medical Association,2005.
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1 杜治政,许志伟主编,医学伦理学辞典.郑州大学出版,2003:255-256.
2 戴正德.医学伦理教育及其教学法的研究探讨.医学与哲学,2001,22:49-53.
3 张金钟.按医德养成规律开展教学基地建设.中国医学伦理学,2003,16:51-52.
1 戴正德.医学伦理教学有效性之研究.医学与哲学,2003,24:55-8.
2 丛亚丽.北京大学和芝加哥大学医学伦理学教育和实践机制比较研究.中外医学哲学,2002:第Ⅳ卷1期
3 丛亚丽.学以致用——中德医学伦理学教学培训班体会.医学与哲学,2003,24:62-64.
4 杜治政.医学伦理探新.河南医科大学出版社,2000:391-2.
1 Martin F.McKneally,Peter A.Singer.Teaching bioethics in the clinical setting.CMAJ,2001,164(8):1163-7.
2 王锦帆,季晓辉,王心如.高等医学教育中开设医患沟通学课程的探索.中围高等医学教育,2004,6:48-49.
3 王锦帆主编.医患沟通学.人民卫生出版社,2003,2006.
4 丛亚丽.医学伦理学教育评论——兼评“为什么医学生进入临床后变‘坏'了”.中国医学人文评论,第一卷.P82-92
5 藤朝宇.湘雅二医院医患沟通研究.硕士学位论文,2005.
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1 Bayer-Fetzer Conference on Physician-Patient Communication in Medical Education.Essential elements of communication in medical encounters:the Kalamazoo Consensus Statement.Academic Medicine,2001;76:390-393.
1 AAMC.Learning Objectives for Medical Student Education.Association of American Medical Colleages,1998.
2 AAMC.Contemporary Issues in Medicine:Communication in Medicine.Association of American Medical Colleages,1999.
1 Accreditation Council for Graduate Medical Education.ACGME Outcome Project.www.acgme.org/Outcomes.
1 Duffy,FD.,Gordon,GH.,Whelan,G,Cole-kelly,K.,Frankel,R.& all participants in the american academy on physician and patient's conference on education and evaluation of competence in communication and interpersonal skills(2004)assessing competence in communication and interpersonal skills:the kalamazoo ⅱreport,Academic Medicine,79:495-507.
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6 参见美国医帅执业证书考试网站,http://www.usmle.org/examinations/step2/step2.html.
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1 Peggy Wallace.Coaching Standardized Patients:For Use in the Assessment of Clinical Competence.Springer Publishing Company,2006.
1 Beck,Andrew H.The Flexner Report and the Standardization of American Medical Education," Student JAMA,2004,291:2139-40.
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1 Yali Cong.Doctor-Family-Patient Relationship:The Chinese Paradigm of Informed Consent,Journal of Medicine and Philosophy,2004,Vol.29,No.2,pp.149-178
2 张金钟.关于医学伦理学案例教学的内涵与外延.医学与哲学,2007
3 吴易叡.医学伦理在变动社会中以及制度中呈现的形貌——一个医学生的观.台湾医学人文学刊.5卷1&2期:149-158
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2 杜治政.医学高教五题.医学教育探索,2004,3:8-10.
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1 于其智.凝视之爱.中央编译出版社,2002.
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1 在美期间,我利用访谈方法,向数名留美多年的华裔人士请教,请他们就自己经历谈谈对美国医生的印象,普遍反映美国医生专业化、态度好,愿意花时间听病人倾诉等等;有意思的是,何人也表达了不适感,即有的时候医生的沟通行为显得有点“假”和“过”,这种观点可能不很具代表性,但也可能是由于文化差异造成的对医生态度认知差异的反映,也可能是美国行为主义对医学教育的影响,值得研究。
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