30/03/2018

醫學生臨床教學的的第一步

醫學生臨床教學的的第一步

蘇冠賓
中國醫藥大學 醫學院副院長
精神醫學及神經科學教授

指導學生接觸病患的第一步,是從最基本的「打招呼(暖身)、介紹(自我及團隊)以及說明來意」紮實做好;接下來學生要能夠熟練地使用開放式的問題,聆聽病人的主觀陳述,再根據主訴去評估及處理。如果已經詳細評估並處理病患的主訴,而病患仍環繞同樣的問題,學生可以再次練習如何向病人做更有效說明,或報告自己評估和處理的結果,讓病患和團隊一同討論。在初步處理病患開放式主訴的同時,學生也開始有機會培養對病患的核心病灶的敏感度,進而深入研習進階的專科會談、評估和檢查。


一、「打招呼、自我介紹(或介紹團隊)、並說明來意」如果有需要(例如病患緊張、有強烈的情緒),可以再加強一下以建立關係為目的的交談。

二、開放式的問題(「請問現在有什麼問題?有沒有什麼想要討論的?」
)
  • (A)聽過病人的主觀陳述,學生應該要能根據病患主訴去做評估(學習操作「問題導向的評估 Problem-oriented assessments」,例如頭痛、便秘、腹痛、失眠、疲倦...)。
  • 
(B)已經作過詳盡的評估和處置,病患還是停留在一樣的問題,表示病人沒有真正了解或滿意。所以學生不需要再重複操作一次「問題導向的評估」。這個階段如果學生想要學習如何有效解釋,可以重申「這些問題剛剛已經評估和討論過,我再跟你說明一次...」。或者如果學生想學習病情簡報,可以說明:「我跟團隊做一個簡單的報告,再一起來討論怎麼樣幫助你...」。這個部分,學生學習操作的是「有效率的溝通和說明、簡要個案報告、包括病人並以病人為中心的團隊病情討論」,幫助學生處理病患的問題、建立關係的基本技巧。
  • 
(C)如果學生沒有能力迅速完成這個步驟,以致於病患的基本的需求未受到初步處理,就難以進入精神病理診斷和處置(以精神科為例子)的第三及第四步驟。
三、「精確性會談(精神病理學導向)」:在初步處理完主訴之後,學生會進一步學習到進階的精神病理會談和評估。這個階段的會談技巧,都是具有「方向性、精確性、引導性、相對封閉式」之系列問題,也是真正探索病患內心病理狀態的菁華(如果在非精神科,則是精實的病史詢問和理學評估),一個傑出的臨床精神科醫師,在這個階段的問句和評估,可以比擬傑出的外科醫師般之精準。

四、「診斷及計畫」:這個部分對於學生而言是最困難、最有挑戰性的。如何綜合病患的臨床表現、優先處理緊急危及安全的問題、安排有效率的檢查、縮小精神病理的診斷範圍、並提出具體的治療計畫。更複雜的技能還包括,如何運用病人可以理解的語言來溝通、讓病患及家屬對自己的狀況獲得一定程度的了解、對後續處置有一定的共識、達到化解病患疑慮和不安的目的、對診斷和治療產生一定的信心。學生除予要有相當豐富的鑑別診斷能力、緊急病症處理技巧、疾病之藥物和非藥物治療的理論與實務的知識、更要能有效地和病患溝通,以確保治療計畫能夠順利執行。

  • 學生教學重點摘要:
  1.  落實完整之交班程序及內容,強調同學見習結束前一定要確實交班,於下一梯驗收交班成果(意即:被交班的下一組同學的一開始的臨床表現,是交班同學結業成績的重要部分)。
  2. 從第一日起,醫學生每天皆擔任團隊查房之第一線,住院醫師擔任主要之助教。
  3. 以每日之床邊教學做練習 、每週之會談教學做觀摩。
  4. 學生接觸病患的第一步,是從最基本的「打招呼(暖身)、介紹(自我及團隊)以及說明來意」紮實做好;使用開放式的問題,聆聽病人的主觀陳述;學習溝通之基本技巧「積極聆聽、不打斷鼓勵表達、開放式問句、正向回饋」。







3 comments:

  1. Patient Engagement: 9 Ways to Engage Patients on Their Own Terms
    https://hitconsultant.net/2018/09/17/patient-engagement-goals/

    by Peter Borden, Chief Digital Officer, Healthcare, Cognizant, and Charlotte Vangsgaard, Partner at ReD Associates 09/17/2018

    Prioritizing measurable clinical outcomes, defining an evidence-based, codified patient journey, and incenting strict adherence to treatment plans have been the base for many patient engagement initiatives. These seem to be logical ways to improve outcomes, reduce costs and encourage patients to follow post-care plans mapped to a journey designed to yield specific clinical measures. Yet despite the industry’s focus on patient centricity, the healthcare industry is still struggling to realize the promise of effective engagement.

    According to recent research conducted by Cognizant and ReD Associates, many of the healthcare industry’s efforts to engage patients are based upon an array of faulty assumptions grounded in a cold system of care that calls for patient engagement to prioritize measurable outcomes, reinforce one-size-fits-all patient journeys, and reduce the risk of patients deviating from treatment plans.

    1. Help me measure healing according to my life goals.

    Almost 85% of the respondents said clinical metrics did not reflect their experience of healing, so initiatives aligned to purely clinical goals will be less effective.

    2. Help me optimize my quality of life

    Patients reported their treatment plans often were difficult to follow and did not offer real choices appropriate for their situations. Today’s technology, including smartphones and tablets, can offer contextualized recommendations and guidance based on a specific patient’s goals, lifestyle, abilities, and resources that are backed with artificial intelligence (AI), machine learning and analytics that “know” a specific patient.

    3. Help me get information from my peers

    4. Help me personalize my healing journey.

    5. Help me minimize the impact of my illness.

    Healthcare’s mantra is to minimize what’s asked of patients—to keep requests simple in hopes of improving adherence. Yet the survey showed patients and caregivers will put a great deal of effort into minimizing the effects of illness.

    6. Help me share my story.

    The study showed that almost 70% of the respondents had not heard from their primary care provider outside of a scheduled visit in the last two years. That’s a long time in which the details of a patient’s personal health story accrue. Engagement tools need to capture these narratives that don’t fit neatly into electronic health records, provide a mechanism for two way communication between the patient and healthcare provider, and flag potential areas of concern.

    7. Help me intelligently adjust through experimentation.

    In line with making health management fit into their lives, patients experiment with the best ways to accomplish that, going through a process of trial and error. Of respondents taking prescription drugs, for example, 47 percent experimented with the timing and dosages of their prescriptions. Engagement programs could provide patients with personalized guidance through their experiments, such as providing plain language explanations of safe timings for drug dosages.

    8. Help me see the cause and effect.

    While patients said they measure their healing by how their bodies feel, engagement tools can help them see the links between those feelings and their actions, whether that’s taking a lower dosage of a drug or adding a physical therapy exercise to their day.

    9. Help me connect and heal within my circle of care.

    Most patients don’t travel alone on their healing journeys. Their healing is influenced by relationships at home and in the community as well as in their healthcare system. Engagement tools should help patients connect to and gain support from these systems.

    ReplyDelete
  2. HOW TO ENGAGE PATIENTS WITH EFFECTIVE COMMUNICATION
    By Michelle Bright, BA

    https://www.studergroup.com/resources/articles-and-industry-updates/insights/april-2017/how-to-engage-patients-with-effective-communicatio

    In "The E-Factor", written by my colleague, Craig Deao, MHA, he describes engagement as giving discretionary effort (even when no one is watching) because of the level of commitment one has for the work they are doing.

    Patient anxiety during healthcare visits or hospital stays is commonplace, perhaps brought about by pain, concern over the financial impact of care, or merely a disruption in their daily routine. When patients get anxious, they often don't listen well, don't communicate vital information, become defensive, feel overwhelmed with even basic instructions, or don't follow through on physician recommendations. Caregivers may misinterpret this behavior as a lack of engagement or discretionary effort to comply with their care plan. In actuality, the patient is likely confused, scared or simply coping with general anxiety.

    Decrease Patient Anxiety and Increase Patient Commitment
    Nothing builds trust with patients as quickly as effective communication in which healthcare professionals express empathy and build the patient's confidence in the caregiver's expertise. AIDET® is Studer Group's communication framework that addresses what patients say they want most from their caregivers: empathy and competence.

    When AIDET is used effectively, it works to decrease patient anxiety and increase their commitment to their own healthcare. It's a simple way to incorporate fundamental patient communication elements throughout the healthcare culture so that it influences every patient interaction. AIDET is not a script. It is a simple framework for all healthcare professionals to follow to ensure patient communication consistently addresses key concerns, conveys empathy, builds confidence, and promotes patient ability to collaborate with their healthcare team.

    I have seen real-world application of effective communication and AIDET to drastically improve patient activation in many of the large healthcare systems I have coached.

    A Cultural Competency
    To fully leverage the talent throughout an organization, it's important that every interaction is positioned as an opportunity to reduce anxiety and promote patient activation; the responsibility of empowering and activating patients is not strictly reserved for clinical staff. Recently while onsite at a Studer Group partner organization, I was validating the use of the AIDET communication structure with an Environmental Services (EVS) employee on an oncology unit. In that evaluation, we saw how impactful each interaction can be when an employee takes advantage of the unique opportunities in their everyday work.

    The EVS employee demonstrated strength in her overall AIDET competency, and completed her "tasks" efficiently. During her 3-minute interaction with one patient, I'd checked off everything on my competency checklist except for one thing; she hadn't taken the opportunity to "manage up" others on the care team to foster ongoing collaboration. As we were walking out of the room, I was about to discuss my reactions with the employee, when she stopped. She realized that the patient didn't have a tray in her room and asked if she had eaten breakfast. The patient said she had just finished a round of chemo and wasn't hungry. She said she didn't think she would eat breakfast that day.

    The employee calmly replied, "You know you need to eat so that you can get better and go home. And I have seen what we are serving for breakfast. In fact, that's what I had for breakfast. I could have had breakfast at home, but I prefer to have breakfast here because it's so good."

    ReplyDelete
  3. HOW TO ENGAGE PATIENTS WITH EFFECTIVE COMMUNICATION
    By Michelle Bright, BA

    https://www.studergroup.com/resources/articles-and-industry-updates/insights/april-2017/how-to-engage-patients-with-effective-communicatio

    The next thing we knew, the patient changed her mind. "Well, you know what? I think I could eat just a little bit now." The employee promptly connected with the dietary aide delivering trays, and the patient had her tray within minutes. We were only on that unit another 20 minutes, and by the time we walked back by that patient's room, she had eaten her entire meal. That EVS employee made a difference that day - for the nurse on that unit and for the patient - simply by managing up the quality of the food.

    Partnering with Patients
    One of the most important reasons to foster a cultural communication competency such as AIDET that promotes better partnership with our patients is so our communities are better served through our work. I was recently rounding with a COO on a Med/Surg unit, validating AIDET with a respiratory therapist.

    We went into a patient room and the respiratory therapist went through the motions of AIDET - she introduced herself, explained why she was there, and what the treatment would entail. Before the respiratory therapist could even finish, the patient stopped her and said, "Not right now. I just don't feel like it." Just looking at the patient, we could tell the patient didn't feel good, and he wasn't breathing well either. He clearly needed that treatment, but the respiratory therapist followed the patient's lead and postponed the treatment. I didn't say anything at that time as I was still processing the exchange, but then we went to the next room and again the next patient refused therapy. The respiratory therapist told the patient she would come back and left without giving a treatment.

    When we left the room, I asked the COO when the respiratory therapist would circle back to those patients to give them their treatments. I knew she was about to go off shift. He said, "I guess she will just make the rounds until it's time for her to clock out. We don't have a respiratory therapist on at night. The next shift in the morning can try again." That means those patients could conceivably have gone 12 hours before anyone tried to give them another treatment.

    The Bottom Line
    As we know, our revenue margins have decreased significantly throughout healthcare. Not only can we not afford for a respiratory therapist to make multiple rounds over five hours hoping to eventually give treatments to all their patients, we can't afford the inefficiency that comes from a disengaged patient base.

    In this era of healthcare, we need patients to assume more responsibility for their role in improving their health. However, they are at a disadvantage. Patients typically don't have clinical expertise, and, on top of that, they are sick and vulnerable. Providers have the responsibility to reach out and engage them. And we need to take the time to train our healthcare teams to better engage patients. If we do that, patients become partners in the solution. We can first reduce their anxiety to a point where they are willing to engage, and then intentionally communicate in a way that makes it possible for the patient to actively participate in their care.

    The bottom line is that with the level of efficiency we seek to achieve in healthcare, there is no way we can make transformational changes without our patients' partnership. We must commit to not only involving them in their care but also "building a better patient" through their time in our care. As healthcare leaders, we maximize the investments we make in our organizations when we intentionally leverage our clinical expertise through a cultural competency that activates patients to also invest in the things they can do to improve their health.

    ReplyDelete