本帖最後由 lsc0019 於 2009-5-24 20:58 編輯
作者：Allison Gandey
出處：WebMD醫學新聞
May 8, 2009(加州聖地牙哥) — 細心訪談病患且完整聆聽他們的反應，可以提供給醫師有關治療疼痛的有用資訊。這是美國疼痛協會第28屆年度科學會議中，全體會議的演講主題。
最近從維吉尼亞大學健康體系退休的David Morris博士討論有關與病患完整溝通的重要性，他形容這是一種敘事能力的過程，他認為，缺乏技巧的方法會使結果惡化。
Morris博士表示，敘事能力不同於詢問「哪裡痛？」、「怎麼了？」，第一個問題可能用手指比一下就回答完畢，第二個問題則可以鼓勵病患與醫師對話。
Morris博士指出，最初是由紐約哥倫比亞大學外科學院的Rita Charon醫師在美國醫學協會期刊 (JAMA. 2001;286:1897-1902)提出敘事能力。Morris博士形容這是一項指標性研究，推崇Charon醫師與其貢獻。
美國疼痛協會前任主席Judith Paice博士在訪問中提出同樣看法。Charon醫師的研究相當傑出。在西北大學，我們提供醫學生更多強調醫療人性面的課程，Charon醫師的研究在閱讀書單上。Paice博士是西北大學醫學研究教授、癌症疼痛計畫主任。
【鼓勵溝通】
Charon醫師的研究討論醫病關係，強調同理心、回應、專業與信任的重要。她寫道，有效的醫療實務需要敘事能力，也就是對其他人的敘事和狀況有瞭解、吸收、詮釋、行動的能力。
Morris博士在全體會議中表示，我相信，有強烈敘事能力的醫師可以幫助減少病患的恐懼、降低認為的疼痛強度、改善整體生活品質。
Morris博士引述的研究認為，病患對於疼痛的看法和治療結果有關；他表示，對話可以幫助病患用新的角度思考其狀況，避免會讓他們焦慮、恐懼與無望的負面思考模式。
他相信，改善溝通對醫師也有潛在好處。敘事醫學將是讓醫師回到醫療本位－幫助病患改善生活品質的希望－的最成功方法。
他表示，這對醫師很重要。他們是否真正高興、他們的醫療是否在這5分鐘的病患訪談中滿足？
【與病患互動】
聽眾之一、加州Sonoma Valley醫院的Robert Geiger醫師被要求提估評論時表示同意。若無傾聽，我們無法做出正確的診斷與治療。太多人聚焦在數據而非溝通，我保守估計，95%的診斷可來自病史。
例如，Geiger醫師表示他與病患互動可以得到比影像檢查結果更多的訊息。
Paice博士指出，人們不只是症狀、藥歷、診斷發現。他們是複雜的，有情緒、目標和恐懼，我們必須加以瞭解才可以有所幫助。
Paice博士表示，在她的診間有一份問題表列。她會問病患：
* 你靠什麼營生？
* 什麼帶給你力量？
* 什麼帶給你喜悅？
Paice博士表示，這三個簡單的問題幫助她瞭解病患，這些問題提供有關病患如何處理疼痛以及是否需要協助的重要資訊。
David Morris博士宣告沒有相關資金上的往來。
美國疼痛協會第28屆年度科學會議：摘要102。發表於2009年5月7日。
APS 2009: Thorough Patient History Essential to Treat Pain
By Allison Gandey
Medscape Medical News
May 8, 2009 (San Diego, California) — Carefully interviewing patients and thoughtfully listening to their responses can provide a wealth of information to help clinicians treat pain. This was the subject of the plenary lecture here at the American Pain Society 28th Annual Scientific Meeting.
David Morris, PhD, recently retired from the University of Virginia Health System in Charlottesville, talked about the importance of thoroughly communicating with patients. It is a process he calls narrative competence, and he warns that an unskilled approach can adversely affect outcomes.
Dr. Morris says narrative competence is the difference between asking, Where does it hurt and What is the matter? The first question can be answered with the point of a finger and may shut down communication, while the second encourages conversation.
Dr. Morris noted that the concept of narrative competence was first presented by Rita Charon, MD, from the College of Physicians and Surgeons of Columbia University, in New York, in the Journal of the American Medical Association (JAMA. 2001;286:1897-1902). Dr. Morris calls it "landmark work" and applauds Dr. Charon for her contribution.
During an interview, American Pain Society past president Judith Paice, PhD, voiced similar praise. "Dr. Charon's work is excellent. At Northwestern, we offer courses for medical students highlighting the more human side of medicine, and Dr. Charon is on our reading list." Dr. Paice is the director of the cancer pain program and a research professor of medicine at Northwestern University.
Encouraging Communication
Dr. Charon's paper discusses the patient-physician relationship and highlights the importance of empathy, reflection, professionalism, and trust. She writes, "The effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others."
During the plenary, Dr. Morris said, "I believe clinicians with strong narrative abilities can help reduce their patients' fear, lower perceived pain intensity, and improve overall quality of life."
Dr. Morris cited work suggesting that patients' beliefs about pain correlated with treatment outcomes. He said that dialogue can help patients think about their condition in new ways and avoid patterns of negative thinking, which can leave them feeling anxious, fearful, and hopeless.
He believes improving communication has potential benefits for physicians as well. "Narrative medicine might be most successful in allowing physicians to return to what drew them to medicine in the first place — a desire to help patients and to improve their quality of life."
This matters for clinicians, he said. "Are they really happy and are their medical desires fulfilled with a 5-minute encounter with patients?"
Interacting With Patients
Asked by Medscape Neurology & Neurosurgery to comment, meeting attendee Robert Geiger, MD, from Sonoma Valley Hospital, in California, said he agrees. "We cannot make an appropriate diagnosis and treatment without listening. Too many people focus on the numbers and not on communication, and I would say that 95% of the diagnosis comes from personal history — and that's a conservative number."
Dr. Geiger says he learns more from interacting with patients than from imaging results, for example.
"People are so much more than their symptoms, list of medications, and diagnostic findings," Dr. Paice added. "They are complex, with emotions, goals, and fears, and we have to get at that, if we are going to be able to help."
Dr. Paice says she has a list of questions that help her in clinic. She asks patients:
What do you do for a living?
What gives you strength?
What brings you joy in life?
Dr. Paice says these 3 simple questions help her get to know her patients, and they provide important information about how people are coping and whether they have support to help deal with their pain.
Dr. David Morris has disclosed no relevant financial relationships.
American Pain Society 28th Annual Meeting: Abstract 102. Presented May 7, 2009. |
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