慢性病管理與患通-thehongkongmedicalassociation

1、第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,慢性病管理與醫(yī)患溝通——如何把病人領(lǐng)回生命的春天,Management of Chronic Diseases and Doctor-patient Communication --how to “revitalize” our patients,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,北京朝陽(yáng)區(qū)建外社區(qū)衛(wèi)生服務(wù)中心 （航空工業(yè)中心醫(yī)院第二門診部）黃 萍，全科醫(yī)

2、生，內(nèi)科主任醫(yī)師E-mail :Dr.huangping@gmail.com聯(lián)系電話：（010）65665101 手機(jī)：13671185906English Translation: Dr. Martin WONG, CUHK,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,高血壓、糖尿病、冠心病和缺血性腦血管病等慢性病的有效管理，是社區(qū)全科醫(yī)生的重要工作內(nèi)容，也是一個(gè)比較困難的課題。,It i

3、s an important yet a difficult task for family physicians to efficiently manage chronic diseases like hypertension, diabetes, coronary heart diseases and ischemic cerebrovascular diseases.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,因?yàn)榇祟惣?/p>

4、病不但需要有效藥物的治療，有責(zé)任心的醫(yī)生的隨訪，而且更需要病人的長(zhǎng)期的積極配合——特別是在改變生活方式方面——這一項(xiàng)可以說(shuō)起著決定性的作用。,Besides drug therapy and regular follow-up, the most crucial factor for effective management depends on our patients’ compliance—especially life styl

5、e modifications.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,而醫(yī)生與病人的良好溝通是提高病人治療依從性必不可少的途徑。,Patient’s compliance depends very much on effective doctor-patient communication.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,這就像世界醫(yī)學(xué)教育聯(lián)合會(huì)《福岡宣言》所指出的一樣：所有醫(yī)生必須學(xué)會(huì)交流和處理人

6、際關(guān)系的技能。缺少共鳴（共情）應(yīng)當(dāng)看做與技術(shù)不夠一樣，是無(wú)能力的表現(xiàn)。因此，應(yīng)當(dāng)認(rèn)為醫(yī)患交流是醫(yī)生的必修課。,As stated in by World Federation for Medical Education, all doctors must learn how to communicate effectively with their patients. Lack of empathy should be rega

7、rded as incapability, or lack of skill. Hence, “doctor-patient communication” is an indispensable subject,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,病例1 ，張某 男性 74歲 因患糖尿病、冠心病，心肌梗死，冠脈搭橋術(shù)，術(shù)后下肢傷口感染開裂請(qǐng)醫(yī)生出診換藥。,Case No.1, Mr. Zhang,74/M,Di

8、abetes, CHD, old myocardial infarct, post-CABG?lower limbs wound infection with “cracking”?doctor consulted for home wound dressing.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,初見病人情緒沮喪，右下肢大隱靜脈手術(shù)傷口幾乎全層開裂，寬15厘米，深約1.2厘米，有少許膿性分泌物覆蓋。（圖1）,T

9、he patient was very depressed as layers of operated deep vein wound (for CABG) remained open. It was 15cm wide and 1.2cm deep with a little pus on it (Figure 1),第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,,,2006年6月28日 空腹血糖7.8mmol/L，餐后

10、2hr11.7mmol/L,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,當(dāng)時(shí)病人非常悲觀，眉頭緊鎖，認(rèn)為痊愈希望渺茫。查空腹血糖與餐后血糖均高于不正常。,The patient was very sad and pessimistic about the chance of recovery. His FBG and 2hrppG were all abnormal.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,醫(yī)

11、生首先說(shuō)明傷口愈合與血糖水平密切相關(guān)，后者又與飲食、運(yùn)動(dòng)情況直接聯(lián)系，而情緒好壞在穩(wěn)定血糖方面有不可替代的作用。,Doctor explained that wound healing was related to blood sugar level which directly relates to diet and physical activity. Moreover, mood stability is a key facto

12、r in keeping blood sugar normal.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,所以首先要有對(duì)治療的信心，才能獲得康復(fù)的“通行證”。說(shuō)白了，嘴角朝上走（笑著），血糖才會(huì)朝下走。病人被醫(yī)生逗樂了，一下子氛圍充滿溫馨。,Therefore, the patient must have confidence in treatment before he could get the “passport” f

13、or healing. The more laughter, the better will be the blood sugar control, said the doctor. The atmosphere became so warm the patient was pleased.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,醫(yī)生在每天上門換藥治療時(shí)，指導(dǎo)病人自我監(jiān)測(cè)血糖和飲食營(yíng)養(yǎng)配餐，調(diào)整胰島素用量，囑咐病人每天要

14、有活動(dòng)。,During the daily home visit for wound dressing, the doctor taught the patient self-monitoring of blood sugar, diet control, insulin adjustment, as well as advice on daily exercise.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,經(jīng)過20天病人血

15、糖接近正常水平，但是仍常波動(dòng)，傷口愈合緩慢。,Twenty days later, the patient’s blood sugar was close to normal, though still unstable. Wound healing was yet slow. (picture 2),第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,,,2006年7月17日FPG 7.8mmol/L, Night BS 10.8m

16、mol/L,F 1,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,醫(yī)生發(fā)現(xiàn)病人由于腿傷走路困難，活動(dòng)量不足，建議病人多活動(dòng)上肢，病人說(shuō)不知道如何增加活動(dòng)，有畏難情緒。,The doctor found that the patient had insufficient physical activity due to walking problems. The patient was advised to do upper li

17、mb exercise but felt difficult.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,醫(yī)生手把手教病人作“伸張正義”的手操，并設(shè)計(jì)了一張記錄表，要求每日登記運(yùn)動(dòng)量。,The doctor designed a special “schedule of action” chart and requested him to record details of his daily exercise,第八屆京港醫(yī)學(xué)

18、交流會(huì)議 2006-11-11～12,康復(fù)鍛煉量化計(jì)劃執(zhí)行情況表schedule of action plan for rehabilitative exercises,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,正由于目標(biāo)明確，病人非常配合，血糖迅速恢復(fù)正常并得到保持，傷口愈合明顯加速。,The blood glucose level normalized and wound began to heal after good

19、 compliance with specific targets,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,,,2006年7月26日FPG6.0mmol/L, NPG 4.1mmol/L,F 2,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,在第45天時(shí)病人晚餐吃得過飽，夜間發(fā)作腹脹和胸痛，血糖驟升，病人情緒產(chǎn)生波動(dòng)。醫(yī)生再次予以鼓勵(lì)，并主動(dòng)作檢討，認(rèn)為自己沒有囑咐周到，相信只要注意控制飲食情況會(huì)很快好轉(zhuǎn)。,On da

20、y 45, the patient took a big meal and presented with bloating, chest pain and raised blood glucose at night, as well as some mood fluctuation.The doctor encouraged the patient and he himself evaluated his plan for the

21、patient realizing his advice was not comprehensive enough. He believed the patient’s condition would dramatically improve upon better diet modification.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,病人信心得到增強(qiáng)，血糖在二周后恢復(fù)正常水平，傷口在60天后痊愈。（F3、4、5)

22、,With reinforcement his blood glucose level returned normal after 2 weeks and the wound healed 60 days later (Figure 3, 4 & 5).,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,,,,2006年8月16日FPG7.0mmol/L, NPG 3.7mmol/L,F 3,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-

23、11-11～12,,,2006年8月23日 FPG 6.8mmol/L, NPG 6.4mmol/L,F 4,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,,,2006年8月25日 FPG 5.4mmol/L, NPG 5.0mmol/L,F 5,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,從以上案例中可以體會(huì)，慢性病管理與治療中非常強(qiáng)調(diào)醫(yī)患溝通中的重要作用。,From the above example the impo

24、rtance of doctor-patient communication is highlighted in chronic disease management.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,這就需要醫(yī)生非常認(rèn)真地對(duì)待病人提出的各種問題，通過醫(yī)患溝通來(lái)恢復(fù)他的權(quán)威和說(shuō)服力，提高病人治療的依從性和積極性。,It requires careful consideration to patients’ vario

25、us problems, and restores his authority and persuasiveness via good communication skillsPatient’s would be more compliant and proactive in the treatment plan.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,一、強(qiáng)調(diào)在慢性病治療中

26、 醫(yī)患溝通的重要性 highlighting the importance of communication in chronic disease management,常見醫(yī)生說(shuō)，頻繁地更換藥物，療效仍然不穩(wěn)定。實(shí)際上最可能的是，病人根本沒有按照醫(yī)生的囑咐服藥As often heard from some doctors, frequent change of medications could not ach

27、ieve stable therapeutic targets. The most possible reason behind may simply be patient’s non-compliance to drugs.醫(yī)生要耐心傾聽病人的意見，給與恰到好處的說(shuō)明Doctors should listen to our patients attentively and responds with appropriate a

28、dvice,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,二、醫(yī)患溝通的內(nèi)容選擇Selecting the content of doctor-patient communication,應(yīng)該選擇對(duì)于提高病人治療隨訪依從性有重要?jiǎng)恿ψ饔玫膬?nèi)容來(lái)作為醫(yī)患溝通We should base on strategies which could improve significant patient compliance as the

29、content of doctor-patient communication,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,1、溝通最重要的內(nèi)容：獲得治療動(dòng)力The most important message in communication—acquiring motivations for treatment,正確的治療理念是病人參與治療的持久動(dòng)力。A correct concept in treatment is a

30、 persistent motivator for patient’s compliance in the management plan.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,2、溝通次重要的內(nèi)容：清晰解讀治療方案The second important content in communication—clear explanation of treatment plan,高血壓、糖尿病、代謝綜合征、痛風(fēng)癥等與生活

31、方式密切相關(guān)的慢性病，在治療中必須改變生活方式是非藥物治療的重要組成部分，需要向病人詳細(xì)說(shuō)明，方能保證治療的有效Hypertension, Diabetes, metabolic syndrome, and gout etc. are closely related to lifestyles. In our management, lifestyle modification is an important non-pharmac

32、ological measure and should be clearly explained to our patients to make sure effective treatment.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,3、應(yīng)該照顧到的其他溝通內(nèi)容：病人的心理狀態(tài)。Other contents in communication of relevance--patients’ psychological

33、status,醫(yī)生要注意在這個(gè)過程中給與耐心、愛心、理解、心理支持和個(gè)體化指導(dǎo)，幫助病人度過這一困難時(shí)期。A continuing caring, empathizing attitude and psychological support with tailor-made advice could substantially help our patients to deal with their difficult times.

34、社區(qū)的全科醫(yī)生要善于、也能夠通過努力把病人帶回到生命的春天的陽(yáng)光里。General Practitioners should be able to revitalize our patients through continuous efforts.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,三、醫(yī)患溝通的主要環(huán)節(jié)The major crucial factor in doctor-patient communicatio

35、n,實(shí)踐證明，醫(yī)患之間有效的溝通，能夠改變病人對(duì)疾病的認(rèn)識(shí)誤區(qū)，從而實(shí)現(xiàn)了由被動(dòng)接受治療到主動(dòng)參與自我健康管理的角色轉(zhuǎn)變。Evidence shows that effective doctor-patient communication could change patient’s misconception towards diseases, and allow our patient to change their role i

36、n management—“passively receiving treatment ? active self-management”,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,主要環(huán)節(jié)有：①對(duì)于需要隨訪的慢性病人，要在約定的時(shí)間給病人以充分傾訴的機(jī)會(huì)； ②認(rèn)真傾聽病人對(duì)自身疾病的感受、認(rèn)知、疑問、顧慮和困擾,(1). Allow adequate ventilation in the interview for pa

37、tients with chronic diseases.(2). Attentively listen to patient’s view on his disease, including his awareness, enquiries, concerns and difficulties,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,③ 接受：醫(yī)生對(duì)病人的表述要善于換位思考，表示共情與理解；④ 確認(rèn)問題，使用適當(dāng)方法

38、澄清病人存在的問題,(3). Acceptance—doctor should think based on what patient reveals and show empathy and understanding.(4). Clarify patient’s issues using appropriate strategies.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,⑤過程要注意語(yǔ)言的通俗簡(jiǎn)潔，深入淺出，淺顯易

39、懂；⑥要與病人討論治療康復(fù)計(jì)劃以及生活方式改變的量化目標(biāo)，與病人取得共識(shí)；,(5). Attention should be paid to the use of easily understandable language during the interview (6). Discuss with the patient quantifiable goals in the management plan and lifesty

40、le changes, and negotiate for patient’s consensus.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,⑦幫助病人養(yǎng)成定期隨訪與記錄收獲等自我監(jiān)督習(xí)慣，教會(huì)自我健康管理的技能； ⑧反饋診療情況（如體檢和化驗(yàn)結(jié)果的解釋）,(7). Help patient develop a habit of regular follow-up and self-monitoring, and educ

41、ate on the skills of self-management(8). Feedback the patient’s condition on follow-up (like explaining physical examination & investigation findings),第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,⑨醫(yī)患共同討論新的治療、康復(fù)和保健目標(biāo)，進(jìn)入第二輪溝通。實(shí)踐說(shuō)明醫(yī)生與病人

42、溝通的越好，治療就越主動(dòng)，效果相對(duì)來(lái)說(shuō)就越好。,(9). Discuss new treatment plans, rehabilitative and health maintenance targets with patients. Better communication would lead to a more proactive approach to treatment, and thus a better outcome

43、.,第八屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,參考文獻(xiàn)References,Frederic W. Platt Geoffrey H. Gordon 編著，張勉等譯：《醫(yī)患交流指南》；天津科技翻譯出版公司2004年6月第1版，第168-171頁(yè)鄭靈巧：慢病防治需要新思維新策略；健康報(bào) 2004年2月12日第2版許又新：《現(xiàn)代心理治療手冊(cè)》；北京醫(yī)科大學(xué) 中國(guó)協(xié)和醫(yī)科大學(xué)聯(lián)合出版社，1997年3月第1版，60-61頁(yè),第八

44、屆京港醫(yī)學(xué)交流會(huì)議 2006-11-11～12,參考文獻(xiàn),[美] Phillip L.Rice 著，胡佩誠(chéng) 等譯：《健康心理學(xué)》，中國(guó)輕工業(yè)出版社，2000年10月第1版，第94-98頁(yè) 王漢亮主編：《生活方式疾病防治》；北京大學(xué)出版社，2004年3月第1版，6-26頁(yè)[美] Alan M. Adelman Mel P. Day， 邢華 主譯：《基層醫(yī)療保健譯叢 老年病學(xué)》，高等教育出版社，2003年3月第1版，第164-184頁(yè)