教學門診在輔助建立全人醫療醫病溝通技巧的應用

The Establishment of Bio-psycho-social Communication Skills through Ambulatory Care Teaching Clinics

10.6145/jme.200906_13(2).0004

林姵君(Pei-Chun Lin)；陳芸(Yun Chen)；鄭國祥(Kuo-Shyang Jeng)；朱樹勳(Shu-Hsun Chu)

全人醫療照護 ； 醫病溝通技巧 ； 教學門診 ； ambulatory care education ； doctor-patient communication skills ； bio-psycho-social medicine

Journal of Medical Education

13卷2期（2009 / 06 / 01）

102 - 112

繁體中文

結合生物心理社會三方面的醫病溝通技巧，對於達成全人照護之目標有其關鍵性。溝通技巧也是ACGME認定住院醫師六大核心能力之一。因此本研究以個案研究方式，以參與畢業後一般醫學訓練(PGY1)之住院醫師為研究對象，瞭解教學門診如何能輔助住院醫師建立全人醫療醫病溝通技巧。研究方法包括參與相關討論課程，參與教學門診並針對全人醫療溝通部分給予回饋，課程結束發給結構式問卷，共回收有效問卷21份，回收率為87.5%。研究結果發現，被指導醫師認為經由教學門診的訓練，教學知識以病史詢問(90.5%)，身體檢查(85.7%)，及醫病關係(81.0%)可有效學習。被指導醫師自我評估溝通技巧能力中，以可以使用適當的言辭，非專業術語讓病患聽得懂(76.2%)，可以與病患建立關係(71.4%)及能傾聽病患問題，瞭解病史，描述病情，理學檢查與診斷(71.4%)較具有信心。除了教學門診外被指導醫師期望亦可以提升全人醫療醫病溝通技巧的教學方式，以床邊教學(81%)及巴林小組教學(81%)居多；認為在醫病溝通時，最容易忽略病患生活經驗(76.2%)；認為最影響醫師醫病溝通的原因主要以醫師的生理狀態（如疲勞）(65%)比例佔最高。同時，在本研究中有15位住院醫師(75%)曾發生醫病溝通困難的經驗，另有11位住院醫師(52.4%)擔心自己未來會面臨醫療糾紛。被指導醫師認為造成醫療糾紛主要原因為病患與家屬態度(71.4%)所佔比例最高。研究的結果，讓我們瞭解實際透過教學門診輔助培養全人醫療醫病溝通技巧能力之成效及被指導者對於影響醫病溝通其認知，用不同角度分析探討，進而作為日後醫病溝通技巧課程內容及教學門診實施方式之參考，以提升被指導者全人醫療醫病溝通技巧能力，確保醫療品質。

The key to providing holistic healthcare is combining patient-doctor communication with the bio-psycho-social (BPS) aspects of medicine. The Accreditation Council for Graduate Medical Education (ACGME) recognizes the importance of interpersonal and communication skills and lists them as one of the six core competencies for a physician. In this study, we explored how ambulatory care teaching clinics (ACTC) can be used to teach BPS communication skills to residents. Residents in Post Graduate Year 1 (PGY 1) training were enrolled and received BPS related group discussion and ACTC training with a focus on BPS feedback. A structure questionnaire was used at the end of training, and 21 responses to the questionnaire (87.5%) were collected from 24 trainees for analysis. The results showed that the trainees efficiently obtained skills in history taking (90.5%), physical examination (85.7%), and patient-doctor relationship (81.0%). The trainees felt more confident in providing appropriate talk with understandable language (76.2%), building patient doctor relationships (71.4%), and listening and describing the patient’s medical history, physical examination and diagnosis. It was suggested that bedside teaching and Balint group teaching (81.0%) be included to improve BPS communication skills. During patient-doctor communication, the trainees often overlooked the patient’s life experience (76.2%), and thought that communication quality was influenced by a doctor’s physical state such as fatigue (65.0%). Fifteen trainees (75.0%) had previous experience with difficult patient-doctor communication, and eleven (52.4%) were worried about future medical malpractice involvement. The trainees felt that the patient's or family's attitude was the primary contributor to malpractice litigation. From this study, we demonstrated the efficacy of ACTC in establishing and teaching BPS communication skills and reported the perspectives of trainees in patient-doctor communication. These results can be a good reference for future teaching models which combine BPS communication skills with ACTC to further improve the quality of medical care.

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