慢性病管理与医患沟通 —— 如何把病人领回生命的春天

第八届京港医学交流会议 2006-11-11～12第八届京港医学交流会议 2006-11-11～12

慢性病管理与医患沟通慢性病管理与医患沟通————如何把病人领回生命的春天如何把病人领回生命的春天

Management of Chronic Diseases and Management of Chronic Diseases and Doctor-Doctor-patient Communicationpatient Communication

--how to “revitalize” our patients--how to “revitalize” our patients


北京朝阳区建外社区卫生服务中心北京朝阳区建外社区卫生服务中心（航空工业中心医院第二门诊部）（航空工业中心医院第二门诊部）黄萍，全科医生，内科主任医师黄萍，全科医生，内科主任医师 E-mail :E-mail :[email protected]@gmail.com 联系电话：（联系电话：（ 010010 ）） 6566510165665101 手机：手机： 1367118590613671185906

English Translation: Dr. Martin WONG, CUHKEnglish Translation: Dr. Martin WONG, CUHK


高血压、糖尿病、冠心病和缺血高血压、糖尿病、冠心病和缺血性脑血管病等慢性病的有效管理，性脑血管病等慢性病的有效管理，是社区全科医生的重要工作内容，是社区全科医生的重要工作内容，也是一个比较困难的课题。也是一个比较困难的课题。

It is an important It is an important yetyet a difficult a difficult tasktask for family for family physicianphysicianss to efficiently manage chronic disea to efficiently manage chronic diseases ses likelike hypertension, diabetes, coronary hear hypertension, diabetes, coronary heart diseaset diseasess and ischemic cerebrovascular disea and ischemic cerebrovascular diseasesess. .


因为此类疾病不但需要有效药物的治疗，有责任心因为此类疾病不但需要有效药物的治疗，有责任心的医生的随访，而且更需要病人的长期的积极配合—的医生的随访，而且更需要病人的长期的积极配合——特别是在改变生活方式方面——这一项可以说起着—特别是在改变生活方式方面——这一项可以说起着决定性的作用。决定性的作用。

BesidesBesides drug therapy and drug therapy and regular follow-upregular follow-up, t, the most he most crucialcrucial factor factor for effective for effective management depends on ourmanagement depends on our patients patients’ ’ compliance—especiallycompliance—especially life style life style modificationsmodifications..


而医生与病人的良好沟通是而医生与病人的良好沟通是提高病人治疗依从性必不可少的提高病人治疗依从性必不可少的途径。途径。

Patient’s compliance Patient’s compliance dependsdepends very very much on much on effective doctor-patient effective doctor-patient communication.communication.


这就像世界医学教育联合会《福冈宣言》所这就像世界医学教育联合会《福冈宣言》所指出的一样：所有医生必须学会交流和处理指出的一样：所有医生必须学会交流和处理人际关系的技能。缺少共鸣（共情）应当看人际关系的技能。缺少共鸣（共情）应当看做与技术不够一样，是无能力的表现。因此，做与技术不够一样，是无能力的表现。因此，

应当认为医患交流是医生的必修课。应当认为医患交流是医生的必修课。 As As statedstated in <Fukuoka Pronunciamento> by World Fe in <Fukuoka Pronunciamento> by World Fe

deration for Medical Education, all doctors must learn deration for Medical Education, all doctors must learn how to communicate effectively with their patients. how to communicate effectively with their patients.

Lack of empathy should be regarded as incapabLack of empathy should be regarded as incapabilityility, , oror lack of skill. lack of skill. HenceHence, “doctor, “doctor--patient communicatipatient communication” on” is an indispensable subjectis an indispensable subject


病例 1 ，张某男性 74 岁因患糖尿病、冠心病，心肌梗死，冠脉搭桥术，术后下肢伤口感染开裂请医生出诊换药。 Case No.1Case No.1, , Mr. Zhang,Mr. Zhang,74/M74/M,, Diabetes, CHD, old Diabetes, CHD, old myocardialmyocardial infarct, infarct, post-post-CC

ABABGG

lower limbs lower limbs wound infection with wound infection with ““cracracking”cking”

doctor doctor consulted for home wound consulted for home wound dressing.dressing.


初见病人情绪沮丧，右下肢大隐静脉手初见病人情绪沮丧，右下肢大隐静脉手术伤口几乎全层开裂，宽术伤口几乎全层开裂，宽 1515厘米，深约厘米，深约1.21.2厘米，有少许脓性分泌物覆盖。（图厘米，有少许脓性分泌物覆盖。（图11 ）） The patient was very depressedThe patient was very depressed as as layer layer

s of s of operatedoperated deepdeep vein vein wound (for wound (for CABG)CABG) remainedremained openopen. .

It was 15cm wide and 1.2cm deep with a It was 15cm wide and 1.2cm deep with a little pus on itlittle pus on it (Figure 1) (Figure 1)


2006年 6月 28日空腹血糖 7.8mmol/L ，餐后 2hr11.7mmol/L


当时病人非常悲观，眉头紧锁，当时病人非常悲观，眉头紧锁，认为痊愈希望渺茫。查空腹血糖认为痊愈希望渺茫。查空腹血糖

与餐后血糖均高于不正常。与餐后血糖均高于不正常。 The patient was very The patient was very sad and sad and pessimistipessimisti

c c about the chance of recovery.about the chance of recovery.

His FHis FBBG and 2hrG and 2hrppppG were all abnormal.G were all abnormal.


医生首先说明伤口愈合与血糖水平密切相医生首先说明伤口愈合与血糖水平密切相关，后者又与饮食、运动情况直接联系，而关，后者又与饮食、运动情况直接联系，而情绪好坏在稳定血糖方面有不可替代的作用。情绪好坏在稳定血糖方面有不可替代的作用。

Doctor explained that Doctor explained that wound wound healing was healing was related to related to blood sugar levelblood sugar level which directl which directly relatey relatess to diet and physical activity. to diet and physical activity. MorMoreovereover, mood , mood stability stability is a key factor iis a key factor in keeping blood sugar normal.n keeping blood sugar normal.


所以首先要有对治疗的信心，才能获得康复所以首先要有对治疗的信心，才能获得康复的“通行证”。说白了，嘴角朝上走（笑的“通行证”。说白了，嘴角朝上走（笑着），血糖才会朝下走。病人被医生逗乐了，着），血糖才会朝下走。病人被医生逗乐了，一下子氛围充满温馨。一下子氛围充满温馨。

Therefore, the patient must have Therefore, the patient must have confidence inconfidence in treatment before he coul treatment before he could get the “passport” for healing. The d get the “passport” for healing. The more laughter, the more laughter, the betterbetter will will be be the blthe blood sugar ood sugar controlcontrol, , said said the doctor. the doctor. The The atmosphere atmosphere becamebecame so so warmwarm the the patient was pleasedpatient was pleased..


医生在每天上门换药治疗时，指导病人医生在每天上门换药治疗时，指导病人自我监测血糖和饮食营养配餐，调整胰自我监测血糖和饮食营养配餐，调整胰岛素用量，嘱咐病人每天要有活动。岛素用量，嘱咐病人每天要有活动。

During the daily home visit During the daily home visit forfor wound dre wound dressing, the doctor taught the patient ssing, the doctor taught the patient self-self-monitoring ofmonitoring of blood sugar blood sugar, , diet diet controlcontrol,, insulin adjustmentinsulin adjustment, a, as well ass well as advice advice on daily exercise.on daily exercise.


经过经过 2020 天病人血糖接近正常水平，但是天病人血糖接近正常水平，但是仍常波动，伤口愈合缓慢。仍常波动，伤口愈合缓慢。

Twenty days later, the patient’s blood Twenty days later, the patient’s blood sugar was close to normal, though sugar was close to normal, though still still uunstable. Wound healing was nstable. Wound healing was yet yet slow. slow. (picture 2) (picture 2)

第八届京港医学交流会议 2006-11-11～12第八届京港医学交流会议 2006-11-11～122006 年 7 月 17 日 FPG 7.8mmol/L, Night BS 10.8mmol/L

F 1


医生发现病人由于腿伤走路困难，医生发现病人由于腿伤走路困难，活动量不足，建议病人多活动上肢，活动量不足，建议病人多活动上肢，病人说不知道如何增加活动，有畏病人说不知道如何增加活动，有畏难情绪。难情绪。 The doctor found that the patient The doctor found that the patient

had insufficient physical activity due had insufficient physical activity due to walking problems. The patient to walking problems. The patient was advised to do upper limb was advised to do upper limb exercise but felt difficult.exercise but felt difficult.


医生手把手教病人作“伸张正义”的手医生手把手教病人作“伸张正义”的手操，并设计了一张记录表，要求每日登操，并设计了一张记录表，要求每日登记运动量。记运动量。

The doctor designed a special The doctor designed a special “schedule of action” chart and “schedule of action” chart and requested him to record details of his requested him to record details of his daily exercise daily exercise


康复锻炼量化计划执行情况表康复锻炼量化计划执行情况表schedule of action plan for rehabilitative schedule of action plan for rehabilitative

exercisesexercises

运动内容运动内容ActivityActivity

伸伸（手）（手）

张（手）张（手）正正（绷手）（绷手）

义义（手分叉）（手分叉）

计划次数计划次数frequencfrequencyy

1010次次（双）（双）

200200次次 55分钟分钟 55分钟分钟

日期日期 datedate//实际次数实际次数No. of No. of timestimes

2020次次 400400次次 2020次次 2020


正由于目标明确，病人非常配合，血糖正由于目标明确，病人非常配合，血糖迅速恢复正常并得到保持，伤口愈合明迅速恢复正常并得到保持，伤口愈合明显加速。显加速。

The blood glucose level normalized The blood glucose level normalized and wound began to heal after good and wound began to heal after good compliance with specific targetscompliance with specific targets


2006年 7月 26日 FPG6.0mmol/L, NPG 4.1mmol/L

F 2F 2


在第在第 4545 天时病人晚餐吃得过饱，夜间发作腹胀和胸天时病人晚餐吃得过饱，夜间发作腹胀和胸痛，血糖骤升，病人情绪产生波动。医生再次予以痛，血糖骤升，病人情绪产生波动。医生再次予以鼓励，并主动作检讨，认为自己没有嘱咐周到，相鼓励，并主动作检讨，认为自己没有嘱咐周到，相信只要注意控制饮食情况会很快好转。信只要注意控制饮食情况会很快好转。 On day 45, the patient took a big meal and On day 45, the patient took a big meal and

presented with bloating, chest pain and raised presented with bloating, chest pain and raised blood glucose at night, as well as some mood blood glucose at night, as well as some mood fluctuation.fluctuation.

The doctor encouraged the patient and he The doctor encouraged the patient and he himself evaluated his plan for the patient himself evaluated his plan for the patient realizing his advice was not comprehensive realizing his advice was not comprehensive enough. He believed the patient’s condition enough. He believed the patient’s condition would dramatically improve upon better diet would dramatically improve upon better diet modification.modification.


病人信心得到增强，血糖在二周后恢复正常水平，伤口在 60 天后痊愈。（ F3 、4、 5)

With reinforcement his blood glucose level returned normal after 2 weeks and the wound healed 60 days later (Figure 3, 4 & 5).


2006年 8月 16日 FPG7.0mmol/L, NPG 3.7mmol/L

F 3


2006年 8月 23日 FPG 6.8mmol/L, NPG 6.4mmol/L

F 4


2006年 8月 25日 FPG 5.4mmol/L, NPG 5.0mmol/L

F 5


从以上案例中可以体会，慢性病管理与从以上案例中可以体会，慢性病管理与治疗中非常强调医患沟通中的重要作用。治疗中非常强调医患沟通中的重要作用。

From the above example the From the above example the importance of doctor-patient importance of doctor-patient communication is highlighted in communication is highlighted in chronic disease management. chronic disease management.


这就需要医生非常认真地对待病人提出的各种问题，通过医患沟通来恢复他的权威和说服力，提高病人治疗的依从性和积极性。

It requires careful consideration to It requires careful consideration to patients’ various problems, and restores patients’ various problems, and restores his authority and persuasiveness via good his authority and persuasiveness via good communication skillscommunication skills

Patient’s would be more compliant and Patient’s would be more compliant and proactive in the treatment plan. proactive in the treatment plan.


一一、强调在慢性病治疗中医患沟通的重要性 highlighting the importance of communication in

chronic disease management 常见医生说，频繁地更换药物，疗效仍然不稳定。实际上最可能的是，常见医生说，频繁地更换药物，疗效仍然不稳定。实际上最可能的是，

病人根本没有按照医生的嘱咐服药病人根本没有按照医生的嘱咐服药 AAs often heard from some doctors, frequent change of s often heard from some doctors, frequent change of

medications could not achieve stable therapeutic targets. medications could not achieve stable therapeutic targets. The most possible reason behind may simply be patient’s The most possible reason behind may simply be patient’s non-compliance to drugs.non-compliance to drugs.

医生要耐心倾听病人的意见，给与恰到好处的说明 Doctors should listen to our patients attentively and

responds with appropriate advice


二、医患沟通的内容选择Selecting the content of doctor-

patient communication

应该选择对于提高病人治疗随访依从性有重要动力作用的内容来作为医患沟通

We should base on strategies which could improve significant patient compliance as the content of doctor-patient communication


11 、沟通最重要的内容：获得治疗动力、沟通最重要的内容：获得治疗动力TThhe most important message in e most important message in

communication—acquiring communication—acquiring motivations for treatmentmotivations for treatment

正确的治疗理念是病人参与治疗的持久动力。 A correct concept in treatment is a persistent

motivator for patient’s compliance in the management plan.


22 、沟通次重要的内容：清晰解读治疗方案、沟通次重要的内容：清晰解读治疗方案TThhe second important content in e second important content in

communication—clear explanation of communication—clear explanation of

treatment plantreatment plan 高血压、糖尿病、代谢综合征、痛风症等与生活方式密切相高血压、糖尿病、代谢综合征、痛风症等与生活方式密切相

关的慢性病，在治疗中必须改变生活方式是非药物治疗的重关的慢性病，在治疗中必须改变生活方式是非药物治疗的重要组成部分，需要向病人详细说明，方能保证治疗的有效要组成部分，需要向病人详细说明，方能保证治疗的有效

Hypertension, Diabetes, metabolic syndrome, and Hypertension, Diabetes, metabolic syndrome, and gout etc. are closely related to lifestyles. In our gout etc. are closely related to lifestyles. In our management, lifestyle modification is an important management, lifestyle modification is an important non-pharmacological measure and should be clearly non-pharmacological measure and should be clearly explained to our patients to make sure effective explained to our patients to make sure effective treatment. treatment.


3 、应该照顾到的其他沟通内容：病人的心理状态。Other contents in communication of relevance--patients’ psychological status

医生要注意在这个过程中给与耐心、爱心、理解、心理支持和个体化指导，帮助病人度过这一困难时期。医生要注意在这个过程中给与耐心、爱心、理解、心理支持和个体化指导，帮助病人度过这一困难时期。 A A continuing caring, empathizing attitude and psychological support with tailor-made advice could continuing caring, empathizing attitude and psychological support with tailor-made advice could

substantially help our patients to deal with their difficult times.substantially help our patients to deal with their difficult times. 社区的全科医生要善于、也能够通过努力把病人带回到生命的春天的阳光里。社区的全科医生要善于、也能够通过努力把病人带回到生命的春天的阳光里。 General Practitioners should be able to revitalize our patients through continuous efforts.General Practitioners should be able to revitalize our patients through continuous efforts.


三、医患沟通的主要环节、医患沟通的主要环节TThhe major crucial factor in doctor-e major crucial factor in doctor-patient communicationpatient communication

实践证明，医患之间有效的沟通，能够改变病人对疾病的认识误区，实践证明，医患之间有效的沟通，能够改变病人对疾病的认识误区，从而实现了由被动接受治疗到主动参与自我健康管理的角色转变。从而实现了由被动接受治疗到主动参与自我健康管理的角色转变。

Evidence shows that effective doctor-patient communication Evidence shows that effective doctor-patient communication could change patient’s misconception towards diseases, and could change patient’s misconception towards diseases, and allow our patient to change their role in management—allow our patient to change their role in management—

““passively receiving treatment passively receiving treatment active self-management” active self-management”


主要环节有：①对于需要随访的慢性病人，主要环节有：①对于需要随访的慢性病人，要在约定的时间给病人以充分倾诉的机会；要在约定的时间给病人以充分倾诉的机会； ②认真倾听病人对自身疾病的感受、认知、 ②认真倾听病人对自身疾病的感受、认知、疑问、顾虑和困扰疑问、顾虑和困扰

(1). Allow adequate ventilation in the (1). Allow adequate ventilation in the interview for patients with chronic diseasesinterview for patients with chronic diseases

.. (2). Attentively listen to patient’s view on (2). Attentively listen to patient’s view on

his disease, including his awareness, his disease, including his awareness, enquiries, concerns and difficultiesenquiries, concerns and difficulties


③ ③ 接受：医生对病人的表述要善于换位思考，接受：医生对病人的表述要善于换位思考，表示共情与理解；表示共情与理解；④ 确认问题，使用适当方法澄清病人存在的④ 确认问题，使用适当方法澄清病人存在的问题问题

(3). Acceptance—doctor should think (3). Acceptance—doctor should think based on what patient reveals and based on what patient reveals and show empathy and understanding.show empathy and understanding.

(4). Clarify patient’s issues using (4). Clarify patient’s issues using appropriate strategies.appropriate strategies.


⑤⑤过程要注意语言的通俗简洁，深入浅出，过程要注意语言的通俗简洁，深入浅出，浅显易懂；浅显易懂；⑥要与病人讨论治疗康复计划以及生活方式⑥要与病人讨论治疗康复计划以及生活方式改变的量化目标，与病人取得共识；改变的量化目标，与病人取得共识；

(5). Attention should be paid to the use of easily (5). Attention should be paid to the use of easily understandable language during the interview understandable language during the interview

(6). Discuss with the patient quantifiable goals in (6). Discuss with the patient quantifiable goals in the management plan and lifestyle changes, and the management plan and lifestyle changes, and negotiate for patient’s consensus.negotiate for patient’s consensus.


⑦⑦帮助病人养成定期随访与记录收获等自我帮助病人养成定期随访与记录收获等自我监督习惯，教会自我健康管理的技能；监督习惯，教会自我健康管理的技能； ⑧反馈诊疗情况（如体检和化验结果的解⑧反馈诊疗情况（如体检和化验结果的解释）释）

(7). Help patient develop a habit of regular (7). Help patient develop a habit of regular follow-up and self-monitoring, and educate follow-up and self-monitoring, and educate on the skills of self-managementon the skills of self-management

(8). Feedback the patient’s condition on (8). Feedback the patient’s condition on follow-up (like explaining physical follow-up (like explaining physical examination & investigation findings)examination & investigation findings)


⑨⑨医患共同讨论新的治疗、康复和保健目标，医患共同讨论新的治疗、康复和保健目标，进入第二轮沟通。实践说明医生与病人沟通进入第二轮沟通。实践说明医生与病人沟通的越好，治疗就越主动，效果相对来说就越的越好，治疗就越主动，效果相对来说就越好。好。

(9). Discuss new treatment plans, (9). Discuss new treatment plans, rehabilitative and health maintenance rehabilitative and health maintenance targets with patients. Better targets with patients. Better communication would lead to a more communication would lead to a more proactive approach to treatment, and proactive approach to treatment, and thus a better outcome.thus a better outcome.


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许又新：《现代心理治疗手册》；北京医许又新：《现代心理治疗手册》；北京医科大学中国协和医科大学联合出版社，科大学中国协和医科大学联合出版社， 19199797年年 33月第月第 11版，版， 60-6160-61 页页


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20042004 年年 33月第月第 11版，版， 6-266-26页页 [[ 美美 ] Alan M. Adelman Mel P. Day] Alan M. Adelman Mel P. Day ，邢华主译：《基层，邢华主译：《基层

医疗保健译丛老年病学》，高等教育出版社，医疗保健译丛老年病学》，高等教育出版社， 20032003年年 33月第月第 11版，第版，第 164-184164-184页页

Margaret Lloyd. Robert Bor: Communication Skills for Margaret Lloyd. Robert Bor: Communication Skills for MedicineMedicine；； Oxford 2004, ELSEVIER SCIENCE, Oxford 2004, ELSEVIER SCIENCE, 第第 9-259-25页页

王全楚：医患交流的技巧；孟小捷：《医生，你要懂些交王全楚：医患交流的技巧；孟小捷：《医生，你要懂些交流学》；健康报流学》；健康报 20052005年年 1111月月 2121日第日第 33版版


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慢性病管理与医患沟通 —— 如何把病人领回生命的春天

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