医生要学习与患者沟通

BETSY came to Dr. Martin for a second — or rather, a sixth — opinion. Over a year, she had seen five other physicians for a “rapid heartbeat” and “feeling stressed.” After extensive testing, she had finally been referred for psychological counseling for an anxiety disorder.

贝蒂来找马丁医生是想问问第二个大夫的意见——实际上是第六个。在过去一年里，因为“心动过速”和“受迫感”的问题，她咨询过五位医生。在经过大量的检查后，医生最终建议她去做焦虑症方面的心理咨询。

The careful history Dr. Martin took revealed that Betsy was taking an over-the-counter weight loss product that contained ephedrine. (I have changed their names for privacy’s sake.) When she stopped taking the remedy, her symptoms also stopped. Asked why she hadn’t mentioned this information before, she said she’d “never been asked.” Until then, her providers would sooner order tests than take the time to talk with her about the problem.

马丁医生仔细地询问病史，终于得知贝蒂当时正在服用一种减肥用的非处方药，其中含有麻黄碱。（为了保护隐私，文中用了化名。）停止服用这种药物后，她的症状也就消失了。在被问到过去为什么没有提过这件事时，她说，“从来没人问过。”在那以前，她的医生都会很快让她去做检查，而不是花时间和她谈病情。

Betsy’s case was fortunate; poor communication often has much worse consequences. A review of reports by the Joint Commission, a nonprofit that provides accreditation to health care organizations, found that communication failure (rather than a provider’s lack of technical skill) was at the root of over 70 percent of serious adverse health outcomes in hospitals.

贝蒂的情况还算幸运，沟通不畅常常会导致更恶劣的后果。非营利组织“医疗机构认证联合委员会”(Joint Commission)发布的一份报告指出，医院中发生的严重不良健康后果中，有逾70%的根源在于沟通不畅（而不是医护人员欠缺专业技能）。

A doctor’s ability to explain, listen and empathize has a profound impact on a patient’s care. Yet, as one survey found, two out of every three patients are discharged from the hospital without even knowing their diagnosis. Another study discovered that in over 60 percent of cases, patients misunderstood directions after a visit to their doctor’s office. And on average, physicians wait just 18 seconds before interrupting patients’ narratives of their symptoms. Evidently, we have a long way to go.

医生能否解释、倾听、与患者产生共鸣，对于病人的诊疗有着深远的影响。然而一项调查发现，有三分之二的病人在不知道诊断结果的情况下，就被要求出院了。另一项研究发现，在超过60%的病例中，患者在问诊后误解了医生的指示。医生平均只会等18秒，就会打断患者对症状的陈述。显然，我们有很长的路要走。

Three years ago, my colleagues and I started a program in Harrisburg designed to improve doctors’ communication with their patients. This large urban hospital system serves a city with a population of about 50,000, together with the surrounding metropolitan area of more than 550,000 people.

三年前，我和同事在宾夕法尼亚州哈里斯堡启动了一个旨在改善医患沟通的项目。这个规模庞大的城市医院系统，为本市大约5万人口提供服务，同时也面向周边城市群共计超过55万的居民。

The hospital faces particular challenges: The city has a high poverty rate (32 percent, compared with the state average of 13 percent), and the metro area has a high rate of childhood obesity. Over all, nearly a third of people around Harrisburg are uninsured, compared with about one in 10 for the rest of Pennsylvania.

医院面临着一些特殊的挑战：这座城市贫困率极高（达32%，与之相对比，全州平均水平为13%），所在城区的儿童肥胖率也很高。总体而言，哈里斯堡及周边人口中，有近三分之一没有医疗保险，而宾夕法尼亚州其他地区的这一比例则约为十分之一。

Our project started with a simple baseline assessment of how we as doctors communicated with our patients. Observation soon revealed that physicians introduced themselves on only about one in four occasions. And without an introduction, it’s no surprise that patients could correctly identify their physician only about a quarter of the time.

项目开始时，我们对医生与患者的沟通状况做了一个简单的基准评估。通过观察，我们很快就发现，只有大约四分之一的情况，医生会向患者做自我介绍。既然没有做自我介绍，另一个现象也就不奇怪了：仅有大约四分之一的情况，患者能正确指出给自己诊断的医生是谁。

Brief, rushed physician encounters were common, with limited opportunity for questions. A lack of empathy was often apparent: In one instance, after a tearful patient had related the recent death of a loved one, the physician’s next sentence was: “How is your abdominal pain?”

与医生会面时简短、仓促的情况十分普遍，提问的机会也很有限。对患者缺乏理解的情况往往很明显：在一个案例中，患者痛哭流涕地倾诉，最近一位亲人去世了，但医生接下来问的却是，“你的腹痛是什么情况？”

We developed a physician-training program, which involved mock patient interviews and assessment from the actor role-playing the patient. Over 250 physicians were trained using this technique. We also arranged for a “physician coach” to sit in on real patient interviews and provide feedback.

我们推出了一项医生培训计划，其中包括由演员扮演的患者参与的模拟问诊和评估。有超过250名医生接受了运用这个技巧进行的培训。我们还安排了“医生辅导员”在实际接诊时坐在旁边，进而提供反馈。

Over the next two years, patient satisfaction with doctors, as measured by a standard questionnaire, moved the hospital’s predicted score up in national rankings by a remarkable 40 percentile points. Several studies have found a correlation between higher patient satisfaction scores and better health outcomes. In one, published in The New England Journal of Medicine, Harvard health policy researchers reported that higher patient satisfaction was associated with improved outcomes for several diseases, including heart attacks, heart failure and pneumonia.

在接下来的两年里，通过一项标准化问卷的衡量，患者对医生的满意度提高了，而这所医院的预期得分，在全美排名中也出现了40个百分点的可观提升。有若干项研究发现，患者满意度指标的提高，与治疗效果的改善存在正相关性。在一篇发表在《新英格兰医学杂志》(The New England Journal of Medicine)上的研究论文中，哈佛大学的医疗政策研究人员写道，患者满意度提高，与若干种疾病治疗效果的改善存在相关性，包括心肌梗死、心脏衰竭和肺炎。

The need to train and test physicians in “interpersonal and communication skills” was formally recognized only relatively recently, in 1999, when the American Board of Medical Specialties made them one of physicians’ key competencies. Although medical schools and residency programs then began to train and test students on these skills, once physicians have completed training, they are seldom evaluated on them. And doctors trained before the mid-1990s have rarely, if ever, been evaluated at all.

对医生在“人际关系和沟通技巧”方面进行培训和检验的需求，直到近年来才正式得到承认。在1999年，美国医疗专科委员会(American Board of Medical Specialties)将这些技巧列为医生的关键能力之一。尽管医学院和住院医项目从那时就开始对学生的这些技巧进行培训和测试，但是医生在完成学业后，极少还会受到这方面的评估。所有在上世纪90年代中期之前接受医学教育的医生，则极少甚至完全没有得到过评估。

I realize that many colleagues may see methods like ours as too intrusive on their clinical practice and may say that they don’t have the time. But we need to move away from the perception that social skills and better communication are a kind of optional extra for doctors. A good bedside manner is simply good medicine.

我明白很多同行可能会认为，我们这样的方法对临床实践的干扰太强，也可能会说他们没时间。不过，我们需要摒弃那种认为社交技巧和改善沟通对医生来说是一种可有可无的额外素质的念头，因为在临床实践中，良好的态度本身就是一剂良药。

A passionate diabetes specialist told me how she sat down with a patient to understand why he was not using his diabetes medications regularly, despite numerous hospital admissions for complications.

一位充满热情的糖尿病专科医师给我讲述了她与一名患者坐下来聊天的情形。尽管那名患者因为并发症而多次入院治疗，但是他还是不肯规律地摄入糖尿病药物，她想弄明白这是为什么。

“I can’t continue to do this anymore,” he told her, on the verge of tears. “I’ve just given up.”

“我不能再这样活了，”他强忍着泪水告诉她。“我干脆放弃了。”

She placed a hand on his shoulder and just sat with him. After a pause, she said: “You have a heart that still beats, and legs you can still walk on — many of my patients don’t have that privilege.”

她把手放在他的肩膀上，坐在了他身旁。停顿片刻后，她说：“你的心脏还能跳，腿也还能走。许多患者根本没有这样的运气。”

Five years later, recalling this episode, her patient credits her with inspiring him to take better care of himself. The entire encounter took less than five minutes.

五年之后，这位患者在回顾这一幕时称赞道，是医生的鼓舞让他更好地照顾自己。那次会面只花了不到五分钟。