六大核心能力(1):
人際與溝通技巧實務應用
Interpersonal & Communication Skills
童綜合醫療社團法人童綜合醫院
醫學研究部暨耳鼻喉科主任
蔡青劭 副教授
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美國畢業後醫學教育評鑑委員會
六大核心能力
1.病人照護(Patient care)
2.醫學知識(Medical knowledge)
3.從工作中學習及成長(Practice-based
learning and improving)
4.人際及溝通技巧(Interpersonal and
communication skills)
5.制度下的臨床工作 (System-based practice)
6.專業素養 (Professionalism)
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美國畢業後醫學教育評鑑委員會
(ACGME)
 Interpersonal and Communication Skills that
result in effective information exchange and
teaming with patients, their families, and
other health professionals
人際關係及溝通技巧：能與病患及其
家人或其他醫護團隊成員，建立有效
的交流訊息
 ttp://www.acgme.org/outcome/comp/com
pmin.asp
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ACGME Outcome Project
人際與溝通技巧
1. 與病人營造且維持一個治療與倫理皆健
全的關係。
2. 使用有效的傾聽技巧，以非言語的、解
說的、詢問的、書寫的技巧誘導和提供
訊息。
3. 無論是身為醫護小組之組員或領導，都
要與他人有效率的一起工作。
“Advancing Education in Interpersonal and
Communication Skills: An educational resource from the ACGME
Outcome Project”:©2005 ACGME.
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三大溝通技巧範圍
1. Communication with the patient
與病患溝通的技巧
2. Communication about the
patient
病患相關訊息的溝通技巧
3. Communication about medicine
and science
醫學相關的溝通技巧
The Macy Initiative in Health Care
Communication(2004)
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人際與溝通技巧影響醫病關係
有效的溝通能增加病患滿意度、醫療療
效及治療的遵從度。
學習一般溝通技巧能減少醫師在告知病
情惡化時的不適度及增加病患滿意度。
醫病溝通不良乃醫療糾紛的原因之一。
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人際與溝通技巧影響醫病關係
最容易被告的醫護人員:
不聽
不說
不尊重病人
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影響溝通的原因
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影響溝通的病人相關因素
人格
家庭背景
社經地位
生活經驗
身體生理的狀態
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影響溝通的病人相關因素
心理因素
(陌生的環境、失去獨立性、焦慮)
前次醫療經驗
本次醫療經驗
「移情作用」。病人有時會將潛意識
中壓抑的情緒或情感，轉移方向，投
射到分析師身上。
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影響溝通的醫師相關因素
人格
溝通技巧的訓練
專業精神
自信心
身體情況(如疲勞)
心理狀態
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The Kalamazoo Consensus
Statement
Communication tasks that should be
part of communication oriented
curricula and evaluation tools:
1. Build the doctor-patient relationship
2. Open the discussion
3. Gather information
4. Understand the patient’s perspective
5. Share information
6. Reach agreement on problems and
plans
7. Provide closure
» Acad Med 2001 76;4:390-393
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人際與溝通技巧
是否會因教導學習而改善?
Gordon提出
住院醫師較會在下列情形下改善溝通技巧:




實證為基礎的技巧
概念型模式
能夠演練技巧及得到回饋
在與病患接觸時經常得到導師提醒並能應用
技巧
» Gordon, B. ACGME/ABM Assessment of Physician Patient Communication
Conference. Rosemont, Illinois. March 21-22,2002.
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人際與溝通技巧的教學
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I. Cinemeducation (Film)
Using film in medical education.
醫學教育中以影片為教學工具
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醫學教育中以影片為教學工具
在觀看影片後以小組討論方式進行。
針對片中溝通技巧討論，學習如何面
對病人會談、告知病情惡化、臨終病
患的身心社會議題等技巧。
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醫學教育中以影片為教學工具
What are might the physicians have
done differently to more successfully
deliver the bad news to the patient
and his wife?
How can you be of assistance to
patients and their families in
facilitating open discussion about
serious illness?
What are challenges faced by
physicians in balancing work and
home lives?
» http://www.acgme.org/outcome/implement/interperco
mskills.pdf
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II. 以引導-傾聽-摘要模式
教導和評估以病人為中心的溝通
Using
the ILS (Invite-Listen-Summarize) Model
to
Teach and Assess Patient Centered
Communication
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II. 以引導-傾聽-摘要模式
以病人為中心的會談技巧獲得病人觀點。
使用標準病人回饋學習。
以漸進難度的情境方式學習。
小組討論。
» Boyle D, Dwinnell B, Platt F. Invite, Listen, and Summarize: A PatientCentered Communication Technique. Acad Med. 2005; 80:29-32.
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引導-傾聽-摘要模式
ILS (Invite-Listen-Summarize) Model
引導 (Invite)
尊重病患知道或不知道的權利
開放式(Open questions): “你有什
麼不舒服？”
探索式(Probing questions):“你說
吃不下是指沒食慾還是吞不下去？”
» Boyle D, Dwinnell B, Platt F. Invite, Listen, and Summarize: A PatientCentered Communication Technique. Acad Med. 2005; 80:29-32.
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引導-傾聽-摘要模式
主動式的傾聽 (Active listening)
1. Be alert and responsive to
verbal and non-verbal cues.
2. Facilitate(幫助) the patient to
continue.
3. Show empathy.
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引導-傾聽-摘要模式
1.主動式的傾聽 (Active listening):
Picking up Cues in an Interview
 A patient may be unable or unwilling to
articulate their real concerns and feelings.
 However, they are likely to reveal
something during the course of the
interview.
 They may reveal these only if you respond
appropriately to their verbal and nonverbal cues.
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引導-傾聽-摘要模式
2. 幫助病人表達
言語上:
– “嗯嗯-----”
– “請繼續”
– “要不要多說一點有關疼痛的部份？
”
– 重複
非言語上:
– 前傾向病人
– 注視病人
– 點頭
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引導-傾聽-摘要模式
3. 同理心 (Show empathy)
設身處地為人著想。
是一種能深入他人主觀世界，深刻瞭解其
感受的能力。
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引導-傾聽-摘要模式
摘要可達到以下目標:
澄清病人所說
鼓勵病人說與病情相關的事情
鼓勵病人添加遺漏的細節
總結並結束會談
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III.以悲傷模式教導和
評估人際與溝通技巧
»Hobgood C, Harward D, Newton K, Davis W.
The Educational Intervention “GRIEV-ING”
Improves Death Notification Skills of Residents.
Academic Emergency Medicine. 2005; 12:296301.
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The GRIEV-ING Mnemonic
 G—gather; gather the family; ensure that all members are
present.
 R—resources; call for support resources available to assist
the family with their grief, i.e.,chaplain
services, ministers, family, and friends.
 I—identify; identify yourself, identify the deceased or
injured patient by name, and identify the state
of knowledge of the family relative to the
events of the day.
 E—educate; briefly educate the family as to the events that
have occurred in the emergency department,
educate them about the current state of their
loved one.
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The GRIEV-ING Mnemonic
 V—verify; verify that their family member has died. Be
clear! Use the words "dead" or "died."
 —space; give the family personal space and time for an
emotional moment; allow the family time to
absorb the information.
 I—inquire; ask if there are any questions, and answer
them all.
 N—nuts and bolts; inquire about organ donation, funeral
services, and personal belongings. Offer
the family the opportunity to view the
body.
 G—give; give them your card and access information.
Offer to answer any questions that may arise
later. Always return their call.
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以悲傷模式教導和
評估人際與溝通技巧
Learning Activity (2-hour workshop):
1. Short didactic
• why death notification is an important skill
• significant verbal and nonverbal characteristics of
empathic communication
2. Small group activity facilitated by
program faculty, hospital chaplain or
hospital social worker.
• share personal experiences about the death of a
patient an
• share communication skills that individuals felt were
effective or ineffective for interacting with the family.
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以悲傷模式教導和
評估人際與溝通技巧
3. Mini-lecture introducing the GRIEVING mnemonic.
4. Paired role-play
•
•
residents received and delivered a death notification
using the GRIEV-ING mnemonic.
encouraged to provide helpful feedback to their
colleagues
5. Simulated survivor encounter –
•
•
Residents provided death notification in each of
three scenarios portrayed by the simulated
survivors.
Residents received feedback on their performance.
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IV. 以人道教育教導人際與溝通技
巧及專業素養
Using the Humanities to Teach
Interpersonal and
Communication Skills and
Professionalism
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以人道教育教導人際
與溝通技巧及專業素養
每週以小組討論方式針對:
medical errors
ethical issues
medical malpractice
racism
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人際與溝通技巧的評估工具
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形成性評量和總結性評量
的評估工具
形成性評量(Formative assessment)：
具有確認學生學會什麼未學會什麼及學習困
難所在的角色。
總結性評量(Summative assessment)：
若把評量當作是提供評鑑的訊息給老師，則
它扮演的角色是一種選擇與證明的角色，經
常在學習告一段落之後實施。
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人際與溝通技巧的評估工具
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360度全方位的評估
360-Degree (Multi-Source) Assessment Techniques
受評者自己、社工、教師、同儕醫師
、護理同仁、醫療團隊其他人員，甚
至病患。
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Focused
Tools
FocusedObservation
Observation Tools
集中觀察工具
集中觀察工具
 Direct observation of a resident-patient
encounter and concurrent written
evaluation
 Faculty or others observe live or videotaped
resident-patient encounters intypical patient
care settings
 Followed by assessment and feedback using
an instrument developed especially for
communication skills
 Alternatively, a standardized patient could
evaluate the resident and provide feedback
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Focused
Observation
Focused
Observation Tools
Tools
集中觀察工具
集中觀察工具
The Segue form and framework
The Harvard Medical School
Communications Skills Form
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Focused Observation Tools
集中觀察工具
The Segue form and framework
 Used by trained observers to assess and
direct provision of feedback to over 1000
medical students.
 Segue reliability ranged from .8 -1.0 when
raters were trained.
 Instrument validity was established by
face validity, content validity and construct
validity.
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Focused Observation Tools
集中觀察工具
The Harvard Medical School
Communications Skills Form
captures the essential elements of
communication
following the framework set by the
Kalamazoo Consensus Statement I.
Training faculty raters will increase
reliability.
This instrument has face, content, and
expert validity.
Psychometric data is currently being
collected.
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