以病人的「疾患意義」為中心的健康照護

Patient's "Meanings of Illness" - Centered Health Care

自1969年巴林依據她們巴林小組的經驗，提出「以病人為中心」的觀點，為施行全人醫療之思考方式後，近半世紀來，她的觀念不僅影響醫療人員對醫病關係之建構，更對醫療照護體系與醫學教育思維，產生了巨大的衝擊。然而，直至最近，醫界對於「以病人為中心」的內涵，並沒有明確而具體的界定，對其定義，也沒有普遍的共識。影響所及，許多研究對於採取「以病人為中心」取向之醫療照護，是否真有助於提升病人滿意度、改善健康行為與健康狀態，常有不一致之結果。本文作者擷取醫療人類學區別「疾病」與「疾患」的想法，以及近二十年所發展敘事醫學的觀點，建議所謂「以病人為中心」的醫療照護，可以具體描述為「以病人的『疾患意義』為中心」的醫療照護。所謂病人的「疾患意義」，具體的內涵為何？根據Platt的建議，「以病人為中心」的醫病溝通，醫師對病人的了解，應包括五個層面：病人背景、病人對疾病的認知、情緒反應、疾病對病人社會功能的影響，以及病人對治療處置與未來生活的期待。他鼓勵醫師應使用適當的語言，具體地針對上述部份提問。在對病人的疾患意義，有基本了解後，進一步可與病人共同詮釋、協商共識，並協助於生活中落實，共同改寫疾患的意義。簡言之，「以病人為中心」的醫療照護，可具體描述為「以病人『疾患意義』為中心」的醫療照護，這與新近發展敘事醫學之精髓是相通的。醫師應探索病人五個層面之疾患意義，加以詮釋，協商，並協助落實於日常生活。

In 1969, Balint proposed the possibility of patient-centered medicine as a way of medical thinking. After nearly half a century, this concept not only significantly influenced the physician-patient relationship, but also greatly impacted the reform of medical care system and medical education. But, until recently, there is no specifically defined meaning of patient-centeredness that is universally agreed upon. As a consequence, some conflicts existed as to the effect of patient-centeredness on patients’ satisfaction, health behavior, and health status. Furthermore, some medical experts have not accepted the concept as evidence based or appropriate in medical care. In this article, I borrowed some concepts from medical anthropology and the more recently proposed narrative medicine to argue that the patient-centeredness is actually centered on the patient’s meanings of illness; so-called patient-centered medicine could be described more specifically as patient’s meanings of illness-centered medicine. According to Platt’s idea, patient’s meanings of illness can be divided into five components: background, cognitive perception, emotional response, social functional impact, and expectations about management as well as future life. He encouraged physicians to ask appropriate and sophisticatedly worded questions to illuminate details of the patient’s story during patient-centered interview. Then physicians can further interpret, negotiate and co-rewrite the illness narratives with their patients. In conclusion, patient-centered medicine can be described as patient’s “meanings of illness” -centered medicine which is compatible with the essence of newly developed narrative medicine. Physicians should investigate 5 components of their patients’ stories, try to interpret it, negotiate with their patients and help them to fulfill in patients’ real life. This is how we, as physicians, can do to practice patient-centered medicine.