以焦點團體探討住院醫師執行生理心理社會醫學照顧模式的促進與阻礙因素

Using focus groups to explore the enabling and barrier factors of bio-psychosocial medical care among residents

研究目的：醫療中以生理、心理、社會模式照顧患者是患者為中心的核心概念，也是重要的臨床實境技能，它對協助患者疾病治療有其重要性與效益性。但是自從Engel提出至今，實際使用與採行的醫療單位與人員仍然有限。本研究目的有二，一為探討住院醫師使用BPS醫療照顧模式的促進因素與障礙因素，二為了解醫師執行BPS的需求，以提供合宜學習訓練的建議。研究方法：研究採取質性研究方式，44位住院醫師受邀參與焦點團體，共分七個團體，成員平均年齡為29.56歲，男性27人，女性17共人。資料分析步驟為：1.將錄影資料轉錄謄寫成文字資料，由專業人員依據團體討論的重要主題與事件單位進行標識，並透過共識會議，確立內容分類與共同面向。2.依據各面向區分有利或阻礙因素架構，將述說事件進行內容歸類、內容整理與概念分析。研究結果：1.不同層級住院醫師對BPS的界定應用之理解有所不同。2.住院醫師有利的BPS概念為BPS是統整互動、歷程及未來導向觀點，需投入與專業合作；要養成中立、患者為中心的深化態度；要具備溝通、關係建立、衡鑑問題及概念化技巧。至於阻礙BPS執行之因素，包括在概念上誤為醫療以生理為主，以為患者有特殊需要才執行BPS架構，在態度上擔心談社會心理問題患者願意低或介入不符經濟效益，缺少技巧練習與勝任能力等。研究結論：住院醫師宜同步建立正確概念與人本內化的態度，作為BPS模式的基本養成，再加上精熟的技巧練習，三方面相互為用才能做好BPS的醫療照顧。本研究建議未來訓練的方針應加入精緻化的概念與深化的態度培訓，臨床實作上應加強臨床策略與技能的多元方法、多元層次的訓練方案。

Purpose: The bio-psychosocial (BPS) model has been a central concept in medical care and an important clinical technique in the treatment of illness for the past three decades. The aims of this study is to explore the enabling and barrier factors for medical residents in applying the BPS model at clinical settings and to discover the best training strategies for applying the BPS model. Methods: We organized 44 residents (mean age = 29.56) into 7 focus groups. Participants were asked to report how they used the BPS model in their clinical work. We used a qualitative approach for data analysis, which included the following steps: 1. Gain consensus among experts for categorizing utilization-related BPS themes and content using transcripts of the video-recorded focus groups. 2. Based on each theme, we elicited and conceptualized the enabling and barrier factors contained in the participants’ dialogue records. Results: 1. Although the BPS model was endorsed by residents of different years, we found a discrepancy in the definition of BPS and in comprehension and application of the model. 2. The benefits of implementing BPS medical care encompass the concepts of an integrative future-oriented approach, and involvement and cooperation with interdisciplinary, patient-centered care in the resident’s communication. Relationship skills and assessment or case conceptualization are important techniques for physicians. Barriers to implementing BPS can be caused by overemphasizing medical problems, a decline in patients’ satisfaction, and reduced efficiency with this type of care. A deficit in training or competence can cause residents to resist using this approach. Conclusions: Both cognitive knowledge and affectivevolitional attitudes are important components of the BPS approach. If they are supported with proficiency in techniques, the impact of the approach can be enhanced. Results supported the need for multiple methods and multi-levels of training in physicians’ education. Suggestions for important points related to BPS that require particular attention in a clinical setting are highlighted.