학부 의학교육에서 타과 의뢰의 의사소통 기술을 향상시키기

의료진간의 의사소통은 환자 케어의 질을 향상시키고 실수를 줄이는데 반드시 필요하다.

- Effective, easy communication between medical colleagues improves patient care and prevents errors.

- Communication failure was a leading root cause of these events(= patient harm),1,2 responsible for 66% of reported sentinel events between 2011 and 2012.1

- Safe, effective intercollegial communication in health care requires a sophisticated skill set that encompasses relationship building, argument structuring, clinical synthesis, cultural competency, and professionalism.3

이러한 의사소통 향상을 위한 도구/기술로서 만들어진 것들이 있고, 연구도 많이 진행중이다.

- The PACT (Patient assessment, Assertive communication, Continuum of care, Teamwork with trust) project demonstrates that standardization of the transition process improves nursing handovers.7

- In the past few years, there has been an increasing amount of research seeking to enhance collaborative behavior and improve clinical communication skills amongst health care practitioners through the development of standardized communication tools.13–22 

최근 관심을 끄는 분야 중 하나가 '업무교대'이다.

- One area that has received specific attention recently is the “handoff”—the exchange that occurs when responsibility and authority over a patient’s care are transferred from one provider to another, for example, at shift change.9

- Many studies have examined paradigms for improving the safety of these care transitions by suggesting mnemonics and other models to decrease interprovider variability.17,20,21,23 One example is the “I-PASS” (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver) model, which includes actions for both the provider who is leaving and the one arriving

그리고 타과의뢰(consultation)은 업무교대와 유사한 면이 있다.

- mnemonics currently in use are too heterogeneous to allow for analysis of their efficacy.24

- Consultations are similar to handoffs in that they are an exchange of patient data between two providers with a common goal of caring for a patient.

하지만 이렇게 서로 다른 점이 있다.

Consultation

Handoffs

- Traditionally, consultations occur when one provider seeks the formal recommendations of a specialist regarding the care of a patient.25 consultations call on different team members (sometimes newly recruited) to perform unique tasks, as in a baseball game  - Their communications will inherently require more clarification and careful attention than do those between physicians in the same discipline. - Consultations can occur at any time, physician may have limited time or other priorities, especially in highstakes environments such as emergency departments

- Handoffs are also more likely to occur at dedicated times, such as shift changes.  - Doctors must quickly and effectively establish rapport, concisely convey patient data, and communicate a clear clinical question.  - Communication is further complicated by the fact that many consultations take place over the phone, which can present significant challenges in establishing rapport and ensuring that information is accurately heard and understood.26

응급의학과로 온 환자 중 40%가 궁극적으로는 타과의뢰를 받게 되는데, 서로 다른 진료과 사이에는 업무 환경이나 훈련 과정, 사용하는 용어의 뉘앙스나 용어 자체의 차이가 있어서 어려움이 많다.

- Beaulieu et al,31 reports significant barriers to teaching family physicians and specialists to collaborate in the training environment due to the increasing distances between specialty and general medicine in the workplace and training arenas.

- Nearly 40% of patient encounters in the emergency department will ultimately result in consultation between an emergency physician and a physician colleague (e.g., cardiologist or surgeon).25,35

- A unique challenge of consultations is that they typically involve practitioners from different specialties, sometimes speaking different medical “languages” with nuanced differences in jargon, and coming from different medical cultural backgrounds. Moreover, differences in attitudes or actual management decisions

5C와 PIQUED model이 잘 정립된(evidence-based) 두 개의 모델이다.

- The key elements of “The Five Cs of Consultation” are Contact, Communication, Core question, Collaboration, and Closing the loop.27–29

- PIQUED model, which includes six items: Preparation before the encounter, Identification of involved parties (speaker, listener, and patient), Questions (clinical question; answering questions), Urgency of the request (e.g., emergent consultation versus arranging outpatient follow-up), Educational modifications (e.g., acknowledging the role of senior physicians in teaching junior ones), and Debriefing and discussions after the consultation request.

5C 모델은 주로 타과의뢰에 필요한 요소를 중심으로 서술하고 있으며, PIQUED 모델은 분명한 교육적 목적을 가지고 있어서 junior learner에게 교육하는 방법으로 사용하려는 목적으로 만들어졌다.

- The 5Cs model focuses on desired elements of a consultation, and the PIQUED model has an explicit educational focus and is intended to serve as a teaching method for improving junior learner consultations.

- The 5Cs model is currently the most evidence-based model for improving physician communication during emergency department consultations. A randomized, controlled trial with the consultation model as the educational intervention was performed to assess the effectiveness of the 5Cs model.28

- The PIQUED model expands on some of the elements present in the 5Cs model and allows specific focus on teaching and feedback. Therefore, the two models complement each other as a guide for learners performing consultations. 

- The 5Cs model has an emphasis on collegiality and the desired aspects of a consultation exchange, and the PIQUED model supplies more specific guidance and includes explicit room for educational engagement. 

하지만 앞으로 이러한 연구가 더 되어야 할 것이다.

1. Validate the 5Cs and PIQUED models in other health care settings

2. Integrate consultation models within educational curricula

Communication skills can clearly be improved with focused educational interventions

3. Explore the effects of clinical communication on patient outcomes

To date, there has also been a dearth of literature addressing patient outcomes as a result of improved communication between health care providers

4. Research the role of the consultant in effective consultations

Similarly, this is an opportunity or a call to action for further research concerning consultation and communication skills from the perspective of the receiving party—the consultant

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Acad Med. 2013 Jun;88(6):753-8. doi: 10.1097/ACM.0b013e31828ff953.

I'm Clear, You're Clear, We're All Clear: Improving Consultation Communication Skills in Undergraduate Medical Education.

Kessler CS, Chan T, Loeb JM, Malka ST.

Source

Dr. Kessler is deputy chief of staff, Durham VA Medical Center, Duke University, Durham, North Carolina. Dr. Chan is a resident, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. Ms. Loeb is a medical student, College of Medicine, University of Illinois-Chicago, Chicago, Illinois. Dr. Malka is a resident, Department of Emergency Medicine, Department of Pediatrics, Indiana University, Indianapolis, Indiana.

Abstract

Requesting and providing consultations are daily occurrences in most teaching hospitals. With increased attention on transitions of care in light of the recent scrutiny of duty hours, consultations and other interphysician interactions, such as handoffs, are becoming increasingly important. As modern medicine increases in complexity, the skill of communicating with medical colleagues throughout the continuum of care becomes more challenging. Like many of the other skills acquired by medical students, consultation communication is often learned by casual observation and through trial and error. Without formal training, however, miscommunications will continue to occur, nearly ensuring that medical errors happen. Interphysiciancommunication skills, therefore, need to be emphasized in undergraduate and graduate medical education instead of being left to happenstance or hit-or-miss practice. In this article, the authors review two models for understanding and teaching the consultation process-5Cs and PIQUED-both of which were developed for specific subsets of learners. They then combine the two to create a consultation model that may be more widely applied.