When praise is worth considering in a difficult conversation.
When praise is worth considering in a difficult conversation.
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当在困难的谈话中值得考虑表扬时。
DOI：
10.1016/s0140-6736(10)61401-8
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发表时间：
2010
期刊：
影响因子：
--
通讯作者：
Tulsky,JamesA
中科院分区：
文献类型：
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作者：
Back,AnthonyL;Arnold,RobertM;Baile,WalterF;Edwards,KellyA;Tulsky,JamesA
在我们最近的一次沟通技巧研讨会上，我们正在帮助一名见习医生与一名复发淋巴瘤患者的妻子交谈。在这个教学场景中，患者已经败血症，在重症监护病房的舞台下；医生正在与患者的妻子交谈，他非常了解她。妻子有一大堆看似无穷无尽的问题。这位医生本想表现出同理心，但他却努力表现得文明礼貌(他后来解释说，我想说的是，你错过了大局)。尽管医生试图回答妻子的所有问题，但她似乎越来越不满意。主持人停止了这一场景，以便进行讨论和集思广益；医生和小组的其他成员被困住了。这是不可能的！“于是主持人提出了一个建议：“承认自己被激怒了是很好的。但当你回应时，如果你提到妻子的行为有什么好处呢？如果你说：“你为你丈夫辩护做得很出色。我知道你正在努力确保他护理的每一个细节都得到了正确的处理。实习生看起来很怀疑。“真的吗？”医生往往忽视赞扬，因为这是交流的一部分。尽管我们承认，从经验上讲，表扬很少受到关注，但我们认为，表扬值得特别提及，因为我们发现，如果使用得当，表扬是一个强大的工具，可以帮助深化对话，使医生和患者能够顺利度过艰难的对话。主持人重新开始了谈话，医生称赞了妻子的努力。妻子说：“当然，这是我的丈夫，他的生命危在旦夕。”医生回答说，“我照顾了很多重病患者，并不是每个家庭都做出这样的努力。”你的所作所为给我留下了深刻的印象。“嗯，”妻子想了一会儿，又说了一句，“谢谢你这么说。有时我担心护士会认为我爱管闲事。但每次我离开的时候，我都很担心会发生什么。他命悬一线。“在后来的汇报中，医生称这一时刻是对话的转折点。当主持人问这位妻子她当时在想什么时，她说：“我觉得医生意识到了我正在经历的一些事情，他能看出我正在努力成为最好的妻子。”医生的赞扬使妻子能够清楚地表达出她问题背后的担忧。与其他沟通技巧一样，当专家流利地表达时，表扬似乎是直观的。然而，沟通技巧在很大程度上是可以学习的，并构成了医生领域的一项独特的专业技能。关于医生为什么倾向于忽视表扬的一个猜测是，他们将表扬与对自己表现的反馈联系在一起。在美国，一种常见的教育实践是“反馈三明治”，即在两个正反馈之间“夹”一个负反馈，想必是为了让这个负反馈更容易被接受。其结果是，许多美国医学实习生已经习惯于将积极反馈视为负面反馈的介绍性陈述。这些实习生已经学会了在“但是”之后为真正的要点做好准备。因此，我们希望区分教育工作者对受训者行为的积极反馈与临床医生对患者或家属的意图或努力的赞扬。我们用赞扬来表达对这个人的一种尊重，对他们处理可怕的、复杂的、常常是孤独的情况的方式表示尊重。在考虑使用…时
In one of our recent communication skills workshops, we were helping a physician trainee talk to the wife of a patient with relapsed lymphoma. In this teaching scenario, the patient has become septic and is offstage in the intensive care unit; the physician is talking to the patient’s wife, who he knows quite well. The wife has a seemingly bottomless well of questions. The physician, who had wanted to be empathic, was instead struggling to be civil (“I wanted to say”, he explained later,“you’re missing the big picture”). Although the physician tried answering all the wife’s questions, she appeared more and more dissatisfied. The facilitator stopped the scenario to allow for discussion and brainstorming; the physician and the rest of the group were stuck.“I’ve seen people like this before. They’re impossible!” So the facilitator made a suggestion.“It’s fine to acknowledge to yourself that you are irritated. But when you respond, what if you address what’s good about the wife’s actions? What if you say,“You have done an amazing job advocating for your husband. I realise that you are trying to make sure that every detail of his care is handled correctly.” The trainee looked sceptical.“Really?” Physicians tend to overlook praise as part of the communication repertoire. Although we acknowledge that praise has received little attention empirically, we think praise deserves special mention because we find that, if used judiciously, praise is a powerful tool that can help deepen conversation and enable physician and patient to move through difficult conversations. The facilitator restarted the conversation, and the physician praised the wife’s effort.“Of course”, said the wife,“this is my husband whose life is on the line”.“Well”, the physician responded,“I have taken care of a lot of very ill people and not every family makes this kind of effort. I’m impressed with all that you have done.”“Hmmm”, said the wife, who thought for a minute before speaking again.“Thank you for saying that. Sometimes I worry that the nurses just think I’m nosy. But every time I leave I’m so worried about what could happen. He’s hanging on by a thread.” Later in the debriefing, the physician named this moment as the turning point in the conversation. The wife, when asked by the facilitator what she was thinking about at that moment, said “I felt the doctor recognised something of what I was going through, that he could see that I was trying to be the best wife possible.” The physician’s praise enabled the wife to articulate the concerns running underneath her questions. As with other communication skills, praise seems to be intuitive when performed fluently by an expert. Yet communication skills are largely learned, and constitute a distinctive expertise repertoire within doctoring. One speculation about why physicians tend to neglect praise is that they associate praise with feedback on their performance. A common educational practice in the USA is the “feedback sandwich”, in which a piece of negative feedback is “sandwiched” between two pieces of positive feedback, presumably to make the negative feedback more palatable. The upshot is that many American medical trainees have been conditioned to regard positive feedback as an introductory statement for negative feedback. These trainees have learned to brace themselves after the “but” for the real point. Thus, we want to distinguish positive feedback given by educators on a trainee’s behaviour from praise given by a clinician to a patient or family member about their intentions or efforts. We use praise to show a kind of respect for the person, offering our esteem for the way they cope with a scary, complicated, and often lonely situation. In considering the use of …