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쌍방향 균형 커뮤니케이션으로서 공유된 의사결정 시스템 구축을 위한 탐색적 연구 : 신장투석환자의 커뮤니케이션 중심 분석
초록
본 연구는 의료현장에서 공유된 의사결정의 개념을 검토하고 쌍방향 균형 커뮤니케이션으로서 공유의사결정 시스템 구축에 영향을 미치는 의사-환자 간 커뮤니케이션 영향 요인을 검토하는데 목적이 있다. 이를 위해 공유의사결정이 필요한 질병 이슈로서 만성콩팥병을 선정하고 만성콩팥병으로 인해 신장투석을 받고 있는 환자 20명을 대상으로 FGI를 진행했다. 투석유형별 환자의 커뮤니케이션 차이, 투석 유형별 환자가 인지하는 의사-환자 간 커뮤니케이션 영향요소 그리고 공유된 의사결정과정에 대한 투석유형별 환자가 인지하는 의사-환자 간 커뮤니케이션을 알아보고자 환자의 일상생활과 관련된 요인, 심리적 요인과 정서적 요인, 혜택과 장애요인과 커뮤니케이션 성향을 질문했다. 인터뷰 결과, 위험인식, 불확실성인식, 커뮤니케이션행동(정보성향), 시간활용과 의사에 대한 태도에서 투석유형별 환자의 차이가 나타났다. 혈액투석환자는 투석방법과 관련된 불확실성, 불편함과 관련된 위험요소를 피하거나 최소화하기 위해 혈액투석방법을 선택하는 경향을 보인 반면, 복막투석환자는 투석방법이 지닌 상대적인 장점과 이점에 기대어 투석방법을 결정하는 경향을 보였다. 혈액투석환자들은 병원에서 의료진에 의한 치료관리에 대한 신뢰 및 안도감을 나타낸 것으로 보아 의료상황에서 직면할 수 있는 불확실성에 대한 반감이 복막투석환자에 비해 상대적으로 높으며 불확실성을 인내하기 보다는 회피하는 것으로 나타났다. 혈액투석환자는 건강 관련 정보를 찾음으로써 치료과정에 적극적으로 개입하고자 하는 정도가 복막투석환자에 비해 상대적으로 낮은 것으로 나타났다. 또한 시간활용이라는 부분은 투석환자에게 있어 큰 중요도가 있는 부분이었다. 혈액투석환자와 복막투석환자 모두 의사에 대한 높은 신뢰를 보였으나 의사를 만날 기회가 잦은 혈액투석환자에 있어 의사는 인생동반자의 의미로, 복막투석환자에게는 일상을 관리해주는 역할 인식이 더 부각되었다. 환자들은 공통적으로 투석방법 결정을 위한 충분한 상담시간의 부족, 주치의가 제공하는 정보의 양적, 질적 한계, 그리고 의료진 외에 투석관련 정보를 얻을 수 있는 경로부재를 커뮤니케이션 한계로 꼽았다. 본 연구는 의사 환자 간 균형적 커뮤니케이션을 바탕으로 공유의사결정의 의미를 연계하고 의료 현장에서 실질적으로 이루어질 수 있는 환자중심의 커뮤니케이션 촉진을 위한 청사진을 제공했다는 데에 학문적인 의미가 있다. 향후에는 의료현장에서 공유의사결정이 필요한 다양한 이슈에 본 논의를 적용함으로써 의사와 환자 그리고 사회가 함께하는 이루어가는 균형적 커뮤니케이션 실천에 대한 노력이 확대되어야 할 것이다.
Abstract
This study is aimed at articulating the concept of shared decision-making in medical encounter and to examine the factors influencing doctor-patient communication as a two-way symmetrical communication process. To this end, chronic kidney disease was selected as a case requiring shared decision-making, and FGI was conducted for 20 patients undergoing kidney dialysis. Three research questions were posed. First, how is the difference in communication among patients according to the kidney dialysis modality? Second, what are the factors that influence doctor-patient communication that patients perceive according to the dialysis modality? Third, what is the difference between doctor-patient communication according to the dialysis modality (hemodialysis, peritoneal dialysis) in the shared decision-making process? Analysis of interviews founds some interesting differences between the patient groups by dialysis modality. It seems that hemodialysis patients tend to choose the dialysis modality in order to avoid or minimize risk factors such as uncertainty and discomfort related to the dialysis method, whereas peritoneal dialysis patients choose the dialysis modality based on the perceived relative advantages of the dialysis method. Hemodialysis patients showed confidence and relief in the management of treatment by medical staff in hospitals, and their ambiguity aversion encountered in medical situations was relatively higher than that of peritoneal dialysis patients. Therefore, it can be said hemodialysis patients are uncertainty avoiders rather than uncertainty tolerators. Hemodialysis patients also showed a relatively lower level of participation in the treatment process by seeking health-related information compared to peritoneal dialysis patients. Both hemodialysis patients and peritoneal dialysis patients showed high trust in doctors. It seems that the doctor is a life companion for the hemodialysis patients since hemodialysis patients visit and see their doctor more frequently and a daily supervisor for the peritoneal dialysis patients who seldom visit and see their doctor. In addition, patients pointed out some communication limitations such as a lack of sufficient communication for decision making of treatment choice, the limited quantity and quality of information provided by the physician, and channel deficiency to obtain dialysis-related information other than medical staff. This study has academic significance in that it provides a blueprint for facilitating patient-centered communication in medical encounters by linking the meaning of shared decision-making based on two-way symmetrical communication between doctors and patients. In the future, by applying various implications from this study to the issues that require shared decision-making in medical encounters, efforts to practice symmetrical communication between doctors, patients, and society should be extended.
Keywords:
Shared Decision-Making, SDM, Two-way Symmetrical Communication, Chronic Kidney Disease(CKD), Dialysis Modality키워드:
공유된 의사결정, 공동의사결정, 쌍방향 균형커뮤니케이션, 만성콩팥병, 투석방법Acknowledgments
This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number : HC20C0054).(본 연구는 보건복지부의 재원으로 한국보건산업진흥원의 보건의료기술연구개발 사업 지원에 의하여 이루어진 것임(과제고유번호: HC20C0054)).
References
-
Anagnostou, A., Hourihane, J. O’B. & Greenhawt, M. (2020). The Role of Shared Decision Making in Pediatric Food Allergy Management. The Journal of Allergy and Clinical Immunology: In Practice, 8(1), 46-51.
[https://doi.org/10.1016/j.jaip.2019.09.004]
- Babrow, A. S., Hines, S. C., & Kasch, C. R. (2000). Managing uncertainty in illness explanation: An application of problematic integration theory. Explaining illness: Research, Theory, and Strategies, 41-67.
-
Babrow, A. S., Kasch, C. R., & Ford, L. A. (1998). The many meanings of uncertainty in illness: Toward a systematic accounting. Health Communication, 10(1), 1-23.
[https://doi.org/10.1207/s15327027hc1001_1]
-
Brashers, D. E. (2001). Communication and uncertainty management. Journal of Communication, 51(3), 477-497.
[https://doi.org/10.1111/j.1460-2466.2001.tb02892.x]
-
Brewer, N. T., Chapman, G. B., Gibbons, F. X., Gerrard, M., McCaul, K. D., & Weinstein, N. D. (2007). Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination. Health Psychology, 26(2), 136.
[https://doi.org/10.1037/0278-6133.26.2.136]
-
Carrotte, E. R., Hartup, M. E., Lee-Bates, B. & Blanchard, M. (2020). “I think that everybody should be involved”: What informs experiences of shared decision-making in supporting people living with schizophrenia spectrum disorders?. Patient Education and Counseling
[https://doi.org/10.1016/j.pec.2020.11.012]
-
Charles, C., Gafni, A., & Whelan, T. (1997). Shared decision-making in the medical encounter: what does it mean?(or it takes at least two to tango). Social Science & Medicine, 44(5), 681-692.
[https://doi.org/10.1016/S0277-9536(96)00221-3]
-
Chen, S. W., Yang, C. C., Te, J. C., Tsai, Y. L., Shorten, B. & Shorten, A. (2021). Birth choices after caesarean in Taiwan: A mixed methods pilot study of a decision aid for shared decision making. Midwifery, 95,
[https://doi.org/10.1016/j.midw.2020.102920]
- Cho, A. R., Kim, J. H., Ko, D. R., Chung, H. S., Shin, Y. S., Kim, J. H. & Cho, J. H. (2019). The effect of lecturing about communication skill with standardized patient for medical students. Health Communication, 15(1), 11-16.
- Coulter, A., & Collins, A. (2011). Making shared decision-making a reality. London: King's Fund.
- Coulter, A., & Ellins, J. (2006). Patient-focused interventions: a review of the evidence (Vol. 1). London: Health Foundation.
-
Edwards, A., & Elwyn, G. (2006). Inside the black box of shared decision making: distinguishing between the process of involvement and who makes the decision. Health Expectations, 9(4), 307-320.
[https://doi.org/10.1111/j.1369-7625.2006.00401.x]
-
Elwyn, G., Hutchings, H., Edwards, A., Rapport, F., Wensing, M., & Cheung, W. Y. (2005). The OPTION scale: Measuring the extent that clinicians involve patients in decision-making tasks. Health Expects, 8(1), 34-42.
[https://doi.org/10.1111/j.1369-7625.2004.00311.x]
-
Epstein, R. M., Franks, P., Fiscella, K., Shields, C. G., Meldrum, S. C., Kravitz, R. L., & Duberstein, P. R. (2005). Measuring patient-centered communication in patient–physician consultations: theoretical and practical issues. Social Science & Medicine, 61(7), 1516-1528.
[https://doi.org/10.1016/j.socscimed.2005.02.001]
- Fischhoff, B., Bostrom, A. & Quadrel, M. J. (2013). Risk perception and communication. McGraw-Hill handbook of terrorism and counter-terrorism. New York: McGraw-Hill.
- Han, H. K. & Kim, J. M. (2011). A Study on the Operation of Blog as a Horizontal Communication Channel between Doctors and Patients : Focusing on in-depth interviews with physician bloggers. Journal of Communication Science, 11(2), 533-562.
- Hyun, D. W. & Lee, S. Y. (2010). Health 2.0-The New Paradigm of Health Care, Nanam
- Jo, Y. H. & Ra, J. S. (2019). A Comparative Study of the Importance and Satisfaction of Emergency Room Patient-nurse Communication Needs. Health Communication, 14(1), 1-10.
-
Jo, K. H. (2012). Development and Evaluation of Shared Medical Decision-Making Scale for End-of-Life Patients in Korea. Journal of Korean Academy of Nursing, 42(4), 453-465.
[https://doi.org/10.4040/jkan.2012.42.4.453]
-
Jo, K. H., An, K. J. & Kim, G. M. (2012). Development of Korean Shared Medical Decision-Making Model for Dignified Dying Based on King's Theory. Korean Journal of Medical Ethics, 15(2), 184-205.
[https://doi.org/10.35301/ksme.2012.15.2.184]
-
Jo, K. H. & Kim, G. M. (2014). Types of Shared Medical Decision Making for Terminally Ill Patients. Korean Journal of Hospice and Palliative Care, 17(4), 278-288.
[https://doi.org/10.14475/kjhpc.2014.17.4.278]
-
Joosten, E. A. G., DeFuentes-Merillas, L., de Weert, G. H., Sensky, T., van der Staak, C. P. F. & de Jong, C. A. J. (2008). Systematic review of the effects of shared decision-making on patietn satisfaction, treatment adherence and health status. Psychotherapy and Psychosomatics, 77, 219-220.
[https://doi.org/10.1159/000126073]
- Kang, S. J. & Seo, N. S. (2019). A Structural Equation Model on Quality of Life in Hemodialysis Patients. Journal of the Korea Academia-Industrial cooperation Society, 20(7), 589-598.
-
Kaplan, R. M. & Frosch, D. L. (2005). Decision Making in Medicine and Health Care. Annual Review of Clinical Psychology, 1, 525-556.
[https://doi.org/10.1146/annurev.clinpsy.1.102803.144118]
-
Kehl, K. L., Landrum, M. B., Arora, N. K., Ganz, P. A., Van Ryn, M., Mack, J. W., & Keating, N. L. (2015). Association of actual and preferred decision roles with patient-reported quality of care: shared decision making in cancer care. JAMA oncology, 1(1), 50-58.
[https://doi.org/10.1001/jamaoncol.2014.112]
-
Kim, H. A., An, B. S. & Kim, Y. H. (2015). The Effect of the Type on Doctor-Patient Communication on Hospital Reputation. Journal of the Korean Advertising & PR Practitioner Society, 8(3), 54-72.
[https://doi.org/10.21331/jprapr.2015.8.3.003]
-
Kim. J. K. (2008). Shared Decision-Making as a Model of Medical Decision-Making. Korean Journal of Medical Ethics Education, 11(2), 105-118.
[https://doi.org/10.35301/ksme.2008.11.2.105]
- Kim, M. (2009). Study on the Factors Influencing Doctor’s Communication Styles: Individual Characteristics and Patient-Centered Trait, Korean Journal of Journalism & Communication Studies, 53(3), 146-172.
-
Kim, M. Y., Lee, J. H. & Doo, E. Y. (2020). Factors Influencing Healthcare Provider-Patient Communication of Patients with Chronic Diseases. Journal of Korean Academy of Nursing Administration, 26(2), 73-83.
[https://doi.org/10.11111/jkana.2020.26.2.73]
- Kim, S. K. (2010). Medical Ethical Review on Decision Making in Terminal Patient Care. The Catholic Thought, 42, 57-95.
-
Ko, E. K. & Yeo, J. S. (2020). Rights of Healthcare Consumers and Shared Decision-making in Medical Services. Journal of Consumer Studies, 31(2), 49-81.
[https://doi.org/10.35736/JCS.31.2.3]
- Korea Disease Control and Prevention Agency (2012). Guideline for Prevention and Management of Chronic Kidney Disease. Retrieved 10/12 from http://www.kdca.go.kr/contents.es?mid=a20303020600
-
Kriston, L., Scholl, I., Hölzel, L., Simon, D., Loh, A., & Härter, M. (2010). The 9-item Shared Decision Making Questionnaire(SDM-Q-9). Development and psychometric properties in a primary care sample. Patient Education and Counseling, 80(1), 94-99.
[https://doi.org/10.1016/j.pec.2009.09.034]
-
Kwon, B. K. (2015). A Survey of Korean Adults’ Understanding of Medical Decision-Making. Korean Journal of Medical Ethics, 18(3), 251-261.
[https://doi.org/10.35301/ksme.2015.18.3.251]
-
Kwon, K. E. (2019). A Study on the Model of life-sustaining treatment Decision Making through Shared Decision Making at the end of life. Journal of the Korean Bioethics Association, 20(1), 45-61.
[https://doi.org/10.37305/JKBA.2019.06.20.1.45]
-
Kushner, B., Holden, T., Politi, M., Blatnik, J. & Holden, S. (2020). A Practical Guideline for the Implementation of Shared Decision-making in Complex Ventral Incisional Hernia Repair. Journal of Surgical Research,
[https://doi.org/10.1016/j.jss.2020.09.019]
- Lee, B. H. (2011). A Study on the Communication Barriers between Doctors and Patients. Korean Journal of Communication Studies, 19(1), 35-54.
- Lee, B. K., Byoun, W. J. & Lim, J. L. (2010). The Influence of Individual’s E-Health Literacy on Doctor-Patient Communication. Journal of Cybercommunication Academic Society, 27(3), 89-125.
-
Lee, E. Y. (2012). Ethical Issues in End-of-Life Decision Making:A New Model for Medical Decisions. Korean Journal of Medical Ethics, 15(2), 160-183.
[https://doi.org/10.35301/ksme.2012.15.2.160]
- Lee, E. Y. (2014). A Study of Patient Decision Aids (PtDAs) for Shared Decision Making in Medical Decisions. Asia Pacific Journal of Health Law & Ethics, 8(1), 119-140.
-
Lee, E. Y. (2015). Implications of Decision Coaching in Shared Decision Making. Korean Journal of Medical Ethics, 18(2), 200-216.
[https://doi.org/10.35301/ksme.2015.18.2.200]
-
Lee, J. H. & Kim, C. J (2013). Effect of Doctors' Patient-centered Communication on the Patient Satisfaction and Treatment Outcomes : Focusing on Mediating Effect of Patient Participation. Journal of The Korea Contents Association, 13(11), 249-260.
[https://doi.org/10.5392/JKCA.2013.13.11.249]
-
Lee, J. S. & Choi, M. K. (2018). The Relationship between Physicians’ Patient-Centered Communication and the Quality of Life of Patients with Chronic Diseases: Focusing on Mediating Effect of Health Behavior. Health and Social Welfare Review, 38(3), 279-302.
[https://doi.org/10.15709/hswr.2018.38.3.279]
-
Lee, N. Y., Lee, S. J. & Lee, S. K. (2016). The Perceptions and Needs of Hospice Palliative Care and Shared Decision Making among Middle-Aged Adults. The Korean Journal of Hospice and Palliative Care, 19(4), 310-321.
[https://doi.org/10.14475/kjhpc.2016.19.4.310]
-
Lee, Y. H., Lee, Y. M. & Park, Y. K. (2011). Patients’ Expectations of a Good Dentist: The Views of Communication. Health Communication, 6(2), 89-104.
[https://doi.org/10.15715/kjhcom.2011.6.2.89]
-
Levine, M. N., Gafni, A., Markham, B., & MacFarlane, D. (1992). A bedside decision instrument to elicit a patient's preference concerning adjuvant chemotherapy for breast cancer. Annals of Internal Medicine, 117(1), 53-58.
[https://doi.org/10.7326/0003-4819-117-1-53]
-
Lin, C. Y., Renwick, L. & Lovell, K. (2020). Patients’perspectives on shared decision making in secondary mental healthcare in Taiwan: A qualitative study. Patient Education and Counseling, 103(12), 2565-2570.
[https://doi.org/10.1016/j.pec.2020.05.030]
-
Makoul, G. & Clayman, M. L. (2006). An integrative model of shared decision making in medical encounters. Patient Education and Counseling, 60(3), 301-312.
[https://doi.org/10.1016/j.pec.2005.06.010]
-
McMullan, M. (2006). Patient using the internet to obtain health information: this affects the patient-health professional ing the internet. Patient Education and Counseling, 63(1-2), 24-28.
[https://doi.org/10.1016/j.pec.2005.10.006]
-
Mishel, M. H. (1988). Uncertainty in illness. Image: The Journal of Nursing Scholarship, 20(4), 225-232.
[https://doi.org/10.1111/j.1547-5069.1988.tb00082.x]
-
Mishel, M. H. (1990). Reconceptualization of the uncertainty in illness theory. Image:The Journal of Nursing Scholarship, 22(4), 256-262.
[https://doi.org/10.1111/j.1547-5069.1990.tb00225.x]
-
Na, H. S., Kwon, Y. D. & Noh, J. W. (2013). Development of Physician Coaching Model for Improvement of Patient-Doctor Communication. Journal of The Korea Contents Association, 13(2), 331-340.
[https://doi.org/10.5392/JKCA.2013.13.02.331]
- Park, D. S. (2019). Qualitative Interview Method. Seoul: Communication Books.
- Plsek, P. (2001). Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC National Academies Pr.
- R. L. Street, Jr. (2003). Communication in medical encounters: An ecological perspective. In T. Thompson, A. Dorsey, K. Miller, & R. Parrott (eds.), The handbook of health communication (pp. 63~89). Mahwah, NJ: Erlbaum.
-
Robinski, M., Mau, W., Wienke, A., & Girndt, M. (2016). Shared decision-making in chronic kidney disease: a retrospection of recently initiated dialysis patients in Germany. Patient Education And Counseling, 99(4), 562-570.
[https://doi.org/10.1016/j.pec.2015.10.014]
-
Rosenfeld, B., Breitbart, W., Galietta, M., Kaim, M., Funesti‐Esch, J., Pessin, H., ... & Brescia, R. (2000). The schedule of attitudes toward hastened death: Measuring desire for death in terminally ill cancer patients. Cancer, 88(12), 2868-2875.
[https://doi.org/10.1002/1097-0142(20000615)88:12<2868::AID-CNCR30>3.0.CO;2-K]
-
Rostoft, S., van den Bos, F., Pedersen, R. & Hamaker, M. E. (2020). Shared decision-making in older patients with cancer - What does the patient want?. Journal of Geriatric Oncology,
[https://doi.org/10.1016/j.jgo.2020.08.001]
-
Sanftenberg, L., Kuehne, F., Anraad, C., Jung-Sievers, C. Dreischulte, T. & Gensichen, J. (2021). Assessing the impact of shared decision making processes on influenza vaccination rates in adult patients in outpatient care: A systematic review and meta-analysis. Vaccine, 39(2). 185-196.
[https://doi.org/10.1016/j.vaccine.2020.12.014]
- Seo, N. S. & Sim, E. K. (2020). Influence of Social Support and Health Literacy on Treatment Adherence in Hemodialysis Patients. Journal of the Korea Academia-Industrial cooperation Society, 21(7), 656–666.
-
Søndergaard, S. R., Madsen, P. H., Hilberg, O., Bechmann, T., Jakobsen, E., Jensen, K. M., Olling, K. & Steffensen, K. D. (2020). he impact of shared decision making on time consumption and clinical decisions. Patient Education and Counseling.
[https://doi.org/10.1016/j.pec.2020.12.014]
-
Suh, W. S. & Lee, C. K. (2010). Impact of Shared-Decision Making on Patient Satisfaction. Journal of Preventive Medicine and Public Health, 43(1), 26-43.
[https://doi.org/10.3961/jpmph.2010.43.1.26]
- Yoo, J. E. (2019). Shared decision-making in Patients with Chronic Disease: Concept Analysis. Journal of the Korea Convergence Society, 10(11), 543-555.
-
Yoon, Y. S., Kim, M. H. & Park, J. H. (2014). Perception of Shared Decision-making and Conflict Decision-making related to Surgery in Elderly Patients with Cancer. Journal of Korean Gerontological Nursing, 16(3), 266-275.
[https://doi.org/10.17079/jkgn.2014.16.3.266]
-
Williams, S. J., & Calnan, M. (1996). The ‘limits’ of medicalization?: modern medicine and the lay populace in ‘late’modernity. Social Science & Medicine, 42(12), 1609-1620.
[https://doi.org/10.1016/0277-9536(95)00313-4]