Как найти общий язык с любым пациентом – интервью хирурга-онколога Дмитрия Андреевича Красножона
Дмитрий Андреевич Красножон, хирург-онколог, реконструктивно-пластический хирург, кандидат медицинских наук и врач высшей категории, популярен у пациентов и пользователей НаПоправку: 117 отзывов с оценкой 4.9 балла из 5 возможных и неизменное лидерство в рейтинге докторов сервиса. Мы попросили его рассказать, как он общается с пациентами, относится к отзывам и чему учит ординаторов.
«Где я работаю…»
Я работаю в ГБУЗ «Ленинградский областной клинический онкологический диспансер», еще сотрудничаю с Клиникой высоких медицинских технологий, Клинической больницей РАН, а также Клиникой онкологических решений «ЛУЧ». В месяц амбулаторно принимаю около 150 пациентов по ОМС и около 100 человек в рамках платных услуг. Пациентов не так много, потому что моя основная деятельность – это хирургическое и лекарственное лечение в стационаре.
Чем я больше всего горжусь в работе? Тем, что сделал для родного учреждения: создал и развил реконструктивно-пластическое направление по лечению рака молочной железы (до 2003-2004 годов его в клинике не было), а также начал проводить в учреждении международные клинические исследования. С 2005 года клиника стала одним из лидеров в этом направлении в России, я лично был главным исследователем в 30+ проектах. Мы успешно прошли множество независимых аудитов, в том числе и FDA.
Еще горжусь тем, что за три года мне и моей команде удалось создать замкнутый цикл лечения пациентов с раком молочной железы (от диагностики до реконструкции молочной железы) в Клинике высоких медицинских технологий.
Об этих и других проектах Дмитрий Андреевич регулярно рассказывает на своем сайте.
Признание пользователей НаПоправку 
С командой Клиники высоких медицинских технологий
«Доктор – это сыщик…»
Главное в общении с пациентами – это внимание. Но его нужно уметь проявлять. Оно начинается с незначительных «жестов»: спросить, как пациента зовут, и далее обращаться к нему по имени и отчеству, вдумчиво слушать и ни в коем случае не перебивать. Несколько лет назад я прочитал книгу Лари Кинга «Как разговаривать с кем угодно, когда угодно, где угодно». Эту книгу должен прочитать каждый студент медицинского вуза.
Доктор, как журналист или сыщик, должен пробуждать в самом себе интерес к пациентам. Он должен ими заинтересоваться. Только так можно получить информацию, необходимую для правильного диагноза.
К сожалению, на приеме онколога пациенты часто так напуганы, что не могут о себе рассказать, поэтому врач должен воссоздать историю заболевания сам. Например, если пациенту предложить некоторый сценарий, он перестает стесняться и смело дополняет его обстоятельствами.
Отлично работают отвлеченные, но продуманные вопросы. Я нередко спрашиваю пожилых пациентов об огороде: что они выращивают на грядках, чем поливают, что хорошо растет. Это способ собрать анамнез и проверить, к примеру, насколько человек активен. Он позволяет мне как врачу глубже вникнуть в заболевание и принять правильные решения. Есть и бонус – так среди пациентов не останется «неинтересных», за диагнозом проступает личность.
«На консультации…»
Первым делом я представляюсь. Затем – рассказываю, как пройдет консультация. Если пациент понимает план работы, то она проходит плодотворно. Многие пациенты волнуются, не знают, с чего начать. Врач же, не обозначив «формат переговоров», сбивается, нервничает, в итоге никто не получает удовольствия от встречи.
Обычно я говорю, что задам несколько вопросов, затем изучу результаты исследований и проведу осмотр. Уточняю, что мне необходимо время, чтобы подумать, но после я обязательно выскажу свое мнение. Потом мы обсудим ситуацию, я запишу данные в медицинскую документацию и дам заключение. Иногда даю пациенту листок бумаги. Он записывает возникающие вопросы, пока я работаю с документацией, затем мы еще раз все обсуждаем.
Существует масса приемов, которые повышают эффективность консультации, например, повторение или инструкции. Человеку в принципе сложно понять все и сразу, а на память пациента, которому недавно сообщили неприятные новости, рассчитывать вообще нельзя. Задача врача – помочь и донести важную информацию. Очень давно я написал инструкцию по биопсии молочной железы, описал процедуру в мельчайших деталях. Инструкцию приходится ежегодно обновлять, но вы даже не представляете, насколько она упрощает работу.
Такие же памятки я написал для пациентов, которые готовятся к хирургическому или химиотерапевтическому лечению. В итоге, когда все инструкции были собраны, я издал книгу «Рак молочной железы. Ответы на вопросы». Она серьезно мне помогает, и в настоящее время готовится четвертое издание.
С Игорем Петровичем Костюком и Сергеем Сергеевичем Крестьяниновым 
В 2019 году Дмитрий Андреевич продлил сертификат по пластической хирургии
«Пациент должен уйти от врача с…»
Пациент приходит на прием с проблемой, а должен уйти с решением. Часто врачи забывают не только дать решение, но даже обозначить проблему. Вместо этого проводится «встряска»: «У вас рак, все плохо».
Доктор должен сформулировать задачи, а затем дать пациенту рекомендации. Если случай «простой», нужно дать конкретные указания. Если случай «сложный», надо разбить большую задачу на несколько маленьких.
Например, приходит пациент, я вижу, что речь идет о раке молочной железы. Конечно, в лоб озвучивать такие диагнозы нельзя, да и, наверное, неправильно с юридической точки зрения, если нет гистологического подтверждения.
Поэтому большую задачу «излечение» делим на две поменьше: «диагностика» и «лечение». Затем диагностику дробим на более конкретные: УЗИ, биопсию, маммографию. И вместе с пациентом переходим от одной маленькой задачи к другой. Но чтобы успокоить пациента и ответить на все его вопросы, надо обязательно назначить промежуточные консультации на каждом этапе.
«Иногда врачи даже не понимают, что унижают пациента…»
Пациента нельзя унижать. Звучит несколько странно, но только для тех, кто не сталкивался с постсоветской медициной. Большинство врачей не ругаются матом, не обращаются к пациенту на «ты» и не ведут себя высокомерно, но, к сожалению, это все еще встречается.
Если прочитать отзывы на НаПоправку, основные претензии к врачам – это хамство и равнодушие. Первое характерно для врачей, окончивших институт до 2000 года, второе – для тех, кто после. Почему это происходит? Когда некоторые люди получают даже минимальную власть, проявляются их комплексы, страхи и желание отыграться на слабом.
Чаще всего я вижу: врачи даже не понимают, что унижают пациента. Унизить может даже брезгливая гримаса. Нередко такая гримаса у доктора возникает, если он видит, что перед ним человек бедный или пожилой. Да, пациент может вспотеть. Да, у него может быть запах пота – и что? Поставьте себя на его место: встать в 3 утра, добраться за 5 часов из Лодейного поля до Санкт-Петербурга на прием – и не вспотеть? Нормальный человек в принципе, когда заходит в онкологическое учреждение, уже волнуется и потеет.
Я часто слышу от врачей слова: «бабка», «старый пердун», «цыганка», «дура», «сучка» и др. Я знаю даже одного доктора, который на карточке пишет обозначения «с» и «д», а цифры 2 или 3 означает степень. Это уже говорит о глубокой профессиональной деформации.
Но НаПоправку, другие агрегаторы и вообще интернет серьезно ограничивают врачей в выплескивании своих эмоций на пациента. Информация быстро становится публичной. На мой взгляд, это хорошо.
«Пациенты делятся на два типа…»
Мне кажется, пациенты делятся на два типа: «терпеливые» и «нетерпеливые». Как правило, «терпеливый» пациент прочитал все о докторе в интернете и готов смириться с ожиданием. К сожалению, мои приемы порой затягиваются: некоторым пациентам достаточно и 10 минут, а некоторым и часа не хватает. Возникают накладки, но ничего плохого в этом не вижу. Это особенность работы.
«Нетерпеливый» пациент ждет от врача быстрого решения. Но в медицине быстрые решения – не обязательно правильные. Нельзя работу доктора подогнать под формат Макдоналдса, где есть стандарты, и они четко выполняются во всем и всеми.
Но о каких стандартах может идти речь, когда к вам пришел напуганный человек? Ему неуютно, страшно оказаться в больнице, где лечатся пациенты с диагнозом «рак». У него спрашиваешь: «Что вас беспокоит?». Слышишь: «Меня направили». Уточняешь: «Вам переливали чужую кровь?». Ответ: «Я донор». Получить внятные ответы быстро почти невозможно, приходится подбирать ключик.
Лучший способ превратить «нетерпеливого» пациента в «терпеливого» – дать ему задание: заполнить анкету, изучить инструкцию, сходить взвеситься и измерить рост, разложить документы по порядку. Еще напряжение от ожидания снижает любая визуализация. Хорошо, если в клинике, как у нас, висит телевизор, где постоянно «крутится» полезная информация о врачах, клинике, методах диагностики и лечения.
«Если лечение прошло нормально, доктора порекомендуют…»
Почему у меня много отзывов? Секрета нет. Когда я начал сотрудничать с НаПоправку, количество отзывов выросло. Каждый пациент, который пришел на прием, получает форму обратной связи и может оставить комментарий. Через сервис записывается примерно 50-60 пациентов в месяц – число отзывов быстро растет.
Еще отзывы часто пишут пациенты стационара. На сайте ГБУЗ «Ленинградский областной клинический онкологический диспансер» есть огромный баннер, который ведет на страницу с рейтингом клиники на НаПоправку. Люди с удовольствием оставляют мнения.
Если прием и лечение прошли для пациента комфортно, ему было приятно работать с лечащим врачом, он с высокой вероятностью напишет хороший отзыв. Когда пациент спрашивает, как меня отблагодарить, я смело отвечаю: «Напишите позитивный отзыв». Кстати, я предпочитаю именно такую форму благодарности, а не конфеты и коньяк. Мне кажется, у меня слишком большая коллекция этих продуктов. Как ни странно, пациенты тоже прекрасно воспринимают такой вариант благодарности.
Я не хочу какой-то особенной личной популярности, но на мой сайт приходит каждый день 2000 человек. Это небольшой город. Отзывы пациентов, излечившихся от рака, необходимы, чтобы вновь заболевшие знали, что рак – это не приговор. Излечение возможно и вероятно во многих случаях. Когда о своем выздоровлении пишут сами пациенты, то это мотивирует других бороться с болезнью.
Если лечение прошло нормально, то достаточно оставить пациенту телефон – вас будут рекомендовать. Но есть важный аспект: пациент должен записать ваш контакт в телефон. Визитками я давно не пользуюсь, они бесполезны. Люди обычно не переносят данные в телефон, надеясь на «бумажный носитель», а он быстро теряется.
Если вы врач и хотите, чтобы пользователи НаПоправку записывались к вам на прием, оставьте заявку. Наш менеджер с вами свяжется и ответит на все вопросы.
«Пациентов-экстремистов можно определить, не открывая дверь кабинета…»
Когда человеку плохо, он может вести себя негативно. Это объяснимо и ничего страшного в этом нет. С пациентским экстремизмом я сталкивался. Но если есть опыт, а опыт приходит с годами, то таких пациентов можно вычислить при первом общении и далее с ним уже не работать. Согласно мировой статистике, таких пациентов не более 10%, по моей статистике – примерно 1% или даже меньше. Их можно определить, не открывая дверь в кабинет.
Есть еще «латентные экстремисты». Они ведут себя адекватно, но при определенных обстоятельствах становятся экстремистами. Зачастую винить в этом их нельзя. Если человек переносит лечение тяжело, то из латентного экстремиста он превращается в явного.
Например, пациенту проводится химиотерапия, которая чаще всего ухудшает самочувствие, снижает аппетит, а нередко меняет вкусовые ощущения. Человека постоянно тошнит, ему не нравится еда, и, конечно, он пишет жалобу, что кухня в больнице ужасная. По большому счету он прав. Для него еда действительно ужасная, хотя при этом она нормально приготовлена. Большая ошибка врачей в подобной ситуации – провоцировать пациента, а не пытаться объяснить ситуацию, назначить дополнительное лечение, одним словом «сбавить обороты».
«Причину проблем нужно искать в себе…»
Доктору профессионально расти помогает самоанализ. Ничего просто так не происходит: конфликты на пустом месте не возникают, пациенты не «донимают», а у врача не появляется злость. Надо искать причину в себе. Если вас раздражает «внезапный» пациент, значит, что-то вы сделали неправильно: не назначили дополнительную консультацию или не организовали собственную работу. Если раздражают пациенты с «телефонными вопросами», возникающими в воскресенье утром, то это тоже ваша недоработка: даете личный телефон. Обозначьте границы.
С Полиной Сергеевной Шило и Марией Леонидовной Степановой в Клинике “ЛУЧ” 
С учениками и уже коллегами – Евгенией Михайловной Цыпилевой и Игорем Викторовичем Копытичем
«Врач не должен быть голодным и уставшим на работе…»
Нельзя быть голодным и уставшим при работе с людьми. Если я голоден и устал, то прямо так и говорю: «Я устал и голодный». В 100% случаев пациенты позволяют сделать паузу. Единственный способ профилактики эмоционального выгорания – отдых и забота о себе.
Еще не стоит «копировать» или «тиражировать» негативные эмоции. Часто среди коллег слышу рассуждения: «Вот, она такая, сякая». Ну какой смысл еще раз тиражировать негативные эмоции внутри собственного сознания? Тиражировать надо позитивную информацию. Вот вылечил пациента – похвали себя перед коллегами. Хотя у некоторых коллег это тоже вызывает раздражение, но это, кстати, один из симптомов профессионального выгорания.
«Публичность защищает доктора»
Публичность и личный бренд врача – это данность, характеристика времени и профессии. Бренд доктора формируется автоматически, хочет он этого или нет: информацию о докторе слишком легко найти в интернете. Но если врач пускает этот процесс на самотек, то последствия могут быть непредсказуемыми.
Прочитайте материал нашего блога о том, как доктору работать с личным брендом.
Публичность – это гарантия, что пациенты вас найдут. Ничего страшного в ней не вижу. Более того, это определенная защита от необразованных руководителей. Год назад позвонил мне заместитель главного врача одной клиники, где я работаю, и возмутился, что я провожу операции транссексуалам. Делал я их на законных основаниях, по согласованию с непосредственным руководством уже полтора года.
Но вдруг заместителю главного врача показалось, что эти операции идут вразрез с религиозными догматами. В итоге, к сожалению, я перестал делать их в этой клинике. Но как публичный человек могу легко заявить: руководитель, который даже не понимает, что такое транссексуализм (код по международной классификации болезней – F64), безграмотен. При других обстоятельствах бы не смог.
При этом личный бренд у врача никто отобрать не может. Современные клиники, особенно частные, нанимают сотрудников, имеющих хоть какую-то минимальную известность. Конечно, если врача устраивает работа в общелечебной сети, то можно брендом и не заниматься. Но думаю, что, если вы дочитали интервью до этого места, вы – активный человек, который хочет развиваться.
Читайте интервью врача и предпринимателя Анатолия Ивановича Недозимованого о том, как врачу открыть свою клинику и добиться успеха.
«У молодых врачей огромные провалы в образовании»
К сожалению, у молодых врачей, которые приходят ко мне учиться, огромные провалы и в общем образовании, и в специальном. Заметил грустную тенденцию: провалы в образовании растут вместе с необоснованной уверенностью в собственных силах. Они ждут наград и восхищения. Дело доходит до абсурда: «Я пришел в клинику – дайте мне медаль».
Большинство ординаторов, которых я вижу, «проиграли, не начав игру». У них нет мотивации. Возможно, я строг. Но считаю неприемлемым, когда клинический ординатор не может запомнить по имени и отчеству 16 пациентов, лежащих в моих палатах по 7-10 дней. Значит, диагнозы и прочую информацию он тоже не сможет запомнить.
Обычно ординаторов я обучаю так. Сначала учу формулировать собственные мысли и постоянно тренировать этот навык. Затем требую научиться слепому, десятипальцевому методу печати и заставляю тренировать мануальные навыки: вязать узлы, чертить круги на бумаге, держать ножницы и иглодержатель. Потом обучение становится индивидуальным.
Почему важна десятипальцевая печать? Когда заполняешь историю болезни, дополнительно анализируешь информацию. К сожалению, большинство врачей не умеют быстро печатать на клавиатуре – их мозг ничего не анализирует и занимается только поиском клавиш. Кроме того, у новичка клавиатура вызывает раздражение. Но если работа вызывает раздражение, она приносит плохие результаты.
Если давать глобальные советы, то, наверное, главный совет молодым врачам я сформулировал бы так: «Надо делать в два раза больше, чем от вас требуют». На современном языке это звучит: «Будьте проактивны». К сожалению, молодежь с трудом воспринимает такие советы. Многие считают, что все должно произойти чудодейственным, но естественным путем, нужно только присутствовать на работе. Это не так.
Бесплатно скачивайте книги НаПоправку:
Записать больше пациентов в сезон
Каналы трафика, о которых забывают клиники.
Записать больше пациентов на сайте
Чек-лист сайтов и посадочных страниц.
Маркетинг клиники на жителей района
Как сделать клинику самой узнаваемой в районе.
Спасибо за статью. Интересно почитать интервью такого профессионала.
Добавлю к этому интервью маленький эпизод из моей жизни. Мне было необходимо делать зубные имплантаты. Доктор попросил меня принести заключение онколога (я являюсь пациенткой Дмитрия Андреевича). Когда я принесла этот документ, то прочитав его мой врач -ортопед сказал: «у вас наверное хороший доктор». Думаю, что если попросить пациентов Дмитрия Андреевича дополнить список его методов взаимоотношений с пациентами, то он окажется громадным!Главное в том ,что он стремится помочь !!!
До чего же интересно было читать “Интервью”!!! Я могу подтвердить, что Дмитрий Андреевич так и поступает, как пишет в интервью. 8.5 лет я являюсь его пациенткой. И все эти годы я благодарю Бога за то, что в 2011 году жизнь меня свела с Дмитрием Андреевичем. 3 года я лечилась в рамках КИ( Протокола) в ЛООД. Позитивность доктора вселялась и в меня. С таким настроем было гораздо легче переносить химиотерапию. На каждую капельницу ехала не со страхом, а с мыслью, что каждая следующая капельница приближает меня к выздоровлению. Лечение в рамках Протокола закончилось, но не закончилось наше общение. Я не помню случая, чтобы Дмитрий Андреевич на мой тревожный звонок отказал в консультации или просто в совете. Ггрустно, что таких докторов очень мало.
Пожалуй, я тоже оставлю несколько слов благодарности в адрес Доктора. Мне не довелось лично общаться с Дмитрием Андреевичем. Я несколько раз задавала вопросы на его персональном сайте. Вопросы задавались в период лечения моей мамы от РМЖ. Ответы были быстрыми, конструктивными и ПОНЯТНЫМИ. Благодаря заочным консультациям, мы смогли улучшить качество жизни моей мамы и продлить ее жизнь. Моя благодарность очень велика, так как Дмитрий Андреевич , несмотря на расстояние, оказался единственным врачом, который вселял уверенность в наших силах и помогал выбрать правильное решение в ходе лечения.
Спасибо и пусть Господь оберегает Вас и Ваших близких!
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سالن A6، غرفه 774: دیدار در نمایشگاه
صنعت کفش ایران
یادتون نره که توی نمایشگاه صنعت کفش ایران، سالن A6، غرفهی 774 منتظرتون هستیم.
اونجا میتونید از نزدیک با کفشهای طبی دکتر ماخ آشنا بشید، اونها رو امتحان کنید و از مشاورهی
رایگان کارشناسهای ما بهرهمند
بشید. توی نمایشگاه صنعت کفش ایران منتظرتون هستیم تا با
هم گپ بزنیم و بیشتر با هم آشنا بشیم.
یادتون نره، سالن A6، غرفهی 774!
تاریخ برگذاری نمایشگاه 18 لغایت 21 دی
ماه می باشد . واقع در نمایشگاه آفتاب ابتدا جاده قم روبروی مرقد امام خمینی
ره .
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