Medical practice is one of the most difficult professions. A person who has devoted himself to medicine, of course, must have a vocation for it. The desire to help another person has always been considered a useful personality trait and should have been brought up from childhood. Only when these personality traits become a need can we assume that a person has the main prerequisites for successfully mastering the medical profession. It is no coincidence that the famous writer and doctor V.V. Veresaev wrote that it was impossible to learn the art of medicine, just like the art of the stage or poetry. One can be a good medical theorist, but in practical terms with patients be insolvent.

Doctor's humanism . The patient, first of all, has the right to expect from the doctor a sincere desire to help him and is convinced that the doctor cannot be otherwise. He endows the doctor with the best qualities inherent in people in general. It can be thought that the first person who provided medical assistance to his neighbor did it out of a sense of compassion, a desire to help in misfortune, to ease his pain, in other words, out of a sense of humanity. It is hardly necessary to prove that it was humanity that has always been a feature of medicine and the doctor, its main representative.

Humanism, consciousness of duty, endurance and self-control in dealing with patients, conscientiousness have always been considered the main characteristics of a doctor. For the first time, these moral, ethical and ethical standards of the medical profession were formulated by the physician and thinker of antiquity Hippocrates in his famous "Oath". Of course, the historical and social conditions, the class and state interests of the changing epochs have repeatedly transformed the Hippocratic Oath. However, even today it is read and perceived as a completely modern document, full of moral strength and humanism. Its main provisions are as follows:

respect for life(“I will not give anyone a lethal agent asked of me and will not show the way for such a plan, in the same way I will not hand over an abortion pessary to any woman”);

prohibition against harming the patient("I will direct the regimen of the sick to their advantage according to my strength and my understanding, refraining from causing any harm and injustice");

respect for the patient(“Whatever house I enter, I will enter there only for the benefit of the sick, being far from everything intentional, unrighteous and pernicious, especially from love affairs with women and men, free and slaves”);

medical secrecy("Whatever during treatment - and also without treatment - I see or hear about human life from what should never be disclosed, I will keep silent about that, considering such things a secret");

respect for the profession("I swear ... to consider the one who taught me the art of medicine on an equal footing with my parents ... I will spend my life and my art pure and blameless").

Medical secrecy (confidentiality). In the relationship between the doctor and the patient, not the last role belongs to the ability of the doctor to keep medical secrets. It usually includes three types of information: about diseases, about the intimate and family life of the patient. The doctor is not an accidental owner of this information, the innermost experiences and thoughts of patients. They trust him as a person from whom they expect to receive help. Therefore, it is possible to dispose of the information available to the doctor about the patient at his own discretion only in rare cases. The requirement of non-disclosure of medical confidentiality is removed only in cases where it is required by the interests of society (for example, in the event of a threat of the spread of dangerous infections), as well as at the request of the judicial and investigative authorities.

General and professional culture . We can note a number of common and more frequent personality traits that need to be brought up by a doctor. These include a high general culture and culture of medical practice, organization in work, love for order, accuracy and cleanliness, i.e. features pointed out by Hippocrates. The requirements for the personality of a doctor, his appearance and behavior gradually took shape in a special doctrine - medical deontology, which is regarded as the science of the proper moral, aesthetic and intellectual appearance of a medical worker, about what should be the relationship between doctors, patients and their relatives, and also between colleagues in the medical environment.

professional deformation. In professions related to human-human interaction, the focus on the Other as an equal participant in the interaction is of great importance.

Medical activity is very diverse and is not limited to treatment, as is commonly believed in the non-medical environment. The variety of types of medical activity creates different ways of its implementation, a wide field of activity for a professional, but raises the problem of the specifics of the influence of different types of medical activity on the doctor's professional position, his value orientations.

To describe the influence of the profession on the mental life of a professional, a special concept has been introduced - "professional deformation". For the first time it began to be described in the 60s as a problem of human functional capabilities. In our country, the problem of professional deformation was first studied in the field of pedagogy. Studies have shown that in professions of the "man-man" type, professional deformation exists, as well as different levels of training and qualifications of a professional, and that professional selection should be carried out, since there is an idea of ​​professional suitability.

Professional deformation develops gradually from professional adaptation. A certain degree of adaptation is natural for a medical worker. A strong emotional perception of the suffering of another person at the beginning of professional activity, as a rule, becomes somewhat dulled in the future. Of course, a certain degree of emotional resistance is simply necessary for a doctor, but he must retain those qualities that make him not only a good professional, but also leave him a person capable of empathy, respect for another person, capable of observing the norms of medical ethics. A striking example of professional deformation is the approach to the patient as an object, a carrier of a symptom and a syndrome, when the patient is perceived by the doctor as an "interesting case".

G.S. Abramova and Yu. A. Yudchits (1998) consider professional deformation in the form generalized model, which includes both the socially conditioned causes of it, and the causes caused by the phenomena of individual consciousness. They refer to social reasons as the influences associated with the need for a doctor, as a civil servant, to comply with numerous instructions that regulate his activities. The concept of "instruction" here generalizes all forms of ready-made knowledge (textbooks, classifications of diseases, standards, etc.), which are given to us from the outside, they are not "passed through" through our own experience and understanding. As soon as the professional accepts the instruction as absolute truth, all professional relationships are deformed in a certain way: the doctor may perceive the patient not as a whole person, but as a certain set of symptoms or an object of manipulation.

On the other hand, a doctor can believe in his power and authority over a person, taking on faith numerous myths circulating in the non-medical environment about the possibilities of a doctor and modern medicine. The external side of treatment, which seems magical to an inexperienced person, accessible only to a doctor, gives rise to the "caste" nature of medical knowledge. Thus, another phantom of the doctor's professional activity is formed - a feeling of power over a person for whom medical care is the last chance to protect himself from illness.

Thus, the doctor deals with two realities: inanimate (phantoms and instructions) and living reality - the life of his own and other people. There is a temptation to identify them and create the illusion of simplicity. A professional begins to experience extremely simple feelings, expressed in an attractive formula "I can", "I am a professional and I know better how ... what ...". As a result of accepting phantoms as truth, the consciousness of a professional is also fantomized - it becomes static, motionless, it always knows "how it should", "what should be" and "what to do with it". These phantoms can sometimes be realized by the doctor at the level of experiences - in the form of a feeling of dissatisfaction with oneself, with the profession. However, as long as there is an experience, one can also talk about the possibility of realizing the fact of professional deformation and the prospects for working with it. Professional deformation is not realized in the case when the doctor refuses experiences, because they require effort, suggest manifestations of attitude towards someone or something.

Chronic fatigue syndrome in medical workers. In professions associated with human-human interaction, professional fatigue is primarily fatigue from another person. This is a very specific kind of fatigue, due to constant emotional contact with a large number of people. This is especially true for the profession of a doctor, as it makes great demands on the personality of a professional and involves taking responsibility for the life and health of another person. To a large extent, the appearance of fatigue can be facilitated by the peculiarities of work in health care (duty, shift work), excessively large reception. "Fatigue asthenia" usually always develops gradually (within 6 or more months from the start of hard work), it is preceded by a more or less long period of strong-willed effort, mental stress and continued work in conditions of fatigue. Fatigue reduces a person's working capacity and the efficiency of his work, which creates a constant psychotraumatic situation in the form of a feeling of his own inadequacy and can even lead to a neurotic breakdown. The most common symptom of asthenia is irritability. It manifests itself in increased excitability, impatience, resentment and incontinence. Manifestations of irritability often have the character of short-term outbreaks, which are often replaced by repentance, apologies to others, feelings of lethargy and fatigue. In addition to these main symptoms, those suffering from asthenia complain of absent-mindedness, poor sleep, anxiety, mood instability, and headaches.

In the ordinary consciousness of society, there is an opinion that the state of health of doctors is better than that of other people. However, this is far from being the case, especially when it comes to their psycho-emotional, mental state. Attitude towards one's condition in this regard among doctors is found mainly in two types: 1) negative - does not pay attention to one's own psychological state, considers it the result of simple overwork, does not seek help from specialists; 2) dismissive - underestimates his fatigue; does not change his lifestyle, which, as a rule, is incompatible with psychological health. Very often, a doctor with chronic fatigue syndrome tends not only to imperfect "self-diagnosis", but also to imperfect "self-therapy" - excesses in the use of tranquilizers or the use of alcoholic beverages to relieve "stress".

Fatigue of the doctor negatively affects his professional activity and thus his patients. The consequences of fatigue can be very diverse. They can manifest themselves in impatience and irritability - the doctor reduces the time for each patient, strives to finish the work that causes fatigue as quickly as possible, and the patient gets the impression that the doctor wants to get rid of him, does not perceive the seriousness of his complaints and generally treats him disrespectful. The productivity of a doctor decreases and slows down due to difficulties in concentrating attention, difficulties in making a diagnosis and choosing a method of treatment, the predominance of so-called diagnostic short connections of the type: "increased acidity + blood in the stomach = peptic ulcer" (Konechny R., Bouhal M., 1985). On the patient, such a doctor gives the impression of absent-minded, preoccupied with his own problems, and often simply incompetent. Carelessness and haste can lead to careless statements with mental traumatization of the patient (iatrogenic) and even to direct medical errors - an unreasonable diagnosis or an unsuccessfully chosen treatment.

The experience of one's own professional insolvency with an increase in medical errors, difficulties in concentration, difficulties in perceiving new material are the cause of traumatization of the doctor himself, lead to a feeling of dissatisfaction with the results of his activities. His condition can be aggravated by the emergence of conflicts both with the administration (due to claims for unsatisfactory work), and with colleagues (due to irritation caused by fatigue) and with patients (due to medical errors, lack of a psychological approach, unskilled statements).

Syndrome of "emotional burnout" in health workers. The term "emotional burnout" was introduced by the American psychologist X. J. Freidenberger in 1974 to characterize the psychological state of healthy people who are in intensive and close communication with clients (patients) in an emotionally overloaded atmosphere when providing professional assistance.

The medical profession requires from a professional not only professional skills, but also great emotional dedication. The doctor constantly deals with the death and suffering of other people, and in many other cases the doctor has the problem of "not including" his feelings in the situation, which he does not always succeed in. Naturally, only an emotionally mature, holistic person is able to solve these problems and cope with such difficulties. Probably, there is an individual limit, a ceiling of the possibilities of our emotional "I" to resist exhaustion, to counteract "burnout", self-preserving. The syndrome of "emotional burnout" is typical for professionals who initially have great creative potential, are focused on another person, and are fanatically devoted to their work.

With the syndrome of "emotional burnout", a professional experiences a kind of disappearance or deformation of emotional experiences, which are an integral part of our whole life. Its symptoms are in many ways similar to those of chronic fatigue and form the main framework for the possibility of subsequent occupational deformation.

First of all, a person begins to noticeably feel fatigue and exhaustion after vigorous professional activity, psychosomatic problems appear, such as fluctuations in blood pressure, headaches, symptoms of the digestive and cardiovascular systems, and insomnia.

Another characteristic feature is the emergence of a negative attitude towards patients and a negative attitude towards the activities performed. The doctor's desire to improve in his profession disappears, tendencies appear to "accept ready-made forms of knowledge", act according to a template with a narrowing of the repertoire of working actions, and rigidity of mental operations. Self-dissatisfaction with feelings of guilt and anxiety, pessimism and depression often manifest outwardly in the form of aggressive tendencies such as anger and irritability towards colleagues and patients.

Doctor's authority- a professional with CMEA inevitably loses his authority both among patients and colleagues. Authority is associated primarily with professionalism and personal charm. When a doctor, due to indifference and a negative attitude towards his work, is not able to thoughtfully, carefully listen to the patient's complaints, makes medical mistakes or shows aggressiveness and irritability, he loses confidence in himself as a professional and respect for his patients and colleagues.

Physician optimism- the patient should feel the healthy optimism of the doctor, and not based on the desire to finish the examination as soon as possible (“what are you worrying about in vain, everything is fine with you, you can go”). Conversely, under the influence of burnout, the doctor demonstrates a cynical, often cruel attitude, exaggerating the consequences, for example, of late arrival at the hospital (often this is due to the desire to "punish" the patient for his own emotional failure).

Honesty and truthfulness- with anxiety, restlessness and uncertainty caused by SEB, the doctor loses the ability to truthfully and honestly present information about the state of human health. Either he unnecessarily spares the psyche of a sick person, forcing him to remain in obscurity, or, conversely, loses the necessary measure in the presentation of diagnostic or therapeutic information.

doctor's word- the word has a huge suggestive influence on any person, and even more so the word of a doctor for his patient. A professional with BS who experiences feelings of meaninglessness, hopelessness, and guilt will inevitably convey these feelings to his patients in word, intonation, and emotional reaction.

Doctor's humanism- due to a valuable and holistic approach to another person. A doctor who has lost the content of his psychic reality ceases to refer to this content in other people, thus devaluing both himself and them.

Test control of knowledge:

1. A. Maslow's "pyramid of needs" consists of "floors" arranged in ascending order in this order:

Physiological Needs

The Need for Security

Need for belonging

Needs for love, acceptance

The need for self-actualization

2. The motivation to achieve success is most clearly manifested in the following case:

athlete trains wanting to win an olympic medal

the student is preparing for the session, not wanting to be expelled

skating student shows caution for fear of injury

a soldier runs away from the battlefield, wanting to survive

3. Fast, emotional, impulsive, rather quick-tempered and easily excitable person according to the type of temperament:

1. phlegmatic person

   sanguine

   melancholic

4. The character of a person is a combination of individual psychological characteristics, manifested in:

talents and abilities

sensory organization of personality

typical responses

strategies for solving mental problems

5. The predominant orientation of the personality is described by a couple of concepts:

introversion-extraversion

temperament-character

psychoanalysis-psychosynthesis

accentuation-psychopathy

analyticity-syntheticity

6. Conscious, purposeful human activity is called:

activity

individuality

interaction

designation

7. Property of the psyche, characterizing the dynamics of the course of nervous processes

ability

temperament

character

creativity

8. Active, sociable, emotionally balanced person according to the type of temperament:

1. phlegmatic person

   sanguine

   melancholic

9. Calm, unhurried, loving measured and thorough person by type of temperament:

1. phlegmatic person

   sanguine

   melancholic

10. A strong, unbalanced type of higher nervous activity is characteristic of:

choleric

phlegmatic

sanguine

melancholic

11. Disharmony of character, excessive expression of its individual features is called:

accentuation

polarization

interaction

attraction

sensitization

12. Increased impressionability, a violent reaction to what is happening is a sign of such character accentuations:

dysthymic

pedantic

cyclothymic

exalted

13. The concept of "personality" is used when they want to emphasize

biologically determined properties of a person

socially determined qualities of a person

manifestations of the intelligence of higher animals

psychophysiological differences between people

interspecific communication of higher animals

14. The system of stable ideas of a person about himself is called:

rationalization

i-concept

projection

attribution

metacognition

15. Activity related to the achievement of private goals of activity is called:

motivation

operation

adaptation

1. action

16. The properties of an individual are the following, except:

temperament

value orientations

makings

17. Personal characteristics are the following, except for:

responsibility

position and status

focus

constitution

18. The properties of temperament are the following, except:

activity

emotionality

pace of activity

accuracy

19. The structure of individuality includes all of the following components except:

individual properties of the organism;

individual psychophysiological properties;

individual genetic qualities;

individual mental properties;

individual socio-psychological properties.

20. There are several basic instincts that are common to all people. They

have an innate character, they are not treason and are the essence of human nature. Who is the author of this theory?

S. Anokhin.

2. R. Simonov.

Z. Freud.

G. Sullivan

question number		question number		question number		question number		question number

Theme of the lesson number 5. Elements of developmental psychology and

The profession of a doctor makes demands on the personality associated with emotional overload, frequent stressful situations, lack of time, the need to make decisions with a limited amount of information, with a high frequency and intensity of interpersonal interaction. By the nature of his professional activity, the doctor is faced with suffering, pain, dying, death. The work of a doctor is a special type of activity characterized by a state of constant psychological readiness, emotional involvement in the problems of others related to their state of health, in almost any situation involving interpersonal interaction. From a psychological point of view, illness can be viewed as a situation of uncertainty and expectation with a lack of information and an unpredictable outcome - one of the most difficult psychological situations in life, a frequent emotional reaction to which is fear. This situation is experienced by the patient, a doctor “enters” it, who can reduce the degree of information uncertainty through careful diagnosis, but fully control it. human factor" he can not. Existence in such conditions requires a specialist in a medical institution to have high emotional stability, stability, psychological reliability, the ability to withstand stress, information and emotional overload, as well as well-developed communication skills, developed mechanisms of psychological adaptation and compensation, in particular, constructive coping strategies.

Among the communicative coping resources that are significant for the formation of a doctor's professional activity, empathy, affiliation, and sensitivity to rejection are primarily singled out, adequate interaction of which allows the individual to more effectively resolve problematic and stressful situations. With a very high level of empathy, a doctor is often characterized by painfully developed empathy, a subtle response to the mood of the interlocutor, a sense of guilt due to fear of causing anxiety to other people, increased psychological vulnerability and vulnerability - qualities that prevent the implementation of professional role-playing behavior, with insufficient severity of such properties as decisiveness, perseverance, purposefulness, orientation to the future. Excessive empathic involvement in the experiences of the patient leads to emotional overload, emotional and physical exhaustion. Affiliation is closely related to empathy. Affiliation is a person's desire to be in the society of other people, an instrument of orientation in interpersonal contacts. The ability to cooperate, to build partnerships provides the psychological climate in the team necessary for successful professional activity, underlies the formation of the so-called "therapeutic field".

Personal control over the environment determines the coping process and refers to the doctor's basic coping resources. Personalities with developed internal control, compared with external ones, are more attentive, have more potential opportunities to avoid adverse results, and are more sensitive to danger. They have a higher need for achievement, a positive self-concept, a high level of social interest, and high rates of self-actualization. Internal control is accompanied by greater productivity, less frustration compared to individuals with an external locus of control. In frustrating situations, external patients, in comparison with internal ones, experience greater anxiety, hostility and aggression. They are less effective in coping with life stresses due to anxiety and increased depression, they are less capable of achievements, they use the possibilities of information control over the environment worse. The degree of development of subjective control over the current life situation has a certain influence on the process of overcoming a particular disease. The locus of control is reflected in interpersonal interactions in the dyad "doctor-patient", and is one of the important factors contributing to the maintenance of health and the formation of a healthy lifestyle. The inclusion of an internal locus of control in the process of coping with stress reduces the risk of developing self-destructive behavior. From the point of view of the patient, the most significant traits in the image of a doctor are such traits as confidence in behavior and the ability to empathize. A confident style of behavior, demonstrated in the most unexpected, hopeless, shocking situations, helps to form in the patient a "therapeutic illusion" of the doctor's absolute competence, in particular, determining the ability to control current events with the construction of a realistic prognosis, which contributes to the emergence of faith and hope for a successful outcome of events. In addition to performing their immediate professional duties, the doctor must be able to provide the necessary emotional support to both patients and work colleagues. Chief in providing psychological help another should be an increase in the ability to independently resolve their problems, including through the activation of internal psychological resources. The important role of the psychotherapeutic potential of the doctor is indisputable. Heckhausen proposed a model of psychotherapeutic care, which includes 4 main aspects:

1) readiness for emotional empathy with the internal state of another;

2) the ability to take into account the consequences of their actions for others;

3) developed moral and ethical norms that set the standards for assessing the subject of his altruistic act;

4) the tendency to attribute responsibility for the commission or non-commission of an altruistic act to oneself, and not to other people and external circumstances.

What matters is the formation of techniques and methods of mental self-regulation of a doctor, which help in maintaining one's own emotional stability, psychological reliability of a professional "image", stable in the face of the threat of such destructive factors as unpopularity, rejection by colleagues, periodic doubts about the correctness of the chosen decision, which in to some extent due handicapped modern medicine and the inability to take into account and provide for the impact on the patient's body of all factors - external and internal, organic and psychological nature.

In general, successful medical activity is determined by such psychological characteristics as a high level of communicative competence implemented in relation to patients, their relatives, and medical personnel; important role play the independence and autonomy of the doctor, his self-confidence and stability in situations of unpopularity and rejection, combined with the flexibility and plasticity of behavior in changing non-standard professional situations, high degree resistance to stress, to informational and emotional overload, the presence of developed mechanisms of adaptation and compensation with a high significance of existential-humanistic values ​​that form a long-term life perspective.

LECTURE 6. DOCTOR'S COMMUNICATION AND BEHAVIOR

Psychological aspects communication between doctor and patient.

Socio-psychological portrait of a doctor's personality.

Features of the patient's personality.

To become a doctor, one must be an impeccable person. It is necessary not only to be able to adhere to such ethical categories as duty, conscience, justice, love for a person, but also to understand people, to have knowledge in the field of psychology. Without this, there can be no question of the effectiveness of demonological influence on the patient.

Often the question arises whether it is necessary to study the psychology of communication with a patient at all, because among doctors there are real masters of their craft, although they have never studied psychology. Indeed, among doctors there are inborn psychologists who have become them mainly intuitively, thanks to their personal moral and ethical qualities. However, it by no means follows from this that in order to communicate with the patient, it is not enough to have only intuition or experience. In addition, the doctor also needs special training. It is known that the profession of a doctor has certain psychological characteristics. The doctor cannot dogmatically adhere to certain postulates and instructions, not only from the point of view of the nature of the course of the disease, but also from the point of view of psychological and other factors and the causes of its occurrence. Every time a doctor faces many atypical tasks, which require independent thinking and the ability to foresee the consequences of one's actions.

The psychologization of the work of doctors is also associated with the individual characteristics of both patients and the doctor himself, with his personal qualities, experience, and authority. The same methods of deontological influence that are effective for one doctor may be completely unacceptable or hardly acceptable for another. This is one of the most important psychological aspects of the doctor's activity. In fact, not everyone is capable of this work, therefore, when choosing the profession of a doctor, professional orientation is important.

It is impossible to become a good doctor without love for your work, for a sick person. A doctor who is indifferent to the patient, to people, generally “deaf” to social problems, is a great social and professional evil, for which society pays dearly. After all, the doctor treats not only by using various medications, but also by influencing the patient with his own personality. Unfortunately, the moral and psychological principles of medical activity, their deontological embodiment have not yet been sufficiently studied.

The work of a doctor as a specific social phenomenon has its own characteristics. First of all, this work involves the process of human interaction. In the work of a doctor, the subject of labor is a person, the instrument of labor is a person, the product of labor is also a person. Here, treatment and diagnostic methods are inextricably intertwined with personal relationships. Therefore, it is so important to study the moral and psychological aspects of the doctor's work. The communicative competence of a doctor is based on knowledge and sensory experience, the ability to navigate in situations of professional communication, understanding of motives, intentions, behavioral strategies, frustration of both his own and communication partners, the level of mastering the technology and psychotechnics of communication.

Competence in the implementation of perceptual, communicative and interactive functions of communication;

Competence in the implementation, first of all, of subject-subject interaction with communication partners (it is clear that communication is by the type of orders, orders, instructions, requirements, etc.) (subject-object model of interaction) must also be mastered;

Competence in solving both productive and reproductive tasks of communication;

Competence in the implementation of both behavioral, operational-instrumental, and personal, deep levels of communication.

The determining side of the doctor's communicative competence in modern conditions is the competence in the subject - subjective communication, in the decision production tasks, in mastering the deep, personal level of communication with other people.

In the structure of the communicative competence of a doctor, we single out:

Gnostic component (a system of knowledge about the essence, structure, functions and characteristics of communication in general and professional in particular; knowledge about the style of communication, in particular, about the features of one's own communicative style; background knowledge, that is, general cultural competence, which, not having a direct relationship to professional communication, allows you to catch, understand hidden hints, associations, etc., that is, to make understanding more emotional, deep personal; creative thinking, as a result of which communication acts as a kind of social creativity);

The conative component (general and specific communication skills that allow you to successfully establish contact with the interlocutor, adequately know his internal states, manage the situation of interaction with him, apply constructive strategies of behavior in conflict situations; a culture of speech; expressive skills that provide adequate mimic-pantomimic accompaniment with the statement; perceptual-reflective skills that provide the ability to penetrate into inner world a partner in communication and self-understanding; the dominant use of organizing influences in interaction with people (in comparison with evaluating and, especially, disciplining ones);

Emotional component (humanistic attitude to communication, interest in another person, readiness to enter into personal, dialogic relations with her, interest in one's own inner world; developed empathy and reflection; high level of identification with professional and social roles performed; positive self-concept; adequate requirements of professional activity psycho-emotional states).

Here are the basic communication skills required in practical activities doctor:

1. the ability to communicate with the patient;

2. ability to manage their mental states and overcome psychological barriers;

3. sufficient understanding of the individual psychological characteristics of patients and the ability to take them into account;

4. the ability to penetrate into the inner world of the patient;

5. the ability to show sympathy (empathy) for the patient in his illness;

6. ability to listen and give advice to the patient;

7. the ability to analyze all the components of one's activity and oneself as a person and individuality.

The peculiarities of studying the psychological foundations of medical communication are to be able to overcome these difficulties, namely: the ability to know the patient and oneself, to draw up a psychological portrait of the patient, the ability to communicate psychologically competently, etc. The doctor must have a positive attitude towards the patient’s personality, recognition of his value without prejudice, over-criticism. Based on the above, let us pose a problematic question: what should a doctor of the 21st century be like, what is his professionalism?

2. Socio-psychological portrait of a doctor's personality

Professional qualities of a doctor's personality:

Professional training of a doctor, the presence of a set of all professional skills and abilities.

Psychological preparation of the doctor. The specificity and complexity of this training lies in the fact that the doctor must have a deep knowledge of psychology and related scientific disciplines.

The professionalism of a doctor is also influenced by the features of his personal life: how prosperous his own life is - whether there is love, mutual understanding with loved ones, material security, home improvement, etc. A lot is required of a doctor, he is responsible for a lot, but he himself is largely defenseless : society represented by the state does not adequately provide worthy and necessary conditions life. This applies to both material and legal, social security of a professional. But, despite the different living and working conditions, despite the individual personal characteristics of specialists, the profession of a doctor has significant professional values ​​that should be present in his activities and determine the level of professionalism. The profession of a doctor presupposes, first of all, love for one's work, love for a person, for a sick person. Without this, it is impossible to become good, in full sense of this word, a doctor.

The profession of a doctor is a unique profession that should contain a set of such characteristics: a constant desire for self-improvement, vast practical experience, knowledge of the specifics of this activity, the ability to work as a doctor, and knowledge of the prospects for the development of the medical industry.

We single out a set of personal qualities that a doctor should have.

1. Moral and ethical qualities of a doctor: honesty, decency, commitment, responsibility, intelligence, humanity, kindness, reliability, adherence to principles, disinterestedness, ability to keep one's word.

2. Communicative qualities of a doctor: personal attractiveness, politeness, respect for others, willingness to help, authority, tact, attentiveness, observation, being a good conversationalist, sociability, accessibility of contacts, trust in others.

3. Volitional qualities of a doctor: self-confidence, endurance, risk-taking, courage, independence, restraint, poise, determination, initiative, independence, self-organization, perseverance, purposefulness.

4. Organizational qualities of a doctor: exactingness to himself and others, a tendency to take responsibility, the ability to make decisions, the ability to correctly assess himself and the patient, the ability to plan his work.

The activity of a doctor is a complex, multifaceted, dynamic phenomenon. Its specificity is predetermined, first of all, by the expansion of communication between the doctor and the patient. For a doctor, this is not a luxury, but a professional necessity. With its help mutual influence of two equal subjects - the doctor and the patient is carried out. An indicator of the effectiveness of such mutual influence is the predominance of positive aesthetic feelings, humanity, and creativity. The doctor must have certain qualities that contribute to the effectiveness of the doctor. First of all, it is the ability to control oneself, to control one's behavior. It is quite clear that the doctor needs to be prepared for this.

We will offer a few rules for optimizing the doctor's communication with patient which will optimize the treatment process:

1. Greet the patient cheerful, confident, energetic.

2. The general feeling in the initial period of communication with the patient is vigorous, productive, confident.

3. There is a communicative mood: the readiness for communication is pronounced.

4. When communicating with the patient, an appropriate positive emotional mood is created.

5. Manage your own well-being (smooth emotional mood, the ability to manage well-being, despite adverse circumstances, etc.).

6. Achieve communication performance.

7. Speech should not be oversaturated with medical terms.

8. Expressive facial expressions are emotionally expedient, that is, they must correspond to the emotional state of the patient.

Great importance should be given to the well-being of the doctor. It is not a personal matter for the doctor, because his mood is reflected both in the patient and in his work colleagues, which creates a certain atmosphere in the treatment process. To achieve such an optimal internal state is extremely difficult, since to some extent the work of a doctor has aspects of routine.

The doctor must be able to maintain efficiency, master situations to ensure success in his work and maintain his health. To do this, you need to work on yourself, be self-confident, be able to control your emotions, relieve yourself of emotional stress, be purposeful, decisive.

The activity of a doctor should be based on a positive emotional attitude towards himself, his patients, and his work in general. Exactly positive emotions activate, inspire the doctor, give him confidence, cause a feeling of joy, positively affect relationships with patients, work colleagues. And negative emotions, on the contrary, inhibit activity, disorganize behavior and activity, cause anxiety, fear, and suspicion in the patient.

A doctor needs to be able to play like an actor, and not only from the outside.

The facial expression of the doctor should be friendly not only in order to tune in to a good mood, but also to change the methods of behavior. Therefore, a doctor should not walk in front of patients with a gloomy, bored face, even when his mood is bad. If, nevertheless, a bad mood does not leave you, you should force yourself to smile, hold back a smile for a few minutes and think about something pleasant.

In addition to the fact that the doctor must be in control of his internal state, he must be able to control his body, which clearly reflects the internal state, thoughts, feelings. The elements of the doctor's external technique are verbal (speech) and non-verbal means. It is through them that the doctor discovers his intentions, it is through them that the patients “read” and understand.

Appearance doctor should be aesthetically expressive. You can't be careless about your appearance. The main requirement for clothing is modesty and elegance. Aesthetic expressiveness is also manifested in the friendliness and friendliness of the doctor's face, in composure, restraint of movements, in a stingy, justified gesture, in posture, gait. Fussiness, artificiality of gestures, their flabbiness are unacceptable. Even in how to receive a patient, look at him, say hello, how to push a chair, there is a power of influence. In movements, gestures, look, the patient should feel restrained strength, complete self-confidence and a benevolent attitude.

Body plasticity, or pantomime, allows you to highlight the main thing in the appearance of a doctor, draws his perfect image. The effectiveness of communication is helped by open postures and gestures of the doctor: do not cross your arms, look into the patient's face, reduce the distance, which creates an effect of trust.

The facial expression of the doctor affects patients the most, sometimes even more than his word. It is gestures and facial expressions that increase the emotional significance of information. Patients "read" from the doctor's face, remembering his attitude, mood, so the face should not only express, but also hide some feelings: you should not transfer the burden of household chores and troubles to the patient. It should be shown on the face and in gestures that which concerns the case, contributes to the treatment.

The facial expression of the doctor should always correspond to the nature of the speech when talking with the patient. The doctor's face should express confidence, approval, dissatisfaction, condemnation, joy, interest, enthusiasm, that is, express a wide range of emotions, which indicates the moral strength of the doctor's personality.

The doctor in his professional activity must reach the pinnacle of communication skills, namely, the possession of his own body and the ability to influence the patient, the power of his body. Here, biomechanics, the science of formation, can come to the aid of a doctor. motor coordination behavior, the ability to control one's body, which was developed by the Czech theater director Meyerhold. Its final task is to subordinate its motor behavior to the expression of a certain effect on the patient, to make it automatic, to turn it into a perfect technique of communication, an internal need.

An important basis for a number of professionally important qualities of a doctor's personality is emotional stability, anxiety, and a propensity for risk are features of neurodynamics.

For professional psychology, it is very important that the features of neurodynamics influence the formation of professionally important personality traits. It is known that the weakness of nervous processes gives rise to increased anxiety, emotional instability, decreased activity in activity, etc. For individuals with very high strength indicators nervous system increased likelihood of establishing inflexible, inappropriately high self-esteem.

Emotional stability as the ability to maintain optimal performance under the influence of emotional factors also largely depends on the characteristics of self-esteem. It is closely related to anxiety - a property that is essentially biologically determined. Both of these qualities, sometimes considered as properties of temperament, and more often as personal characteristics, professionally significant in many types of activities, which are noted in many types of regular professional activities. A similar relationship is most often observed between the success of activities and emotional stability. In many activities, emotionality is important - an integral ability for emotional experiences. Particularly serious requirements for this area are made by professions that require high emotionality and at the same time emotional stability, for example, the activity of a doctor.

The property of extra-introversion is considered to be professionally important, first of all, for group activities or professions related to communication, working with people. But this quality can also be important for individual work. There is some evidence that introversion is associated with higher resting cortical activation, so introverts prefer activities that avoid excessive external stimulation. Extroverts strive for external stimulation, prefer activities that enable additional movements, emotional and motivational support. It is known that introverts are more resistant to monotonous work, better cope with work that requires increased vigilance and accuracy. At the same time, in stressful work situations, they show a greater propensity for anxious reactions, which negatively affect the success of their activities. Extroverts, on the other hand, are less accurate, but better oriented in stressful work situations. In group work, it is necessary to take into account the greater suggestibility and conformity of extroverts.

Responsibility is most often mentioned as a universal, professionally important quality among personal qualities. Responsibility is considered as one of the properties that characterize the orientation of the doctor's personality, affect the process and results of professional activity, primarily through the attitude to their work duties and in their professional qualities.

Most other personal qualities are more specific and important only for certain types of professional activities. Summing up the above, we can assume that personality traits can act as professionally important qualities in almost any type of professional activity, in particular, in the activity of a doctor.

The abilities of a doctor are usually considered as individual personality traits that contribute to the successful implementation of his activities.

Two large groups of special abilities of a doctor can be distinguished:

1. perceptual-reflexive (perception - perception) abilities that determine the possibility of the doctor's penetration into the individual identity of the patient's personality and understanding him (these abilities are leading);

2. projective abilities associated with the ability to act on another person, on the patient.

Among them, the main ones are:

1. The ability to correctly assess the internal state of the patient, sympathize, empathize with him (the ability to empathize).

2. The ability to be an example for those who are being treated, in thoughts, feelings and actions.

3. Ability to adapt to the individual characteristics of the patient.

4. The ability to instill confidence in the patient, to calm him down.

5. The ability to find the right style of communication with everyone, to achieve his location and mutual understanding.

6. The ability to earn respect from the patient, to enjoy (informally) his recognition, to have authority among those who are being treated.

3. Personality characteristics of the patient

The personal characteristics of the patient include the following qualities: temperament, character, abilities, intellect, etc. The doctor must take into account all these groups of properties when establishing psychological contact with the patient.

Different types of patients come to see a doctor. The doctor sometimes does not know about his personality and, as a result, may not be prepared to meet him. Subconsciously, the doctor always tunes in to the image of the “ideal patient”. This term is sometimes used to refer to such patients who consciously came to recover from the disease, they have no doubts about their strengths and skills as a doctor, a willingness to fulfill all the doctor's prescriptions, the ability to briefly state their problems and complaints, and little awareness in medical terms.

But, as practice shows, the percentage of such patients is small and the doctor directly encounters different patients, with manifestations of their different characters, which, of course, creates certain barriers in treatment. Therefore, the doctor needs to take into account all the characteristics of the patient's personality for the effective formation of contact with him.

Patients vary in their personal characteristics. Let's consider them.

External patients are more turned to the outside world that surrounds them, they are sociable, they have a wide circle of friends, acquaintances, high excitability and impulsive behavior. They are able to blame external circumstances, their fate, chance for their ailments and illnesses. Such patients usually show aggression and anger, both to the doctor and to other patients. The main tactic that a doctor should use is, first of all, establishing emotional contact with such patients, and only then moving on to the informational aspects of the conversation.

Patients-internals. For them, their inner world, their experiences, are of greater interest, and the external environment is not important. Such patients are “closed in themselves”, uncommunicative, they are never bored with themselves, it is difficult to adapt to changes in the external environment, they are prone to introspection, and a mistrustful-skeptical type of communication prevails. For internals, there are no trifles in their health. They lay the blame for their lost health only on themselves and lay responsibility for the events in their lives only on themselves. Such patients are extremely responsible, executive, demanding both to themselves and to the doctor. Therefore, the doctor, while working with such patients, should discuss all issues in as much detail as possible, otherwise the patient may experience a feeling of anxiety. There is no need to economize on time by conducting a consultation, because the pace of thinking of internals is slow. The doctor must come to terms with this and be patient, calm. In this case, the tactics with the patient should be opposite to those previously given, namely: contact with such a patient should begin with a neutral, informational contact, and only then form a positive emotional attitude towards the doctor.

There are some prerequisites for creating a certain relationship between the doctor and the patient, which are in place even before they come into direct contact. It should be taken into account that the patient who comes to the doctor, as a rule, knows more about him than the patient's doctor. The reputation of health care in general and the medical institution where the patient comes is also important. The tension, dissatisfaction and anger of the patient, who was forced to get to the doctor by uncomfortable transport and wait a long time in the waiting room until his turn comes, is often a mechanism for the generalization of affect, which was inadequately manifested when meeting with a nurse or a doctor who has no idea about the reasons this affect. For most patients in the image of a doctor generalized personal experience interactions with people who are authoritarian for him in different periods life. Theoretical basis in the field of the relationship between the doctor and the patient developed 3. Freud in his concept of "transfer" ("transfer"). According to this concept, the doctor subconsciously reminds the patient of some emotional significant person from his childhood, such as his father. Depending on what impressions and attitudes once prevailed during the contact of the patient with the father, in relevant the tendency to the doctor is either negative (hostile) or positive (feeling of love, trust). In the opposite direction there is an "anti-transfer" ("countertransfer").

This is currently the original understanding 3. Freud is considered too narrow and artificial, but sometimes rational, which indicates the possibility that to the patient some elements of the doctor's behavior, appearance or reputation may resemble something positive or negative from his past life and above all - experience with those persons who had great emotional significance for him. In addition to parents, it can be grandparents, uncles and aunts, brothers and sisters, teachers, close friends. And not only in the relationship with the doctor, but in every new contact that occurs between people, it makes sense to think about why someone whom we, quite likely, see for the first time in our lives, evokes in us quite expressive feelings of like or dislike, who from our past than they resemble. If we keep in mind such a "burden of the past", it can help us to more realistically understand and deal with situations related to relationships with other people.

In this context, it is worth mentioning also the possibility of action "transfer aesthetic stereotype. Namely, the fact that beautiful people are more likely to evoke sympathy and trust, ordinary people are more likely to arouse antipathy and uncertainty. This element traditionally appears already in fairy tales in the figures of an ugly witch and a handsome prince. The concept of beauty is associated with good qualities, disgrace - with evil. Although this prediction is unfounded, it subconsciously has a rather strong effect: a seemingly attractive patient makes the doctor more sympathetic, even if in reality he requires less help than the patient, which arouses antipathy with his appearance. Conversely, a doctor who acts aesthetically positive inspires more confidence in the patient.

Consequently, the doctor's knowledge and consideration of the patient's image of the "ideal" doctor contributes to the establishment of a better psychological contact between the two of them.

The doctor will gain the patient's trust if he, as a harmonious personality, is calm and confident, but not haughty, and if his demeanor is quick, stubborn and decisive, which is accompanied by human participation and delicacy. When making a serious decision, the doctor must imagine the results of it for the health and life of the patient, and thereby strengthen in himself a sense of responsibility. The need to be patient and self-controlled makes special demands on him. He must always consider the various possibilities of the development of the disease and not consider ingratitude, unwillingness, or even personal insult on the part of the patient if his condition does not improve.

It is difficult to combine the necessary caution and prudence in the work of a doctor with the necessary determination, composure, optimism, critical attitude and modesty. There are situations when it is inappropriate to show a sense of humor without a hint of irony and cynicism, according to the principle: "Laugh with the patient, but never at the patient." However, some patients do not tolerate humor even with good intentions and understand it as disrespect and humiliation of their dignity.

The balanced personality of the doctor is for the patient a complex of harmonic external stimuli, the influence of which takes part in his recovery. The doctor must educate and shape his personality, Firstly, observing the reaction to his behavior directly (by talking, evaluating facial expressions, gestures of the patient), and, secondly, indirectly, when he learns about his behavior from his colleagues. The colleague himself can also help his colleagues direct their behavior.

There are facts when people with unbalanced, uncertain and absent-minded manners gradually harmonized their behavior towards others, both through their own efforts and with the help of others. Of course, this requires certain efforts, a certain critical attitude towards oneself and the necessary degree of intelligence, which for a doctor should be taken for granted.

A young doctor, about whom patients know that he has less life experience and less qualifications, is at a disadvantage compared to his older colleagues, but he will be helped by the realization that this shortcoming can be compensated for by conscientiousness, readiness to help at any moment and modesty.

Before a young doctor becomes a professional in his field, he must gain authority and trust among patients and colleagues. The main component of the relationship between the patient and the doctor is trust. But the acquisition of trust does not follow only from the psychological side of the relationship between the doctor and the patient, but also has a broader, social side. The doctor can win the patient's trust and establish a mostly positive relationship with him if he satisfies his unreasonable demands for treatment. He can contribute to this so that patients will turn to him and “confidence” in him will increase. The development of such relations, of course, follows from the mutual satisfaction of interests on the one hand of the doctor, on the other hand, of patients who can do some service to the doctor, for example, using their profession (repairmen, artisans, employees of the distribution network, etc.). If such cases become too numerous, then the current and actually necessary examination and treatment of all patients suffers, which should be carried out according to their disease, and not social status or opportunities.

In practice, a psychological problem arises when the doctor notices that the relationship between him and the patient is developing unfavorably. Then the doctor has no choice but to behave with restraint, patiently, not to succumb to provocations, not to provoke himself and try to gradually win the patient's trust with calmness and understanding. Thus, we create the correct experience, that is, the negative manifestations of the patient should be corrected with the help of their own positive manifestations, for example, patience, tact and tolerance. And, on the contrary, the stereotypical, until now, unfortunately, often spontaneous, "natural" reaction - anger for anger, irony for irony, helplessness for helplessness, depression for depression - reinforces the "sinful" and problematic attitude of the patient and the possibility of conflicts, misunderstandings are growing. Such behavior can be characterized by the expression: "pour oil on the fire." At the same time, it is precisely such a “natural” reaction that is a waste of time, while the opposite approach, that is, accepting a person as he is, saves the time of the doctor and the patient.

An equally important aspect in the professional activity of a doctor is knowledge and consideration of the common clinical classification of types of patients and types of doctors. This classification was derived as a result of long-term observations of the behavior of patients and doctors. Let's get acquainted with the clinical classification of types of patients.

Anxious patient. The behavior of such patients is marked by increased anxiety, which is not justified. Very often, these patients have an anxious personality type. They are cowardly, submissive, unsure of themselves, during diagnostic and therapeutic procedures they can lose consciousness, various vegetovascular reactions occur. In dealing with this type of patients, the doctor should seek the help of a medical psychologist who will relieve emotional stress and anxiety, which will contribute to an effective treatment process.

Distrustful patient. The behavior of such a patient is characterized by increased distrust of the doctor's activities and his personality. Such patients are skeptical about the treatment process, with caution. Before agreeing with the doctor, they will think it over a hundred times, and then they will begin to follow his recommendations. If the doctor distinguishes suspicion from possible psychopathy in time, then he should, first of all, begin treatment, overcoming the barriers of distrust and alienation of the patient.

Patient offers. This type of patient is trying to get the attention of both doctors and other patients. Constantly needs recognition that he is really sick, that he is experiencing unbearable torment. The patient shows the doctor what he needs special attention to his personality, exaggerates the description of his complaints. While working with such a patient, the doctor must give the patient a certain amount of recognition of his "heroism", the stability of his character.

Depressed patient. Such a patient is depressed, isolated from others, refuses to talk with other patients and staff, poorly reveals his inner world. He is extremely pessimistic because he has lost faith in the success of treatment and recovery. effective advice for the doctor is his optimism, faith in the recovery of the patient, which have for him great importance; it is worth involving him in the care of other patients, performing simple tasks for him.

neurotic patient. This type of patient is overly attentive to his health, is interested in the analyzes of all laboratory tests, unreasonably assumes the presence of a wide variety of diseases, reads specialized literature. When communicating with such a patient, the main thing is to keep a distance, that is, “not to follow the patient’s lead”, to explain the importance of the treatment process prescribed by the doctor, its effectiveness, by methods of persuasion and suggestion.

To develop the ability to communicate with a patient, in particular a psychotherapeutic approach to him, any doctor needs to have information about his professional type of behavior.

To understand the peculiarities of their communicative abilities, to help the doctor see himself "through the eyes of the patient", gives personality classification doctors for I. Hardy (1973).

Robot doctor. For his activities, the most characteristic is the mechanical performance of his duties. These doctors are meticulous, technically well-qualified, and carry out all orders accurately. However, working strictly according to the instructions, they do not put psychological content into their work. Such a doctor works like an automaton, he perceives the patient as a necessary supplement to the instructions for his care, their relationship with patients is devoid of emotional sympathy and empathy. They do everything, letting one thing out of sight - the patient. It is such a doctor who is able to wake up a patient who is sleeping in order to give him sleeping pills at the appointed time.

Soldier doctor. This type of doctor is well served in popular comedies. Patients already from afar learn about him by his gait or loud voice, quickly trying to organize their bedside tables and beds. This doctor is resolute, uncompromising, persistent, instantly reacts to the slightest violations of "discipline". With insufficient culture, education, low level intellectual development such a tough "strong-willed" doctor can be rude and even aggressive with patients. In favorable cases, if he is smart, educated, with such a decisive character, he can become a good educator for young colleagues.

Maternal type physician ("mother" and "doctor"). He transfers his warm family relationships to work with patients or compensates for their absence in his work. Working with the sick, taking care of them is an essential condition of life for him. He has a good command of empathy, the ability to empathize.

Expert doctor. ego doctor - narrow specialist. Due to the high need for professional recognition, he shows a special curiosity in a certain area of ​​​​professional activity and is proud of his importance in his industry, where sometimes he even “overshadows” the doctor. Young doctors do not hesitate to turn to them for professional advice. Sometimes people of this type become fans of their narrow activities, excluding all other interests from their field of vision, they are not interested in anything except work.

"Nervous Doctor". This type of unprofessional behavior of a doctor should not be in a medical institution and indicates a poor-quality professional selection of personnel, errors in the work of the administration. Emotionally unstable, quick-tempered, irritable, he constantly gives neurotic reactions, is inclined to discuss personal problems and can become a serious obstacle in the work of a medical institution. A “nervous doctor” is either a pathological person or a person suffering from a neurosis. Such people themselves often need serious psychotherapeutic help and are professionally unsuitable for working with patients.

A doctor who belongs to the above types has not yet formed or has already formed as a person, such behavior is marked by unnaturalness. Unnaturalness in communication prevents him from establishing contacts with people, so such a doctor himself must clearly define his professional goals, develop an adequate style of communication with the patient.

Thus, if the main principle in the activity of a doctor is “the patient first”, then planning and conducting medical practice is impossible without the ability to conduct a survey, formulate problems, plan activities and train the patient in self-care skills, and for this, doctors must continuously learn and improve not only in vocational training, but also in the psychological foundations for therapeutic activities.

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The personality of a doctor, his individuality is the object of close attention of society, the subject of public discussions and study in the professional field, in educational organizations, in healthcare management structures. The increased interest in this is quite justified. Despite the technologization of medical activity, all the best equipment of doctors with the latest diagnostic and treatment tools, a person, a doctor with his individuality, remains at the head of this process. Character, psychological characteristics. And if you ask any patient who he would prefer to communicate with if he were given a choice: with the smartest diagnostic machine that does not fail, or with a good doctor, then the answer can probably be predicted with a high probability. The choice will be made in favor of human communication.

Each patient draws the image of an ideal doctor for himself. But in many ways, this image is the same. Students of Karaganda medical academy in the classroom in psychology, communication skills, this question is mostly answered in the same way. The doctor in their view is humane, a kind person, disinterested and attentive, well aware of his profession, constantly improving in it. Students endow the doctor with such character traits as adherence to principles, purposefulness, sense of humor, ability to compassion. Interestingly, first-year students mainly talk about the volitional properties of the doctor's personality. Senior students focus on the intellectual, cognitive properties of the individual. In one of the universities of Belarus, a study was conducted, in which students of the medical and preventive faculty took part (Dubrova V.P., Elkina I.V., 2004). A qualitative analysis of the data obtained in the course of an empirical study made it possible to state that future doctors invest in the content of the concept of "ideal doctor" characteristics that reflect the specifics of the professional role and individual psychological characteristics of the individual. These characteristics relate to various areas of personality psychology: emotional-volitional, effective-practical, need-motivational, interpersonal-social, existential-existential, moral and cognitive-cognitive.

The largest share in the characteristics of the ideal doctor is assigned to interpersonal-social sphere of personality (29%), which usually includes interpersonal information exchanges, interactions, relationships, etc.

Future doctors note the following qualities of an ideal doctor:

1. rendering psychological support (23%);
2. empathy, understanding (18.2%);
3. the ability to establish a therapeutic alliance (13.8%); ,
4. the ability to find an approach to any person (12.3%);
5. sociability, flexibility in communication (8.5%);
6. excellent relations with colleagues, mutual assistance (7.7%);
7. openness, sincerity, friendliness (5.3%);
8. the ability to see a personality in a patient (4.4%);
9. the ability to explain to the patient the diagnosis and method of treatment in an accessible way (3.1%);
10. respect from others, authority (2.6%);
11. the ability to heal the body and soul (1.1%).

Among the qualities associated with moral sphere (21%), which includes moral states, actions, deeds and personality traits, most often students note such personal qualities as benevolence, intelligence, responsibility of a doctor. TO effective-practical sphere (21%) refer to the manifestations of a person as a figure who practically realizes himself in the world around him, and in the description of the ideal doctor this area is represented by professional skills. Cognitive-cognitive sphere (12%) is presented as receiving, storing, recognizing, reproducing and transforming information, it should include cognitive-cognitive states, processes and personality traits. In the views of students, this area is filled with characteristics related to the professional knowledge of an ideal doctor. In the content of the concept of “ideal doctor”, students also include professional self-improvement, love for their profession, full dedication to their profession, passion for their work, value and respect for own life and health, to the life and health of others. Researchers refer to these characteristics as need-motivational sphere (7.6%), which includes various needs (needs experienced by a person in certain conditions of life and development), motives (associated with the satisfaction of certain needs, motivation for activity) and orientations. Existential-existential sphere (3%) manifests itself in states of self-deepening, experiences of one's self, personality traits, due to participation in one's being in the world. The following qualities of the “ideal doctor” identified by students can be attributed to this area. It seems to us extremely important the observation of our colleagues from Belarus on this aspect of the doctor's personality, which was highlighted by the students. Despite the rapid age, the practicality of young people, they consider them to be the necessary personality traits of a doctor.

• self-confidence (31.9%);
• positive self-concept (24.5%);
• autonomy and acceptance of the autonomy of another (22%);
• integral locus of control (4.8%);
• the ability to reflect (4.8%);
• possessing a bright personality (4.8%);
• self-sufficiency (2.4%);
• self-esteem (2.4%);
• high self-esteem (2.4%), -

that is, those properties that do not allow a doctor to be one hundred percent conforming for the sake of gaining benefits and building a career. Evaluate the statements of Belarusian students and compare them with your opinions. For example: "The ideal doctor should have a sense of self-respect, because if a person respects himself, he will always strive to be on top." Or: “A doctor who is independent in making decisions and respects the independence of other people, understands the impression he makes on the patient and has high self-esteem, can be called an ideal doctor.”

The researchers note that students assigned a certain role in the concept of "ideal doctor" image medical specialist. According to some of them, the ideal doctor should be a man, which indicates the attitude towards a male doctor as a carrier of business qualities. In addition, the ideal doctor should be neat, in a snow-white coat, have an attractive appearance and pleasant manners, conduct healthy lifestyle life, to have a stylish car, your own house and a great income. “A man dressed in an expensive suit, tie, expensive shoes. With neat hair and expensive watches. Having a stylish car." “Non-smoker and light-drinker, always in a white shirt, polished shoes and a starched dressing gown.” “The appearance of a doctor should not cause negative emotions at the patient. For example, when seeing a doctor’s long nails, the patient first of all thinks: “How does the doctor help with such hands?” A doctor who promotes cleanliness should be in a clean coat and have order on the table.

Based on the above study, its results, our observations and reflections, summarizing the statements that we receive in the classroom from KSMA students, we consider the authors' conclusions that students, first of all, highlight the interpersonal and social sphere of the personality of an ideal doctor, are fair. This is due to the postulate of medical ethics, according to which the professional activity of a doctor is an activity in the field of communication and one of the sides of the success of this activity is a sufficient level of development of interpersonal and social qualities aimed at the ability to establish therapeutic cooperation with the patient. This postulate serves as a starting point for the public assessment of the success of a doctor as a specialist and as a person.

It is also important for future specialists to have a sufficient level of knowledge and skills that allow them to experience their own value as a specialist, to feel ownership of what is happening. The presence of moral, need-motivational and emotional-volitional qualities allows the doctor to achieve self-actualization, be successful in his professional activities, and make a certain contribution to the development of medicine.

Summing up the analysis of the image of the ideal doctor in the views of students of higher medical school, we can make following conclusions:

1. In the content of the image of the ideal doctor, medical students include individual psychological characteristics of the personality and features of the professional role of a specialist related to the following areas of personality: interpersonal-social, moral-moral, effective-practical, cognitive-cognitive, need-motivational, emotional- volitional, existential-existential.

2. The largest share is given to the interpersonal-social sphere of the individual. Moreover, many of the qualities listed by students speak of the need for an ideal doctor to comply with the doctrine of informed consent, the principles and norms of medical ethics, the "Code of Medical Ethics".

3. The dominance of the interpersonal-social sphere, which reflects the characteristics of the interaction between the doctor and the patient, made it possible to determine the general standard of the ideal doctor as “cooperating” and ready to establish a therapeutic alliance with the patient in the treatment process. We consider this circumstance as a result of the students' assimilation of the basic provisions of medical ethics, methodological foundations And theoretical problems medical interaction, the basic rules of communication in the dyads "doctor - patient", "doctor - other medical specialists", "doctor - relatives of the patient".

4. The image of a collaborating doctor as ideal in the views of students of a higher medical school creates conditions for the formation of professional value orientations and professional self-improvement.

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Lecture course

Psychological foundations of the professional activity of a doctor

Tserkovsky Alexander Leonidovich

Editor Yu.N. Derkach

Technical editor I.A. Borisov

Computer layout E.Yu. Prudnikova

Proofreader A.L. Church

FOREWORD

Treating a disease is a science.

Treating the sick is an art.

The 21st century is the century of medical art.

The 21st century is marked by a very close interaction between psychology and medicine. In this regard, psychological preparation is becoming one of the most rapidly developing and attention-grabbing aspects. medical education. (WHO, 1993).

The clinical competence of a doctor should be based on a socio-psychological culture - the ability to communicate with the patient, his relatives, colleagues, administration.

Studies have shown that there are significant relationships between many aspects of interpersonal skills of clinicians, on the one hand, and the degree of satisfaction and motivation of patients, on the other (Thomson et. al., 1990). Poor communication on the part of the physician is a major factor leading to patient and family dissatisfaction with the treatment provided, leading to accidents and subsequent litigation (Vincent, 1992).

The study by medical students of the basics of general, developmental and social psychology, medical psychology can further influence the cost of treatment and the efficiency of resource use in health care, opening up the possibility for more accurate diagnosis and better patient compliance with treatment plans.

The psychologization of medical knowledge can help the clinician more effectively deal with the need to develop an adequate treatment plan and communicate it to the patient within the time available for this, to prevent unnecessary prescriptions of drugs that are either erroneously prescribed or misused by patients (Kaplan, 1989; Sandler, 1980). The psychological incompetence of a doctor entails Negative consequences for medical, psychosocial and economic aspects of health care.

At present, the formation of communicative competence The importance of a medical specialist has not yet been fully considered as one of the most important components in the professional training of a doctor. This gives rise to social and psychological problems in the health care system itself.

1. Currently, a new model of relations is being actively introduced in medicine, based on the ethical doctrine of "informed consent" and focused (K. Rogers) on the "client-centered approach" (subject - subject interaction). This model clashes with the opposite tradition - "nosocentric" (from Latin nosos - disease), rooted in the structure of medical student education and the healthcare system. It is based on the subject-object interaction. The focus of the doctor is the disease.

Within the framework of a client-centered approach, a person who applied for professional medical help becomes an active participant (accomplice, subject) of the therapeutic process. The doctor must be “at the level” of the client, must be ready for cooperation, in particular, for communication “on an equal footing”. The therapeutic alliance in the doctor-patient dyad, based on trust, is the most important factor determining the success of therapy, regardless of its orientation.

Currently, the relationship between the doctor and the patient is paternalistic in nature - the nature of "subject - object" relations. This relationship may be due to several reasons:

a) the doctor often does not attach a special role to communication with the patient in the therapeutic process and does not bother himself with careful preparation and organization communication space and communication;

b) the doctor does not always know how to interact with himself in such a way as to rely on his potential;

c) in his actions in relation to the patient, the doctor is guided by the notion of the patient as a passive executor of the doctor's orders, as an object that is not competent, not autonomous, and does not have the potential of medical self-education.

2. According to a number of experts, nine out of ten Americans "do not live out their lives", in the absolute first place in the world there are diseases that can be qualified as "lifestyle" diseases.

The usual division between "organic" and "functional" diseases is now increasingly questioned. medical specialists began to understand that diseases often arise on the basis of multiple etiological factors.

Such views on the causes of disease are of particular interest in the role that psychological and social factors can play in this regard.

Practical medicine begins to expand its field of vision: the patient is no longer just a carrier of some diseased organ, he must be considered and treated as a person as a whole, since “illness is the result of an abnormal development of relations between the individual and the social structures in which he is included” ( B. Luban-Plozza, 1994).

Modern medicine tends to absolutize the somatic sphere to the detriment of the psychosocial (N.G. Ustinova, 1997), and the medical model of the disease, which is highly adequate to the clinical paradigm of health, often distorts the patterns of social etiology of the main volume of pathology existing in society. The socio-psychological approach to health, in its theoretical content, is most adequate to the sanocentric paradigm of modern medicine, which is replacing the pathocentric paradigm (IN Gurvich, 1997). The “quality” of medical services, adequate treatment without a deep study of the socio-psychological category is hardly possible (both accents are important: “lifestyle” and “lifestyle”).

3. The family, like other immediate environment, usually gives a person the amount of warmth, attention and love that he needs. Here he is loved without limit, unconditionally, and accepted for who he is.

That is why a number of experts believe that it is more adequate to count the population of the planet “by families”, and count the lonely “as an incomplete family”. The contribution of the family to the health and life of a person is difficult to overestimate, and in this regard, as world statistics prove, 26% of errors in medical diagnostics are attributed to ignorance of the patient's family environment (R.S. Duff, A.B. Hollingshead, 1968). Therapy of gastric ulcer, ulcerative colitis, diabetes, asthma, coronary heart disease, anorexia, migraine requires a family approach (MV Avsent'eva, 1994).

At the same time, a medical graduate is guided in the field of family psychology at the level of common sense and the independent work life experience. The patterns of family functioning can be a powerful factor in recovery or, conversely, an elusive, invisible, but constantly acting factor in pathogenesis (for example, a “schizophrenic family” is known in a psychiatric clinic).

4. The widespread practice of creating groups of patients in the world (“Alcoholics Anonymous”; the society of “exceptional cancer patients” by B. Siegel; groups of patients with severe pain; groups of patients who survived a suicide attempt, etc.) can be initiated by a doctor oriented towards modern psychology and in the field of social psychology, in the first place. Patients discover the possibility of mastering (with subsequent transfer of experience to each other) the principles of such work, but the awareness of the importance of this area of ​​work and the main effects (opportunities and prospects) of group work remains with the attending physician.

5. According to K.K. Platonov (1990), the word "rehabilitation" was first used in the trial of Joan of Arc, and this legal concept is interpreted (in the strict sense) as "the return of the rights of the individual." It is no coincidence that in the history of medicine, psychiatrists were the first to turn to it, and only then it was introduced into other areas of medical work.

The crisis nature of a person's encounter with social stereotypes, labels (up to stigmatization) is well known, and the prospect of life in the status of "OTHERS" frightens many people suffering from serious illnesses.

6. In the strict sense of this term, "management" means "development" of the system, while maintaining the "quality" of the system and the task of "stabilizing" the work, are combined by the term "administration". The professional training of heads of medical institutions does not fully meet the socio-psychological realities of the “attacking behavior of an organization in the service market”, successfully mastered by other areas of social practice (V.P. Dubrova).

The doctor, at least twice, comes face to face with these problems. In one case, he is an element of the management system (integrating into it or not), in the other case, the doctor himself will have to create a treatment management system, where the microenvironment and the patient himself, narrow specialists and nurses, the patient's neighbors in the ward should be combined and colleagues who come to him (the creation of a so-called “therapeutic community” in the health facility). The doctor must create (recreate) this system and transfer its control “into the hands” of the patient himself. All elements of the system should contribute to recovery and not interfere with it.

This problem can also be viewed through the prism of the formation of an “internal picture of treatment”, as teaching the skills of self-management. It should be noted that the “internal picture of the disease” is widely discussed among physicians, the “internal picture of health” is beginning to gain recognition, but the concept of “internal picture of treatment” is practically ignored and not developed.

7) The modern approach to the diagnostic and treatment process involves the use of a sociopsychosomatic approach to the patient and the disease. This approach is systematic. It involves a holistic vision mutual influence disease process, the personality of the patient and her social environment. The use of a sociopsychosomatic approach in one's professional activity can improve the quality of the diagnostic and treatment process.

The listed socio-psychological problems, if not solved, can reduce the quality of treatment, the income of the medical institution and, ultimately, the earnings of the doctor himself.

The expanded introduction of courses in general, developmental and social psychology into the practice of training doctors of all levels contributes to the formation of a doctor's socio-psychological competence. This allows:

1) better recognize and respond more correctly to verbal and non-verbal signs of patients and extract more relevant information from them;

2) more effective diagnosis, since effective diagnosis depends not only on the establishment of bodily symptoms of the disease, but also on the ability of the doctor to identify those somatic symptoms, the causes of which may be of a socio-psychological nature, which, in turn, requires other treatment plans;

3) seek patient compliance with the treatment plan, as studies have shown that communication skills training has positive influence on the consent of the patient to take the medicine prescribed to him;

4) provide patients with adequate medical information and motivate them to follow a healthier lifestyle, thus enhancing the physician's role in health promotion and disease prevention;

5) influence various forms of reflection of the disease (em emotional, intellectual, motivational) and activate compensatory mechanisms by increasing the psychosomatic potential of the patient's personality, help him reconnect with the world, overcome the so-called "learned or trained helplessness", destroy the stereotypes created by the disease and create patterns of healthy response;

6) Physicians are more effective in particularly sensitive aspects of the doctor-patient relationship that are often encountered in practice, such as the need to inform the patient that he or she is terminally ill, to tell the patient's relatives that the patient must die, or other examples of delivering bad news.

This course of lectures is primarily focused on the theoretical socio-psychological training of medical students. It is based on the systemic concept of the psyche, which makes it possible to consider the human psyche as a feedback system (A. Gorbatenko, 1999). Such an approach, in our opinion, contributes to the formation of a holistic view of a person’s mental activity in a medical student, which will allow him to purposefully carry out a medical and diagnostic process in his future professional activity (A.L. Tserkovsky).

The use of examples from medical practice in lectures equips students with concrete knowledge in the field of practical interaction skills. This is especially important now that there is a growing need to increase the number of family doctors.

conflict medical temperament ability

CHAPTER I. PSYCHOLOGY IN MEDICINE

LECTURE 1. THE SIGNIFICANCE OF PSYCHOLOGY IN DOCTOR TRAINING

1. Relevance psychological preparation future doctor

The active interaction of psychology with medicine is currently due to the fact that the relationship between the doctor and the patient is still mainly paternalistic (traditional) in nature, and today it is necessary to ensure cooperation between them, on the other hand, by changing the nosocentric approach to the patient (subject-object relationship between a doctor and a patient) to anthropocentric (subject-subject interaction in the dyad "doctor - patient") and the need for psychological training of doctors in connection with this (V.P. Dubrova).

Consequently, the implementation of the program for the formation of the psychological competence of a doctor is one of the most urgent both psychological and social problems of our time.

IN last years state common problem psychological analysis of medical activity has changed in better side. Studies have been carried out (V.A. Averin, A.G. Vasyuk, M.I. Zhukova, L.A. Tsvetkova, N.V. Yakovleva, etc.), a number of monographs and articles have been published on various aspects of the psychological analysis of a doctor’s activity (V.P. Andronov, N.A. Magazanik, V.A. Tashlykov, F.D. Burg).

However, progress in theoretical developments is not yet sufficiently related to the solution practical tasks which fully applies to the formation of the psychological competence of a doctor in the process of professional training at a university (N.V. Yakovleva, 1994).

The need for such training is obvious and due, according to V.P. Dubrova, for several reasons:

1) recognition of the role of the psychological factor in the occurrence and course of the disease;

2) professional attitude towards the “average patient”, which leads to ignoring the individuality of the patient’s personality and serious medical errors;

3) the specifics of medical activity, which consists in the fact that this is an activity in the field of communication, in the sphere of "person - person" and an important aspect of the success of a doctor's activity is not only the high level of his special medical training, universal culture, but also the socio-psychological aspects of his personal potential;

4) communication problems in the dyads "doctor - patient", "colleague - colleague", "doctor - nurse", "administrator - doctor", "doctor - relatives of the patient", etc.;

5) the intensity of medical work and the need, in connection with this, to maintain high level performance for a long time and quick decision-making in extreme situations.

Partially, the tasks of the psychological training of a doctor are solved by the clinical and general humanitarian departments of a medical university, where, depending on the interests and level of erudition of the teacher, one or another amount of psychological information is included in special courses (L.A. Bykova, V.S. Guskov, N.V. Yakovleva and others).

However, it should be noted that the main way to form the psychological competence of a doctor at a university is the study of psychological disciplines (general and social psychology, "Medical ethics", "Pharmaceutical ethics", elective courses "Psychology of communication", "Practical conflictology", "Psychology of management " and etc.). Only in this case can we talk about the formation of a psychological anthropocentric worldview of a doctor and a sufficient level of his socio-psychological culture (V.P. Dubrova).

The socio-psychological culture of a doctor implies that he has certain professional views and beliefs, an attitude towards an emotionally positive attitude towards the patient, regardless of his personal qualities, and a whole range of communication skills and abilities necessary for a doctor for medical communication.

A more adequate understanding between the patient and the doctor allows you to optimize the professional activities of the latter.

The purpose of psychological training is to expand the humanitarian training of a medical student in the field of fundamental human sciences V.P. Dubrova).

Based on the goal, the following tactical tasks are solved, aimed at the formation of a psychological anthropocentric worldview and a sufficient level of socio-psychological culture of medical students:

The development of medical students' ideas that any human activity and the activity of a doctor, first of all, is regulated by certain values, which are one of the central components of the worldview;

Formation of the "I-concept" of a medical specialist;

Development of a high level of empathy (feeling into the psychology of another person) and self-esteem;

Formation of communicative competence and skills of optimal medical communication (socio-psychological culture);

The development of "clinical thinking" and a professional position that ensures person-centered medical interaction (personality-centered attitude towards the object of one's activity, awareness of one's self-worth and another person, and attitude towards the patient as an active participant in medical interaction).

This view of the tasks and nature of student learning in medical school in the process of studying psychology is currently conditioned by global educational trends, which in the psychological and pedagogical literature are called “megatrends” (M.V. Klarin, A.I. Piskunov, A.I. Prigozhy, R. Seltser, N.R. Yusufbekov). These include:

1) the mass nature of education and its continuity as a new quality;

2) significance, both for the individual and for social expectations and norms;

3) focus on the active development of human methods of cognitive activity;

4) adaptation of the educational process to the needs and needs of the individual;

5) orientation of learning to the personality of the student, providing opportunities for his self-disclosure.

Thus, the most important feature of modern education is its focus on preparing specialists not only to adapt, but also to actively master situations of social change.

At present, science has formulated ideas about the main types of learning, understanding learning in the broad sense of the word - as a process of gaining experience, both individual and sociocultural. These types include "supportive learning" and "innovative learning" (J.W. Botkin, V. Elmandra, M. Malitza).

“Supportive learning” is the process and result of such educational (and, as a result, educational) activity, which is aimed at maintaining, reproducing the existing culture, social experience, and social system. This type of training (and education) ensures the continuity of sociocultural experience, and it is this type that is traditionally inherent in both school and university education.

"Innovative learning" is the process and result of such learning and educational activities, which stimulates, to make innovative changes in the existing culture, social environment. This type of training (and education), in addition to maintaining existing traditions, stimulates an active response to emerging problem situations both for the individual and for society.

Construction training sessions with students based on the ideas of "innovative learning" changes the didactic structure educational process in a medical school in a specific special discipline and influences socially significant results, forming the "I-concept" of the future doctor.

2. Psychology and medicine

2.1 Modern understanding disease

At present, the positive definition of health given by WHO has received wide international recognition: “A state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity” (WHO Charter, 1946).

Currently, health is interpreted as: 1) the ability to adapt and adapt; 2) the ability to resist, adapt and accommodate; 3) the ability to self-preservation, self-development, to an increasingly meaningful life in an increasingly diverse environment (V.A. Lishchuk, 1994).

According to the WHO definition, health consists of three components: physical, mental (or mental) and social.

In medicine, due to the positive definition of health, along with the pathocentric approach (the fight against diseases), the sanocentric approach (focus on health and its provision) is also being established.

The emergence of the sanocentric approach is changing the paradigm of medical thinking, until recently dominant in modern culture, and based on the principle of "pathology", on what is wrong in a person.

There was a stereotype in the public mind, according to which it was considered a success if a person becomes “better” with the help of medicine. At the same time, "better" was understood as the absence of disease. A rarity was the focus on the full realization of all the possibilities of the body or on the optimal lifestyle.

Until recently, culturally accepted beliefs suggested a view of life in which a person learns to cope with the negative rather than move towards a positive goal. This approach was reminiscent of a gardener who spends time looking for and removing weeds and ignoring the planting, care and cultivation of fruit plants (D. Gershon, G. Straub, 1992).

2.2 Socio-psychosomatic approach to man

Modern medicine proceeds from the recognition of the unity of the somatic and mental in all the complexity of their relationships. Being qualitatively different phenomena, they represent only different aspects of a single, living person.

The departure from the dualism of the body and the psyche, the assertion of the systemic organization of a person led to the adoption of a systematic approach in various fields activities: in politics, business, sports, education. Including in medicine. Consistency prescribes to keep in mind the integrality of man.

The systematic approach to health declared at the international level involves the inclusion of the "Body-Psyche" system into the supersystem "Man and Others", "Man and Family", "Man and Society", the study of man in a social context.

1. The influence of somatic diseases on the psyche. The influence (somatogenic and psychogenic) of somatic diseases on the psyche has long been known. The somatogenic effect is carried out through intoxication effects on the central nervous system, and the psychogenic effect involves an acute reaction of the individual to the disease and its consequences.

The range of possible changes in the psyche of patients includes:

Negative emotional reactions associated with changes in the physical condition of patients (anxiety, depression, fear, irritability, aggression, etc.);

Neurotic and asthenic conditions developing against the background of a somatic disease;

Experiences caused by the consequences of the disease, changes in working capacity, marital status, total social status a sick person;

The restructuring of the entire personality of the patient, expressed in the formation of new settings, protective and compensatory personal formations, changes in the life orientation and self-awareness of the patient (Nikolaeva V.V., 1987).

However, the influence of the somatic sphere on the human psyche can be not only pathogenic, but also sanogenic.

2. Influence of psychological factors on the somatic sphere. There is no less data today about the influence (pathogenic and sanogenic) of psychological factors on the somatic sphere of a person. At the origins of this approach is the school of Hippocrates, who interpreted illness as a disorder in the relationship between the subject and reality. The term "psychosomatics" originated in 1818 (R. Heinroth).

Emotional overload can lead to both mental illness and physical illness. A convincing example of this is a gastric ulcer caused by the constant secretion of gastric juice during great excitement.

According to the results of the study by G.Yu. Eysenck, a person with an extremely low external manifestation of emotionality and with a severe reaction to a stressful situation, giving rise to a feeling of depression, depression, hopelessness, helplessness, is prone to cancer. A person prone to coronary artery disease in a stressful situation demonstrates a sense of hostility, aggressiveness, and openly shows his feelings.

Psychosomatic pathology is a kind of somatic resonance mental processes. “The brain is crying, and the tears are in the stomach, in the heart, in the liver ...” - so figuratively wrote the famous domestic doctor R.A. Luria. According to domestic and foreign authors, from 30 to 50% of patients in somatic clinics need only correction of their psychological state.

Among the true psychosomatosis include: bronchial asthma, hypertension, coronary heart disease, duodenal ulcer, ulcerative colitis, neurodermatitis, nonspecific chronic polyarthritis.

Unlike these diseases, the occurrence of which is determined by mental factors, other diseases are influenced by their dynamics by mental and behavioral factors that weaken the nonspecific resistance of the body, involving the autonomic and endocrine systems.

Psychosomatic medicine solves the following theoretical problems:

a) the question of the triggering mechanism of the pathological process and the initial stage of its development;

b) the question of the different influence of the same superstrong stimulus on emotional reactions and vegetative-visceral shifts in different people;

c) the question of why mental trauma can cause different localization of the disease (in some of the cardiovascular system, in others of the digestive apparatus, in others - of the respiratory system, etc.);

e) the sanogenic influence of the mental factor on the general psychosomatic state of a person also constitutes a special aspect of research. In particular, we are talking about a positive impact on the course of somatic disease. These include: psychotherapy, setting a person to fight his illness, to cultivate his health, the positive influence of the social environment on the course of the disease, etc.

So, some experiments have shown that the immune system is more stable when a person who finds himself in a stressful situation has good relations with others (O. Dostalova, 1994). WHO has paid serious attention to the "system of social support against stress."

3. Family. Like other immediate environment, the family gives a person the amount of warmth, attention and love that he needs. But if the same family relationships make a person constantly feel irritated or unhappy, then this situation will soon affect his mental state, and then the state of his body.

Up to 26% of errors in medical diagnosis are attributed to ignorance of the patient's psychosocial environment (R.S. Duff, A.B. Hollingshead, 1968). Therapy of gastric ulcer, ulcerative colitis, diabetes, asthma, coronary heart disease, anorexia, migraine requires a family approach (MV Avsent'eva, 1994).

2.3 Systems to be analyzed in the study of disease

When studying health and disease, certain dynamics are revealed in the change of systems to be analyzed:

a) from the study of individual organs to the study of body systems and the whole organism as a whole,

b) from the study of the organism to the study of psychosomatic and somatopsychological relationships,

b) from the study of the relationship between the body and the psyche to the study of the influence of the psychosomatic characteristics of a person on his behavior and social life (as well as the reverse influences social life mind and body).

Indeed, the most important factors influencing health are (Noack, 1987):

a) biological system and physical and biological environment (physical resources, microenvironment, macroenvironment),

b) psyche (cognitive and emotional systems) and behavior (habits, work, etc.),

c) socio-cultural system (social integration and social connection, health culture and practice, health services, etc.).

2.4 Palliative care

One example of a sociopsychosomatic approach to a person in medicine is palliative care with the aim of creating the most High Quality life for both the patient and his family.

Palliative care supports the patient's desire for life, while considering death as a natural process. Palliative care makes it possible to control pain and other symptoms that disturb the patient, as well as to provide a complex of psychological, physical and social support, which allows the patient to lead an active lifestyle for a longer time until death.

Palliative care also involves a support system for the patient's family both during the illness of the patient and after his death (WHO).

3. Psychological aspect of the disease

The study of a person's personal reactions to his psychosomatic state implies consideration of both the psychological component of the disease and his health.

In the event of psychosomatic diseases, not only the activity of the systems and organs of the human body is disrupted, but also the self-consciousness of a person changes.

Self-consciousness, being inextricably linked with the intensity of stimulation of both interoreceptors and exteroreceptors, forms an idea of physical condition, which is accompanied by a peculiar emotional background (A.V. Kvasenko, Yu.G. Zubarev, 1980).

3.1 Sensory stage

When considering the psychological aspect of the disease and the formation of personal reactions to the disease, it is necessary, first of all, to single out the sensorological stage (from Latin sensus - feeling).

At this stage, there are vague unpleasant sensations of varying severity with uncertain localization. Being early symptoms threat of disease, they cause a condition referred to as discomfort.

In addition to indefinite diffuse subjective feelings discomfort, local discomfort is possible, for example, in the region of the heart, stomach, liver, etc. Discomfort - early psychological symptom morphofunctional changes. It can turn into pain.

Pain can have a positive or negative meaning. In a positive sense, pain is seen as an important and effective signal of danger to the body (surgeons with an "acute abdomen" do not relieve pain until the end of the examination).

The negative aspect of pain is as follows: 1) the lack of a signal function in some cases makes it difficult to diagnose (progressive pulmonary tuberculosis); 2) discrepancy between the strength of pain and the nature of the disease (toothache); 3) a conditioned reflex decrease in pain sensitivity is possible:

US soldiers suffered less severely from severe injuries during World War II because they knew they were being evacuated from the front;

Of the two participants in the fight, the winner bears the pain better;

The masochist perceives pain positively, since it is a form of sexual pleasure;

Thanks to training, the boxer perceives pain more easily.

Thus, pain, being information about the violation of the activity of organs and systems, being processed in the mind, can form the basis for the patient's assessment of his psychosomatic suffering.

Pain can be assessed not only as a symptom of the disease, but also as a threat to life (changes in position in the family, in professional activities, etc.).

There are 3 levels of pain manifestation:

1) the level of physiological feelings (dilated pupils, blanching of the face, cold sweat, tachycardia, increased blood pressure);

2) emotional and motivational level (fear, desires, aspirations);

3) cognitive level (rational, rational attitude to pain and assessment of its role in one's life).

In addition to discomfort, pain sensations at the first stage, the occurrence of deficient disorders in biosocial adaptation is also possible (decrease in creative activity, weakening of incentive motives for activity, etc.). There is a feeling of constrained freedom, limitation of one's former capabilities, a feeling of one's own inferiority.

Thus, the sensorological stage includes the following components: 1) discomfort component (feeling of discomfort); 2) algic component (experience of pain); 3) a deficient component (experiencing feelings of one's own inferiority, limiting one's capabilities).

3.2 Evaluation phase

This stage is the result of internal (intrapsychological) processing of sensory data.

It is at this stage that the “internal picture of the disease” is formed. This concept is important in medical psychology, since the objective picture of the disease and its internal picture, as it is perceived by the patient, are different.

Fear and anxiety about a disease that does not pose a danger on the one hand, and the optimism and confidence of the patient at the most dangerous stage of myocardial infarction or the euphoria preceding death, speak of this. Therefore, the doctor needs to be able to measure and harmonize the internal picture of the disease with the objective state of the patient.

The internal picture of the disease is the inner world of the patient, everything that the patient experiences and experiences, his ideas and feelings about the disease and its causes (RA Luria, 1944).

The evaluation stage has the following structure: 1) vital component (biological level); 2) social and professional component; 3) ethical component; 4) aesthetic component; 5) a component related to intimate life.

The main elements of the internal picture of the disease are:

The sensations of the patient, the perception and experience of symptoms, that is, the protective actions of one's own body;

- emotions associated with illness: fear, pain, anxiety, depression, eif oriya, organic sensations;

Understanding the origin and causes of the disease, that is, the concept of the disease;

Forecast her further development and hope for recovery;

The scheme of the body and its violation.

The internal picture of the disease, refracted in each case in its own way and acquiring an individual color, depends on the following factors:

1) premorbid personality traits (as it was before the disease): age; the degree of general sensitivity to pain, environmental factors (noise, smells); the nature of emotional reactivity (emotional patients are more prone to fear, pity and to a greater extent fluctuate between hopelessness and optimism); nature and scale of values ​​(attitude towards health, comfort, success, as well as the level of responsibility to oneself, family, team, society); medical awareness (real assessment of the disease and one's own situation)

2) the nature of the disease (acute, chronic, life-threatening or non-life-threatening, requiring outpatient or inpatient treatment, etc.);

3) the circumstances in which the disease occurs: the problems and uncertainty that the disease brings (the cost of the drug, the degree of disability, possible changes in family relationships and at work, etc.) the environment in which the disease develops (at home, abroad , visiting friends and relatives); the causes of the disease (whether the patient considers himself the culprit of the disease or others: if he is to blame, he recovers faster).

3.3 Stage of attitude to the disease

At this stage, the attitude towards the disease manifests itself in the patient in the form of experiences, statements, actions, as well as a general pattern of behavior associated with the disease. The main criterion of the stage is the recognition or denial of the disease.

Types of attitude to the disease. Somatognosia is an attitude to the disease, which is formed at the stages of a person's personal response to his disease state.

Normosomatonosognosia is an adequate assessment by patients of their condition and prospects for recovery. The patient's assessment of his disease coincides with the doctor's assessment. The attitude to treatment and medical procedures is positive.

Variants of activity in the fight against the disease: 1) adequate assessment of the disease and high activity in the fight against the disease; 2) adequate assessment combined with passivity and inability to overcome negative experiences.

Hypersomatonosognosia is an overestimation of the significance of both individual symptoms and the disease as a whole.

Options: 1) anxiety, panic, anxiety, increased attention to the disease, greater activity in terms of examination and treatment, enumeration of doctors and medicines; 2) hypertrophied interest in medical literature, lowered mood (lethargy, monotony), pessimistic forecast for the future, scrupulous fulfillment of all doctor's requirements.

Hyposomatonosognosia is an underestimation by patients of the severity and severity of the disease in general and its individual signs.

Options: 1) decrease in activity, external lack of interest in examination and treatment; unreasonably favorable forecast for the future, downplaying the danger; a deeper analysis reveals the correct assessment of one's health; adherence to the regime, the implementation of the recommendations of the doctor; in the chronic course of the disease, they get used to the disease, are treated irregularly; 2) unwillingness to see a doctor, negative attitude to the treatment process, denial of the disease.

Dyssomatognosia- denial of the presence of the disease and symptoms. Complete denial of the disease.

Options: 1) non-recognition of the disease with mild symptoms (oncological diseases, tuberculosis, etc.), deliberate concealment of the disease (for example, syphilis); 2) repression from consciousness of thoughts about the disease, especially with a predicted unfavorable outcome.

Factors influencing the formation of types of attitudes towards the disease.

1. Individual psychological characteristics of the personality (personality premorbid). Normosomatonosognosia is formed in strong, balanced people.

People with hypersomatognosia are characterized by such premorbid personality traits as rigidity, stuck on experiences, anxiety, suspiciousness.

People with the first variant of hyposomatognosia are characterized by superficiality of judgments, frivolity. In the second variant, purposefulness, “hypersociality” stands out among the premorbid features.

2. Age factor.

In all forms of somatognosia, the age factor should be taken into account.

At a young age, there is an underestimation of the severity of the disease, and in cases affecting the aesthetic and intimate aspects of personal reactions, an overestimation of the severity.

In adulthood, dyssomotonosognosia is most often characteristic.

In old age, due to the underestimation of the forces and capabilities of the body, there is a tendency to hypersomatognosia. Hyposomatonosognosia at this age is associated with a decrease in overall reactivity.

Pathological types of attitude to the disease. The pathological reaction to the disease is based on the following reasons:

The reaction does not correspond to the strength, duration and significance of the stimulus;

The impossibility of correcting ideas, judgments, as well as the behavior of the patient.

Duration of pathological reactions: from several hours to several weeks. In the chronic course of the disease, it is possible for a pathological reaction to develop into a pathocharacterological development of the personality.

depressive reaction. It includes:

1) anxiety-depressive syndrome, which occurs, as a rule, at the initial stage of the disease. It is characterized by: concentration of attention on the experiences associated with illnesses, suicidal tendencies.

2) Astheno-depressive syndrome, which occurs at the stage of the height or outcome of the disease. This syndrome is characterized by: lowered mood, depression, confusion, slow motor skills.

phobic reaction. The phobic reaction is characterized by the presence of obsessive fears. During an attack of fear, the experienced danger is perceived as quite real. Outside of acute attacks of phobias, criticality is restored. The phobic reaction has a certain dynamics: 1) the appearance of obsessive fears under the influence of a real traumatic stimulus (hypsophobia - fear of heights that occurs on the balcony); 2) fears arise not only in a traumatic situation, but also when waiting for the impact of a traumatic stimulus (fear of heights that occurs in the room leading to the balcony); 3) the appearance of phobias in an objectively safe situation (on the street, in the entrance).

hysterical reaction. The hysterical reaction is characterized by: a sharp change in mood; demonstrativeness; theatricality; propensity to acts of self-harm in a state of passion; exaggeration of complaints.

Hysterical reactions include such pseudosomatic disorders as psychogenic pains (pseudo-rheumatic, phantom, abdominal), psychogenic suffocation.

hypochondriacal reaction. With this reaction, the patient stubbornly holds on to the idea that he is ill with another, more serious disease, even in spite of the objective situation of recovery.

At the slightest indisposition, patients begin to think about the danger to health and life. Hypochondriacal reactions include psychogenic suffocation, psychogenic nausea and vomiting.

Anosognosia. Anosognosia - denial of the disease, associated not with the personal characteristics of the patient, but with the nature of the disease. It occurs in case of life-threatening diseases (cancer, tuberculosis, etc.). The patient is not aware of the fact of the disease and therefore denies it. Sometimes the slightest somatic disorders are given importance and the symptoms of another very dangerous disease are not noticed.

4. Significance of psychology in the preparation of medical students

To implement an integrated approach to a person and develop a strategy and ways to achieve health, a doctor needs, along with a deep knowledge of biomedical disciplines, an equally deep knowledge of psychology.

Knowledge of psychology is necessary for a doctor not only to influence the picture of the world of his client (in particular, the internal picture of the disease), to manage his cognitive and emotional processes, behavior, psychosomatic relationships, but also to help the patient become an accomplice in the treatment process, intensify its focus on health.

4.1 Traditional medical model

The traditional medical model assumes that the doctor is responsible for the patient, in the sense that the power in their relationship belongs to the doctor. This model states that the disease follows certain laws, the laws of the life of microbes, the accumulation of cholesterol, the increase in blood pressure, etc., and the attitude of the patient to the disease has some, but not the main significance.

The disease can be endogenous or exogenous and comes because a person has become a “victim” of foreign bodies (viruses, bacteria, microbes). Some hint of responsibility in this approach falls on the person if he does not follow his doctor's prescriptions. When a person gets better, it is because he has a good doctor and medicines, or, thanks to a genetic "accident", he has a strong constitution that helped him recover (V. Shute, 1993).

4.2 Choice model

However, there is another model - the choice model. According to the latter, a person himself chooses his disease and heals himself (V. Shute, 1993; A.S. Zalmanov, 1991, etc.).

Viruses are part of the balance of nature and correspond to the nature around them. Some bacteria that exist in a healthy body are beneficial. However, if they are in a toxic environment, they become toxic and enhance toxic processes. Pasteur's dying words in 1895 reflected his understanding of this: “Bernard was right. Microbes are nothing, soil is everything.”

In stressful situations, the content of ACTH (adrenocorticotropic hormone of the pituitary gland), glucocorticoids (hormones of the adrenal cortex) and beta-endorphins (hormones synthesized in the body and acting like opium drugs) increase. An increase in the content of glucocorticoids adversely affects the function of lymphocytes, which is manifested in the suppression of the immune response. It was also found that the immune response depends on how a person psychologically perceives difficult situations (O. Dostalova, 1994).

If a person unconsciously decides to get sick, then he weakens his body, poorly removes waste, creating a toxic environment for viruses. He pauses immune system, allows external substances to infiltrate and becomes ill (R. Glasser, 1976). His decision regarding diseases is made during life, as the organism develops. The role of the doctor, according to the choice model, is to create the conditions under which the patient chooses awareness of the causes of the disease; the doctor helps to accept a conflict-free desire to be healthy, introduces techniques, ways of acquiring health. It is more than symptom suppression; it's about creating a health mindset. The model of choice does not exclude standard medicines. It only suggests additional directions for improving health.

One can argue about the positive and negative aspects of both the traditional medical model and the model of choice. However, it should be recognized that the doctor's tactics can be aimed both at manipulating the patient's sociopsychosomatic relationships, and at bringing the patient's personality to cooperation, so that the doctor and the patient are together against the disease and cooperate in the name of health, so that the patient realizes his responsibility for how he lives, what he feels, whether he is sick or stays healthy.

CHAPTER II. PSYCHE AS A SYSTEM OF SELF-MANAGEMENT

LECTURE 2. PSYCHOLOGY AS A SCIENCE ABOUT HUMAN

1. The formation of psychology as a science

1.1 The concept of "psychology"

Psychology owes its name to Greek mythology. Eros, the son of Aphrodite, fell in love with a very beautiful young woman, Psyche. Aphrodite, unhappy that her son, a celestial, wants to join fate with a mere mortal, forced Psyche to go through a series of trials. But Psyche's love was so strong that it touched the goddesses and gods, who decided to help her. Eros, in turn, managed to convince Zeus - the supreme deity of the Greeks - to turn Psyche into a goddess. Thus, the lovers were united forever.

For the Greeks, this myth was a classic example of true love, the highest realization of the human soul. Therefore, Psyche - a mortal who has gained immortality - has become a symbol of the soul seeking its ideal.

The very word "psychology" from the Greek words "psyche" (soul) and "logos" (study, science) appeared for the first time only in the eighteenth century (Christian Wolff).

1.2 Psychology as an independent science

Psychology has a short history, formed at the end of the last century. However, the first attempts to describe the mental life of a person and explain the causes of human actions are rooted in the distant past. So even in ancient times, doctors understood that in order to recognize diseases, it is necessary to be able to describe the consciousness of a person and find the reason for his actions.

1. Psychology as a science about the soul. Until the beginning of the 18th century, the presence of the soul was recognized by everyone. Moreover, throughout history there have been both idealistic (for example, the soul, as a manifestation of the divine mind) and materialistic (for example, the soul as the finest matter, pneuma) theories of the soul. The soul was seen as an explanatory, but inexplicable force itself, which was the root cause of all processes in the body, including its own "spiritual movements."

Psychology as a science of the soul arose more than two thousand years ago, developed within philosophical science as its integral part.

2. Psychology as a science of consciousness. At the end of the 17th century, due to the development natural sciences and by a strongly causal worldview, the concept of the soul, which is hidden behind the observed phenomena, was excluded from science. From the 18th century, psychology began to be regarded as the science of consciousness. Moreover, consciousness was called the ability to feel, think, desire. The place of the soul was taken by phenomena that a person finds “in himself”, turning to his “inner mental activity”. In contrast to the soul, the phenomena of consciousness are something not supposed, but actually given.

Since the end of the 18th century, psychology for the first time appeared as a relatively independent field of knowledge, covering all aspects of mental life, which were previously considered in various departments of philosophy (general doctrine of the soul, theory of knowledge, ethics), oratory(the doctrine of affects) and medicine (the doctrine of temperaments).

The extension of the natural-scientific, albeit mechanistic, worldview to the “realm of the spirit” led to the idea of ​​the formation of all mental abilities in individual experience.

The study of consciousness sharply raised the question: how does the human body react to information received from the senses? All our knowledge was supposed to come from sensations. The basic elements that make up sensations are combined according to the law of association of ideas. Through sensations are created by association of ideas of perception, which underlie even more complex ideas.

In 1879, at the University of Leipzig, Wilhelm Wundt (Wundt), began to study the content and structure of consciousness on scientific basis, i.e. combining theoretical constructions reality check. He entered the history of psychology as the founder of scientific psychology, since he legitimized the right of experiment to participate in the study of consciousness.

In contrast to the associationist, he laid the foundation for the structuralist approach to consciousness, setting the goal of studying the "elements" of consciousness, identifying and describing its simplest structures. It was assumed that the mental elements of consciousness are sensations, images, feelings. The role of psychology was to give as detailed a description of these elements as possible. Structuralists used the method of experimental introspection (subjects who underwent preliminary training described how they feel when they find themselves in a particular situation).

At the same time, there appeared new approach to the study of consciousness. Since 1881 in the United States, William James, inspired by the teachings of Charles Darwin, argued that "conscious life" is a continuous stream, and does not consist of a series of discrete elements. The problem is to understand the function of consciousness and its role in the survival of the individual. He hypothesized that the role of consciousness is to enable one to adapt to different situations, or repeating already developed forms of behavior, or changing them, or mastering new actions. He made the main emphasis on the external sides of the psyche, and not on internal phenomena. The main method of study has remained introspection, which allows you to find out how the individual develops awareness of the activity in which he indulges.

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