みなさんこんにちは！
今回は「病状説明」についてお話しします。
通称、「IC」「ムンテラ」などと呼ばれます。
まさに内科医として最初に待ち受ける関門・・・。
未だに苦手意識をもっている医療者も多いのではないでしょうか。
今回はこの病状説明について解説します！
病状説明って何？
病状説明って何？
一般的には医療者が患者・家族に病状、治療方針、見立てなどをお伝えする行為です。
慣習的には「ムンテラ」とか「IC(インフォームドコンセント）」と呼ばれます。その違いってどういうところにあるんでしょう？
ムンテラ
その語源は、ドイツ語の「Mund（口）」と「Therapie（治療）」にあります。
実際の行動は病状や病気をお伝えする行為であることに変わりはないのですが、その中には「口で治す」＝「言いくるめる」ような意味合いが内包されていると認識されるようになりました。（一方通行のような印象になるんだと思います。）
このような理由から最近の医療者はこのコトバを使用しない方向性にあります。
筆者の施設では、スラング的に「ムンテラマイシン」＝「ムンテラをする治療」の意（～マイシンというのは抗生剤によくある名称で、「治療」の代表的な存在であることからくっつけた）として、病状を正確に理解していただき、状況を把握していただくような意味合いで使用していたところもあります。
IC（「アイシー」）
「ムンテラ」がやや古い時代の病状説明を意味していたのに対して、「IC」は現代的な呼び方です。
従来の医師主導の決定に比して、医師と患者が対等な中での病状説明の呼称ということになります。
「Informed Consent(インフォームドコンセント)」の略で、「説明と同意」と訳します。
文字通り、医療者が患者にInform(お伝え)して、患者側がConsent(同意)することです。
双方向的な意味合いをもち、契約をするようなイメージと思ってください。
筆者の好み
決して私が古い世代だからじゃない、ということを声高に叫びます。
「IC」という言い方って、なんだか無機質に同意書をもらう作業みたいに聞こえるんですよ。
自分の目の前の患者は機械じゃなくて、自分の意思をもって、家族にも支えられている、一人の病める人間ですからね。
「IC」の意味する作業である「あなたはこういう病気で、ガイドライン上はこういう治療が標準治療で、それをしたら何％よくなって何％偶発症がおきますよ」ってお話しするのって、特別なことではないじゃないですか。契約社会かよって思います。（徐々に契約社会になってきていますが・・・）
いやいや本番は、「そのうえで、あなたの場合には、〇〇の事情もあって標準とされている治療ができないかもしれない、ご家族の支援は、金銭的には、、、。そのうえで、結果どうしていきましょうか？」と一歩踏み込んで相談に乗ってあげるのが大事なはずです。
これってむしろ「ムンテラ」でしょ？
熱くなってしまいました。すいません。
・病状説明の言葉には「ムンテラ」と「IC」がある。
・最近は双方向的なやりとりを意味する「IC」が用いられることが多い
・でも筆者は「ムンテラ」の言い方の方が好き
病状説明の種類
一口に「病状説明」といっても、いろんな情報があります。
- 病状（入院時）
- 現在の治療
- 経過（前回の病状説明からの変化）
- 検査値や画像検査の結果説明
- 今後の予想される経過
- 同意書取得
これらの膨大な量の情報から、いかに効率的に、過不足なく、伝わるように病状説明を構成していくのか、まさにこれが医師の腕なのです。
当然、どんな患者・家族なのか、現在の体調、当日の話の流れによっても、私たちは話す内容や順番を微調整していることをここで告げておきます。
病状説明の難しさ
病状説明は、内科医にとっては最高峰の技術の一つです。
（外科系の処置を主な治療法とする場合にはそちらの方が優先されます。）
内科の治療では、投薬（内服、点滴）が全てです。
そこに「治療が成功した」「失敗した」という概念はなく、「治療が効いた」「効かなかった」というような表現になる、いわば治療の結果は確率論的になるわけです。
そういう意味で、「絶対効くわけではないこと」をきちんと話さなければなりません。
このあたりが、「ムンテラマイシン」と呼ばれる所以になります。好きだな、この言葉。
病状説明ってある意味治療の集大成なわけで、特に駆け出しの内科医にとっては一番の難関です。
初めての病状説明は、そりゃあ緊張しました。
複写式になっている「病状説明用紙」を予め手書きで記載して、それを一緒に読み上げたりしました。
でも・・・すごい時間がかかっちゃうんですよね、そのやり方。
しかも、当日の話の流れによっては柔軟な話もできないですよね。
ある程度慣れてきた現在は、話しながら、相手の顔をみながら、
コアな部分を必ず入れつつ、それ以外はその時の状況で決めるようになりました。
筆者の工夫
病状説明ってみなさんが思っているほど平和なものじゃないですよ。
経過が芳しくないような時に、
治療に失敗したのか！？
ま、ま、まさか・・・
（どもる・・・）
こんな感じになると、一切間違った治療をしていないのに、医師が何かを失敗した・隠しているようにうつってしまいますよね。当然疑念も深まります。
いつの間にか、医療者側と患者側が対立構造になってしまうわけです。
炎上すると、まるで訴訟のようです。
と呼ばれることがしばしばあります、ヘルプに来て、という事ですね。
筆者、解析しました。
たいていそういう時、このようなフォーメーションです。
多分この配置、最悪です。
そこで私が編み出した方法は↓をご覧下さい。
題して、
「人（患者も医療者も）は悪くない！みんなで同じ方向を向いて、
病気という共通の敵を見定めよう」 作戦です（長い）
自分は結構有効だと思います。
病状説明に困っている方は、是非この方法をお試しください。
自然と説明時の炎上が減りますよ（というか筆者は全く経験したことがありません）
病状説明マスターを目指そう！
ここまで、医療者側からみた「病状説明」について記載しました。
これを苦手としないようにしておくと、
是非、同業者の方、また患者側から、色々な意見を伺いたいです。
これは「キホン」の「キ」です！
他にも、
当直中に関わる、初めてお会いする患者さんの病状変化時の説明を頼まれた
電話で病状説明をしなければならない
などの応用編は存在します。
今回は長くなってしまったので、それはまたの機会に。ではでは！
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