关于美国医疗问题的警世恒言

Books
A Prescription for Frustration
By ABIGAIL ZUGER, M.D. July 20, 2013
医疗政策
关于美国医疗问题的警世恒言
ABIGAIL ZUGER, M.D. 2013年07月20日
Time spent in hospitals brings out the inner Chekhov in some doctors, the inner Che in others. Then there are the occasional hybrids, the storytellers who secretly plot revolution and the revolutionaries who wind up telling fairy tales.
在医院度过的时光，会让一些医生释放内在的“契诃夫”(Chekhov)，让另一些医生释放出内在的“切·格瓦拉”(Che)。混合类型偶尔也会出现：默默谋划着革命的故事讲述者，以及最后讲起童话来的革命者。
One might argue that Dr. Leana Wen and Dr. Joshua Kosowsky belong to the latter group. At least, their impressive “When Doctors Don’t Listen” is a manifesto motivated by very active imaginations, not that this necessarily diminishes the book’s importance.
人们可能会觉得，温丽娜医生（Dr. Leana Wen，音译）和约书亚·科索斯基医生(Dr. Joshua Kosowsky)属于后一种类型。至少，他们合著的《医生没有倾听时》(When Doctors Don’t Listen)是一部由活跃奔放的想象力激发的、令人难忘的宣言，这倒不是说想象力活跃就一定会削弱作品的重要性。
The authors, both emergency room physicians at Brigham and Women’s Hospital in Boston, do a fine job of sorting through most of the serious problems in American medicine today, including the costs, overtesting, overprescribing, overlitigation and general depersonalization. All are caused at least in part, they argue, by the increasing use of algorithms in medical care.
两位作者都是急诊室医生，在波士顿的布莱根妇女医院(Brigham and Women’s Hospital)工作。他们对当前美国医疗界存在的大多数重大问题，进行了很好的分类解析。这些问题包括费用、过度检查、过度开处方、过度诉讼和普遍的人格解体(depersonalization)。他们声称，医疗保健系统越来越多地使用算法，是所有这些问题的至少一部分成因。

Algorithms are flow charts, created by groups ranging from individual hospitals to large professional organizations, dictating what tests doctors should order and what medications they should prescribe in hundreds of different situations. Deployed throughout medicine, the algorithms are perhaps used most frequently in emergency rooms, where any single word a patient utters may set off a long cascade of programmed activity.
算法就是流程图，从单个医院到大型专业组织都可以制定算法；它规定了医生在数百种不同的情况下，应该要求患者做那些测试，应该开哪些药。整个医疗系统里都在使用算法，但最常用的地方也许就是急诊室了。在急诊室里，病人说出的任何一个词都有可能启动一长串已经编好程的行动。
Thus, people who say “[要查看本链接请先注册并登录]” and “cough” are likely to find themselves being evaluated and treated according to a “[要查看本链接请先注册并登录]” algorithm; a mention of [要查看本链接请先注册并登录] will land them on a “heart attack” algorithm. And such is the power of these decision trees that even if you are a circus employee and Jumbo the elephant has just stepped on your chest, the chances are that once you say “chest pain” you will wind up on that heart attack pathway, just in case.
比如你说“[要查看本链接请先注册并登录]”和“咳嗽”，医生可能就会采用“[要查看本链接请先注册并登录]”算法来评估你的病情并进行治疗。如果你说自己[要查看本链接请先注册并登录]，医生则可能会采用“心肌梗塞”算法。这种决策树的力量非常之大，即便你是马戏团的员工，胸口刚刚被一头名为“金波”(Jumbo)的大象踩了一脚，只要你说胸痛，医生为了以防万一，也仍然可能会按处理“心肌梗塞”的方式来对待你。
There are good reasons behind this kind of rote decision ***. The great river of suffering and complaint that churns through E.R. doors demands some kind of quickly imposed external order. Algorithms help standardize medical care and ensure that no life-threatening conditions are accidentally overlooked.
这种机械的决策方式也有其合理的一面。痛苦和抱怨像河水一样，汹涌流过急诊室的大门，对它施加某种形式的外部秩序是必需的。算法有助于规范医疗行为，可以防止致命的病情在无意中被忽视。
But doctors who use too many algorithms practice what is commonly disparaged as “cookbook” medicine — you combine ingredients like blood tests and CT scans, and out pops a diagnosis. (Or, more often, the absence of one: “Well, at least we know it wasn’t a heart attack!”) Even dummies can do it.
但是，有些医生使用算法的时候过于多了，他们的工作方式通常被贬称为“菜谱式”诊疗 —— 你把血检结果和CT片这样的配料放在一起，然后就冒出一个诊断结论。 （更多时候是没有结论：“嗯，至少我们知道这不是心肌梗塞了！”）这种事就连笨蛋也办得到。
And just as world-class chefs eschew standard recipes, so medical experts chafe at formulaic care, pointing out that hard-earned medical instincts should not be ignored, that people usually want to know what they have rather than what they don’t have, and that trainees who rely on algorithms will never learn to think.
就像一流厨师跟标准的菜谱保持距离一样，医疗专家也对公式化的诊疗方式非常不满，他们指出：辛辛苦苦培养起来的诊疗直觉不应该遭到无视；人们通常想知道自己得了什么病，而不是没有得什么病；而且，一味依赖算法的实习医生永远也学不会自己思考。
Instead of letting key words dominate practice, Dr. Wen and Dr. Kosowsky argue, doctors should listen more carefully and use a little more common sense. “We advocate for a type of personalized medicine that involves taking a personalized history, performing a personalized physical exam and approaching each patient as an individual rather than as a list of variables,” they write. In other words, remember the elephant even if he’s not in the room.
温丽娜和科索斯基认为，医生不应该任由关键词来主宰诊疗过程，而是应该更加仔细聆听，多运用常识。 他们在书中写道：“我们提倡一种个体化的诊疗方式，包括使用个体化的病史，进行个体化的体检，并把每个患者视为个体，而不是变量列表。”换句话说，就是要记得那些显而易见却又被忽略的事实，即使它们没有那么显而易见。
The book lists many instances in which cookbook medicine fails or backfires. There is the college student suffering through an expensive evaluation for the [要查看本链接请先注册并登录] she does not have; the world-class hangover she had is almost gone by the time she finally ends the madness by running out the E.R. door. The chatty woman with a million complaints isn’t so lucky: she almost dies from an infected gallbladder while her doctors are busy worrying about her heart.
关于“菜谱”诊疗方式的失灵，或者导致了事与愿违的结果，书中列举了很多实例。比如有一名大学生，痛苦不堪地接受了昂贵的[要查看本链接请先注册并登录]评估，但其实她没有脑出血，只是头一天喝了酒，宿醉反应太过严重了。当宿醉差不多消失的时候，她逃出了急诊室的大门，这件糗事也终于告一段落。还有一个很健谈的女人，喜欢抱怨这抱怨那的，她就没有这么幸运了：胆囊感染差点要了她的命，但当时她的医生却忙着担心她的心脏有问题。
The book’s insights and cautionary tales should appeal to medical and lay readers alike: they combine into a superb analysis of how doctors listen and think, and offer detailed suggestions for how they could do both better.
这本书里的观点和警世故事，应该既能吸引医务工作者，又能吸引普通读者：观点和故事结合起来，很好地分析了医生的倾听和思考方式，而且对于医生和患者可以怎样做得更好，也提供了详细的建议。
But when the authors embark on an earnest campaign for patients to grab the reins and steer their own wayward doctors gently but firmly onto the right path — there, I would argue, is where the fantasy begins.
但是，当两位作者开始热切地敦促患者掌握控制权，温和而坚定地把任性的医生引导到正确道路上去时 —— 我觉得这本书的奇幻色彩，就是从这里开始的。
“Participate in your physical exam,” they urge their readers. “Make the differential diagnosis together.” A healthy person might take on that difficult assignment, especially the advice about learning how to tell an effective story (start at the beginning, don’t leave anything out, avoid technical terms).
“参与你自己的体检过程，”他们敦促读者说：“一起进行鉴别诊断。”健康人可能会接受这个艰难的任务，特别是接受作者的建议，学习如何把自己的状况有效地告诉医生（从头开始讲，不遗漏任何东西，避免使用术语）。
But most acutely ill people just want an experienced person to take over, to do what has to be done and do it fast. That doctors who fall ill are often mismanaged just like other patients testifies to an illness’s power to limit effective participation in one’s own care.
但大多数重病患者所希望的，只不过是有个经验丰富的人来主持诊疗过程，采取必要的行动，并且动作要快。医生自己生病时，也常常会像其他患者一样，遭受不当的医疗处置，这证明疾病的杀伤力太大，限制了患者参与诊疗自己的过程的能力。
Still, the democratic examination room is a delightfully seductive fantasy. Even writers of medical fiction don’t venture that far. Like Dr. Louise Aronson in “A History of the Present Illness,” they generally stay so firmly grounded in grim reality that their fiction reads like memoir by another name.
尽管如此，在诊疗室里实现民主也是令人愉快的、充满诱惑力的奇思妙想。即使是医疗小说作家也不敢走得那么远。就像《现病史》(A History of the Present Illness)的作者路易丝·阿伦森医生(Dr. Louise Aronson)一样，医疗小说作家通常牢牢扎根于严峻的现实之中，所以他们的小说读起来就好像是改名换姓后的回忆录一样。
Dr. Aronson, a geriatrician in San Francisco, joins the ranks of those immortalizing the small, realistic details of modern medical care. She offers up the requisite coming-of-age tales of studenthood, residency and disillusioned midcareer, but is at her best in the world of the much too old — the rooms where dyed hair grows out platinum white and small bodies lie in bed “the way a letter lies in its envelope.”
一些人的作品，让现代医疗环境中微小、现实的细节变得不朽，旧金山老年医学专家阿伦森博士就是这些人中的一员。她写过精致的成长小说，这些故事发生在学生时期，住院医生时期，以及理想破灭的职业生涯中期，但她写得最好的，却是高龄老人的世界——在病室里，染过的头发新长出的部分呈现银白色，躺在床上的瘦小身躯就像是“躺在信封里的信”。
Dr. Aronson writes lovely, nuanced description; if her dialogue is occasionally a little stiff and some of her plots stretch the bounds of plausibility, it is still worth staying with her: no revolution in sight, just keen, calm observation, punctuated by sighs.
在阿伦森的作品里，有美好动人、细致入微的描写，虽然对话偶尔有点僵硬，一些情节也超出了合理的界限，但仍然值得一读：没有革命在望，只有敏锐而冷静的观察，其间夹杂着声声叹息。