医闹：病人要枪毙我，我该怎么给他治疗？ [美国媒体]

A patient threatened to shoot me. Could I then give him good care?

病人威胁要枪杀我。然后我能给他好的照顾吗？

【日期】2016年3月14日



JOE RAEDLE/GETTY IMAGES

Difficult patients — those who are angry, abusive, or rude — may not get the best medical care, according to a pair of studies published Monday in BMJ Quality and Safety.

根据英国医疗杂志《质量与健康》周一公布的两篇研究表明，因为认为没有得到最好的医疗照顾，那些难缠的患者也许会很暴躁而粗鲁。

As a medical student, I’ve seen firsthand how a patient’s attitude might affect a clinician’s judgement.

作为一个医学院学生，我的亲身经历（可以说明），病人的情绪可以影响到医生的判断。

As part of an internal medicine rotation during my third year, I accompanied a nurse for a day on home health visits in the rural community of Abingdon, Va. That morning, I arrived at the patient’s home before the nurse did. I waited in my car for more than an hour so we could enter the patient’s home together.

在我上学的第三年，我曾作为内科医生去轮岗，有天我陪同护士前往弗吉尼亚阿宾登的乡下出诊时，我比护士先到所以我在车里等了她超过一个小时才一起进了病人家里。

Upon entering the home, I shook the patient’s hand and introduced myself as a medical student working with his home health team.

当我走进他家的时候，我和病人握了握手，然后介绍自己是在负责他家的社区医生团队中实习的医学生。

“I was going to shoot you,” he said to me, unapologetically.

他理直气壮的对我说：“我刚才差点要毙了你。”

“Why would he shoot me?” I thought. “Is it because I’m black?”

“为啥他要杀我？”我琢磨着，“因为我是黑人？”

I slowly withdrew my hand from the man’s leathery but feeble grip and let out a nervous laugh.

我想把手悄悄的从那家伙牛皮一样的手中抽出来，但是却被用力的握着把我吓的只敢傻笑。

“You don’t look like you are from around here, and that’s what happens when you hang around people’s property,” he said.

他说：“你看起来不像这的人，你在别人家周围闲逛个什么劲”

I participated in visits like this one to understand the delivery of care in the home setting and to better appreciate how patients manage chronic conditions like diabetes, heart disease, and chronic obstructive pulmonary disease. This patient’s attitude, however, made it challenging for me to focus on that task.

我曾参加过一个演讲，差不多是说在家中照顾和更好的鉴别该怎么治疗慢性病，比如糖尿病，心脏病和慢性肺阻塞性疾病。然而这个病人的情绪给我这次出诊搞了个大难题。

Instead, I was preoccupied with imagining a scenario in which I was gunned down for nothing.

这时候，我是认真的在想该怎么不被枪杀。

My crisp white coat from the University of Virginia would not protect me from my patient’s assumption that I was up to no good. Rather than learning how to help this patient, I was distracted by fear.

我那从弗吉尼亚大学中穿出来的薄薄的白大褂可没法从这个病人对于我的负面臆断中保护我，与其说思考怎么帮助这个病人，倒不如说是我已经被他吓尿。

I wasn’t responsible for making any diagnoses or recommending any treatments that day. I’d like to believe that if I had been, I would have been able to care for this patient as if he was the one who first inspired me to pursue a career in medicine. But as I’ve progressed through medical school and become a bit more jaded by difficult doctor-patient interactions, that experience and others have made me wonder if my feelings toward a patient would compromise my ability to be a good doctor.

那天我没做出任何诊断，没有提出一条治疗建议。我也许该相信我已经做到了，如果我那天我给他进行治疗，也许会能鼓励我在医疗事业中继续努力。但实际上我进医学院后就被艰难的医患关系整的筋疲力竭，这个经历和其他人的话让我觉得如果我被一个病人的情绪所干扰，那我整天都会受到影响。

That’s the question the two BMJ studies set out to explore. Both were conducted by the same research team in the Netherlands.In one study, doctors were presented with clinical vignettes that described patients with medical conditions of varying complexity. Each vignette described the patient as either neutral or difficult. For both straightforward and complex medical conditions, the doctors were more likely to misdiagnose the difficult patients.

这就是那两篇《英国医疗杂志》上论文所提出的问题，在荷兰也有一个组织也有类似的研究。在一次研究中，医生们提出了一些临床的小图案来代表复杂医疗环境下的患者，无论中性的还是难缠的，每一个小图案都被用来代表病人，结果是无论医疗环境怎么样，医生更容易误诊难缠的病人。

In afollow-up study, the researchers explored why these mistakes happened. They concluded that dealing with a disagreeable patient saps the mental energy doctors need to make an accurate clinical judgement.

在后续的研究中，研究人员探讨了错误发生的原因，他们的结论是，医生在治疗讨厌的病人时，没有耐心去做更准确的判断。

Most doctors believe they can rise above negative emotions stirred up by difficult patients, whether they are manipulative, hot-tempered, or just plain rude. But it isn’t easy, and simply brushing off difficult behavior may not be enough. As the researchers concluded, “difficult patients trigger reactions that may intrude with reasoning, adversely affect judgements, and cause errors.”

大多数医生相信难缠的病人会给让自己的负面情绪放大，无论病人是颐指气使，情绪暴躁，或者仅仅是没有礼貌。但是这并不容易，逃避困难的行为不能解决问题，根据研究来说“难缠病人的行为会造成错误的争端和结果。”

Both in and out of clinical settings, as a black American female, I’ve grown accustomed to ignorance and insensitivity toward people who look like me, or who identify as minorities in other ways. While my trigger-happy patient made me feel heartbroken and horrified at the same time, medical school has taught me to shake off jarring comments from patients and do my best to care for them, anyway. It’s a resilient behavior I’ve learned from other minority physicians, a quiet refusal to be defined by anything other than my own effort and accomplishment.

无论是否在临床中，作为一个黑人女性，我已经对于别人看我的目光不敏感了，也适应了一些人的无知，虽然那个想毙了我的病人让我感到心碎和恐惧，但是我在医学院里也学到了如何面对病人刺耳的说辞，以及尽我最大的努力去帮助他们。我从其他少数族裔医生那里学到一个实用的做法，即不要在意别人的看法，关键在于自己所付出的努力和取得的成就。

An editorialaccompanying the two studies highlights several strategies to help optimize the care of difficult patients. One approach suggests that patients themselves simply behave better. Recognizing the improbability of that medical miracle, the editorialists suggest that doctors take a step back to reassess the clinical situation when they recognize that a patient may be rubbing them the wrong way. Such awareness could prompt a physician to exercise what’s called metacognitive debiasing, essentially using a mind trick that allows him or her to reimagine a difficult patient with a more pleasant personality.

这两篇研究论文的编辑给出了一些策略来帮助医生更好的照顾难缠病人。其中一个办法就是要求患者自己表现好点。但意识到这其中存在的困难性，该编辑又建议说当医生意识到患者的情绪对自己的诊断造成影响时，医生可以退一步再次对病人的病情进行诊断。医生的这种意识就叫做后设认知以去除偏见，本质上是用一个意识技巧来让医生想象难缠病人的可爱之处。

Other strategies to minimize the potential for diagnostic error include providing diligent follow-up appointments, or asking colleagues for advice or a second opinion.

其他用于误诊的方法包括复诊，询问同事的意见。

Without discounting the complex emotional and social realities of medical practice or invalidating my experience as a black female medical student, these studies empower me to uphold my promise to “do no harm,” even unintentionally. While I intend to continue relying on the resilience I’ve developed, as a new newly minted physician I can employ greater self-awareness to make sure that I give my patients, no matter how difficult they may be, the best care possible.

这些研究证明了医疗实践过程中存在的情绪和社会现实，也没有否认我作为一名黑人女性医学生所遭遇的经历，这更加坚定了我“不造成伤害”的承诺，即使是无意的。虽然我想继续依赖自己所养成的弹性，但是最为一名刚刚毕业的外科医生，我应该提高自我意识从而给病人最好的照顾，不管病人多么的难缠。