◇◇新语丝(www.xys.org)(xys2.dxiong.com)(www.xysforum.org)(xys-reader.org)◇◇ 医患关系——不在于是否签名 作者:旁观者S   我是新语丝的一个忠实读者。从这里我学到了不少东西,所以我要首先谢谢 这个平台的打建者和众多的作者。   最近一段时间有关“医德”(医德这个词太大、笼统,本人更愿意把问题局 限在“医患关系”范围内)的讨论好不热烈。有关的起因、讨论的过程以及各家 的观点就不用多说了。我主要想谈谈一个旁观者的看法:   1.也许激流一代所提供的三个案例还不那么典型,让众多医生觉得案例中 的医生无可指责,甚至做的非常正确,但在我看来这在这三个案例中当值医生在 行为上都不符合正常的医患关系。我个人的理解是,案例一所提供的具体情况不 是让我讨论要不要签名的问题,而是着重讨论针对签名这个问题作为医生应该怎 么作。至于案例二、三中的签名,大部分医生已经说了——为了自保。唉,我能 说什么呢?医生做到这份上大概也没什么乐趣了。总之,从大多数医生的回应来 看,我个人觉得我们的医生作为直接参与者,对目前中国这种不良的医患关系现 状是要负一定(甚至很大)责任的。   2.那么“医患关系”到底是个什么样的关系呢?我这里没有官方答案。但 有一点是明确的,这就是医生是服务者,而患者则是被服务者。再通俗一点就是 患者是医生的客户——是医生的上帝!不知道众位医生意识到这一点没有。如果 我们的医生都能够把病人的利益放在第一位,一切从服务好病人出发,我想这次 讨论就没有必要了。当然,在中国医生不缺病人,所以医生可能从来不会把病人 当自己的上帝。   3.中国医生可以居高临下、甚至可以呵斥病人的原因是多方面的,但有一 条我觉得是很重要的:他们在医学院没有学习本该掌握的一门课程—— Behavioral Science。这门课程包含的内容相当广泛,其中就包括医生从业中应 当遵循的许多原则,处理“医患关系”以及与医疗纠纷有关的一些伦理、法律等 问题的众多原则,等等。在美国,Behavioral Science是医学生的一门必修课, 而且在医生执照考试中也是重要的必考课。相信寻正等许多美国朋友可能更了解 这些。由于没有机会系统地学习这门重要的课程,让我们的医生谈职业道德、处 理好医患关系也的确有难度,因为他们不知道标准 (比如某位回帖者提到有些医 生、护士为贫穷的患者家属买顿午饭为“好医德”可能就不那么准确)。本文后 面抄录了Behavioral Science教科书中有关医患关系和与医疗纠纷相关章节的一 些内容,感兴趣的朋友,特别是医生朋友可以对照自己看看。   4.对医生医学基础知识和专业知识的看法。也许是由于随着医学科学的发 展科越分越细、知识越来越专的缘故,感觉上对我们医生的专业,特别是医学基 础知识都不敢恭维。他们倒是喜欢对那些无关大局的名词争个你高我低。典型的 例子是“鉴别诊断”和“差异诊断”。希望大家以后不要再拿类似的例子说事了。 其实,医生的医学基础知识也是处理好医患关系的重要保证。如果没有过硬的基 础知识,一切靠经验,那和老中医也就没什么分别了。   说到医学基础知识,我不能不提及为这个平台作出很多贡献、为众多读者称 颂的白衣咸饭医生,因为我看了前一阵子他的科普文章《打针与打点滴》。我很 为他行为所感动,也盼望更多的医生写这样的科普文章为大众服务。但客观地说, 我又为该文遗憾。为什么?因为文中许多地方没有把问题说清楚,或者没有说到 点子上。原因我不知道,也许是时间匆忙或者其他。但给我的感觉更像是因为把 医学基础知识还给老师了。这里仅举两例:(1)【还有如缓解心绞痛的硝酸甘油, 要舌下含服,没有必要吞下去,在口腔内也会很快吸收,更没有必要打针了】。 不知道其他医生看到这里有什么反应,反正我看了叹了口气。要是医生给我开了 硝酸甘油后用这段话给我解释,我也许就不是舌下含服而是吞下去了!不是【没 有必要吞下去】,而是不能吞下去!!为什么?因为吞服的硝酸甘油在吸收过程 必须通过肝脏,在肝脏中绝大部分硝酸甘油会很快被灭活,使药效大大降低。而 舌下有舌下静脉丛,当把硝酸甘油含在舌下时,溶化了的药物能够直接快速入体 循环,避开了肝脏的灭活作用。(2) 【比如氯化钾这个药就很怪,口服非常安全, 静脉慢慢地点滴也很安全,但不得快速点滴,更不能推注。氯化钾进入体内时, 对人体有点刺激性,点滴时会有点痛。这样的药物当然不能用于肌注了。如果快 速推入体内,会引起心律紊乱,导致病人很快死亡】。这段话看上去没什么问题, 但鉴于补钾在临床上还是个很严肃、需要认真对待的问题,因此描述时尽可能更 严谨一些才是。【氯化钾这个药就很怪】,有什么怪?医务工作者不应该有这个 说法,除非不知道钾对体内代谢、维持酸碱平衡、以及其对心血管系统,特别是 心脏的兴奋性的重要调节作用。【口服非常安全,静脉慢慢地点滴也很安全,但 不得快速点滴,更不能推注】。这段话也有许多可商讨之处。如果你对病人说 “口服补钾非常安全,你就随便吃吧”,很可能会出问题。前面说过,补钾时是 很严肃的,不管通过那种途径。当然口服是相对安全的途径。但是也要看病人的 肾功能如何。不知道还是否记得“见尿补钾”这个“铁律”?静脉补钾时也不仅 仅是个速度的问题,还要严格掌握浓度和每天的量。【如果快速推入体内,会引 起心律紊乱,导致病人很快死亡】应该是“如果静脉补钾过快、过多,会引起严 重的心律失常,甚至导致病人很快死亡”。要真是发生【快速推入体内】,那么 在你拔出注射器前病人可能已经就死亡了。总之,科普文章与散文、议论文等等 是完全不同的,行文要严谨,不能给读者提供似是而非、可左可右的结论。所以, 要写好能够给众多读者提供帮助的科普文章还真不容易,需要多做作业才是。   5.微笑服务:“什么,我堂堂大医生要对病人微笑服务?有没有高错??” 当然没有!如果不会微笑,如果只能皮笑肉不笑,严格来说都不能从事医生这个 行业。医生是与病人打交道的,在人与人之间的关系中,如果没有微笑结果如何 不用我说。许多人都知道,美国医学院毕业生(以及其他国际毕业生)在参加医生 执照考试时必须通过临床技能(clinical skills)这门实际操作考试。如果你真 的不会微笑,或者只能皮笑肉不笑,你大概很难顺利通过这个考试。即便通过了, 到后来进行住院医师match时,也很难通过interview这一关(如果仍然不会笑)。 想想也是,如果一个医生面对每一个病人都是面带发自内心的微笑,把病人的利 益放在首位,利用自己扎实的医学基础知识和专业知识,把病人的病情、可能的 治疗方案及各个方案的有缺点说清说透,努力作病人的朋友,怎么会出现医患关 系紧张?   6.最后一点,一直看到一个现象,就是寻正似乎总是众人的靶子(当然反过 来说也成立),在这个主题的讨论中也不例外。作为我个人,一个和寻正及其他 任何人都没有关系的看客,我是支持寻正的。其实,你们应该为拥有这样一位热 心的批评者、贡献者感到幸福和自豪。至少我自己是很珍惜这样的人,哪怕他同 样会有这样或那样的错误(在这个主题的讨论过程中我看不出他有什么明显原则 性错误。言辞、文字本身不在我讨论的范畴内)。如果作为医生愿意改善目前这 种不良的医患关系,就要乐于倾听大家的意见,特别是那些善意的批评意见。   本人水平有限,想到哪写到哪;本人也无意针对任何具体个人。不当之处请 诸位高人勘正。 9/19/08 ====================================================================== ==== 附Behavioral Science中关于医患关系、医疗纠纷相关的伦理、法律等问题 Physician-Patient relationships A. General Rules About Physician-Patient Relationships Rule #1: Patient is number one: always place the interests of the patient first. a. Choose the patient’s comfort and safety over anyone else’s. b. The goal is to serve the patient, not to worry about legal protection for the physician. Rule #2: Always respond to the patient. a. Answer any question that is asked. b. Respond to the emotional as well as the factual content of questions. Rule #3: Tell the patient everything, even if he or she dose not ask. a. Do not force a patient to hear bad news if he does not want it at that moment, but do try to discuss it with him or her as soon as possible. b. Information should flow through the patient to the family, not the reverse. c. If you have only partial information, say that it is partial, and tell what you know. Rule #4: Work on long-term relationships with patients, not just short-term problems. a. Make eye contact. b. Defined touch: tell him or her what you are doing. c. Talk to patient, not colleagues; patient is always the focus. d. Arrange seating for comfortable, close communication. e. Shy away from large desks and tables. f. Both patient and physician should both be sitting if at all possible. Rule #5: Listening is better than talking. a. Getting the patient to talk is generally better than having the physician talk. b. Take time to listen to the patient before you, even if other patients or colleagues are waiting. Rule #6: Negotiate rather than order. a. Treatment choices are the result of agreement, not commands by the physician. b. Remember, the patient makes medical decisions from the choices provided by the physician. Rule #7: Trust must be built, not assumed. a. Don’t assume that the patient likes or trusts you. b. Treat difficult or suspicious patients in a friendly, open manner. Rule #8: Admit to the patient when you make a mistake. a. Take responsibility. Don’t blame it on the nursing staff or on a medical student. b. Admit the mistake even if it was corrected and the patient is fine. Rule #9: Never “pass off” your patient to some else. a. Refer to psychiatrist or other specialist when beyond your expertise (but usually not the case). b. Refer only for ophthalmology or related subspecialties. c. Provide instruction in aspects of care, e.g., nutrition, use of medications. Rule #10: Express empathy, then give control: “I’m sorry, what would you like to do?” a. Important when faced with a patient who is grieving or is angry. b. Important when faced with angry or upset family members. Rule #11: Agree on problems before moving to solution. a. Tell the patient your perceptions and conclusions about the condition before moving to treatment recommendations. b. Informed consent requires the patient to fully understand what is wrong. c. Offering a correct treatment before the patient understands his or her condition is wrong. Rule #12: Be sure you understand what the patient is talking about before intervening. a. Seek information before acting. b. When presented with a problem, get some details before offering a solution. c. Begin with open-ended questions, then move to closed-ended questions. Rule #13: Patients do not get to select inappropriate treatments. a. Patients select treatments, but only from presented, appropriate choices. b. If a patient asks for an inappropriate medication that he heard advertised, explain why it is not indicated and suggest an alternative. Rule #14: Be sure who your patient is. a. Is it the injured child, or the mother who brings him in? (the child) b. Is it your long-term patient who is now in a coma, or her husband? (the patient) Rule #15: Never lie. a. Not to patients, their families, or insurance companies. b. Do not deceive to protect a colleague. Rule #16: Accept the health beliefs of patients. a. Be accepting of benign folk medicine practices. Expect them. Diagnoses need to be explained in the way patients can understand, even if not technically precise. b. Be careful about having young family members translate for elderly patients. Rule #17: Accept patients’ religious beliefs and participate if possible. a. Your goal is to make the patient comfortable. Religion is a source of comfort to many. b. A growing body of research suggests that patients who pray and are prayed for have better outcomes. c. Ask about a patient’s religions beliefs if you are not sure (but not as a prelude to passing off to the chaplain!) d. Of course, you are not expected to do anything against your own religious or moral beliefs. Rule #18: Anything that increases communication is good. a. Take the time to talk with patients, even if others are waiting. b. Ask “why?” c. Seek information about the patient beyond the disease. Rule #19: Be an advocate for the patient. a. Work to get the patient what he or she needs. b. Never refuse to treat a patient because he or she cannot pay. Rule #20: The key is not so much what you do, but how you do it. a. The right choices are those that are humane and sensitive, and put the interests of the patient first. b. Treat family members with courtesy and tact, but the wishes and interests of the patient come first. Theme: The key is not what physicians actually do, but what the most ideal physician should do. Ethical and Legal Issues — Legal Issues Related to Medical Practice Rule #1: Competent patients have the right to refuse medical treatment. 1. Incompetent patients have the same rights, but must be exercised differently (via a surrogate). 2. Limitations on patients’ rights often suggested are: (1) preserve life; (2) prevent “the moral equivalent” of suicide; (3) protect third parties; (4) protect the ethical standard of the health professional. 3. In practice, court gives little weight to any of these four arguments. Patients have an almost absolute right to refuse. Patients have almost absolute control over their own bodies. The sicker the patient, the lesser the chance of recovery, the greater the right to refuse treatment. Rule #2: Assume that the patient is competent unless clear behavioral evidence indicates otherwise. 1. Competence is a legal, not a medical issue. 2. Only courts can decide competence. 3. A diagnosis, by itself, tells you little about a patient’s competence. 4. Clear behavioral evidence would be: (1) patient attempts suicide; (2) patient is grossly psychotic and dysfunctional; (3) patient’s physical or mental state prevents simple communication. 5. If you are unsure, assume the patient is competent. The patient does not have to prove to you that he is competent. You have to have clear evidence to assume that he is not. Rule #3: Avoid going to court. Decision-making should occur in the clinical setting if possible. 1. Consider going to court only if (often resolved without action): (1) there is intractable disagreement about a patient’s competence, who should be the surrogate, or make the decision on life support; (2) you perceive a serious conflict of interest between surrogate and patient’s interests. 2. Court approval of decision to terminate life support is, therefore, rarely required. Rule #4: When surrogates make decisions for a patient, they should use the following criteria and in this order: 1. Subjective standard—(1) actual intent, advance directive; (b) what did the patient say in the past? 2. Substituted judgment—(1) who best represents the patients; (2) what would patient say if he or she could? 3. Best interest standard—(1) burdens versus benefits; (2) interests of patient, not preferences of the decision-maker. Rule #5: If patient is incompetent, physician may rely on advance directives. 1. Advance directives can be oral. 2. Living will: written document expressing wishes—(1) care facilities must provide information at time of admission; (responsibility of the institution, not the physician). 3. Health power of attorney: designating the surrogate decision-maker—(1) “speaks with the patient’s voice”; (2) beats all other decision rules. Rule #6: Feeding tube is a medical treatment and can be withdrawn at the patient’s request. 1. Very controversial. 2. A competent person can refuse even lifesaving hydration and nutrition. Rule #7: Do nothing to actively assist the patient to die sooner. 1. Active euthanasia and assisted suicide are on difficult ground: (1) passive, i.e., allowing to die = OK; (2) active, i.e., killing = NOT OK. 2. On the other hand, do all you can to reduce the patient’s suffering (e.g., giving pain medication). Rule #8: The physician decides when the patient is dead. 1. If there are no more treatment options (the patient is cortically dead), and the family insists on treatment? If there are no options, there is nothing the physician can do, treatment must sop. 2. If the physician thinks continued treatment is futile (the patient has shown no improvement), but the surrogate insists on continued treatment? Of course, the treatment should continue. Rule #9: Never abandon a patient. 1. Lack of financial resources or lack of results are never reasons to stop treatment of a patient. 2. An annoying or difficult patient is still your patient. Rule #10: Always obtain informed consent. 1. Full, informed consent required that the patient has received and understood five pieces of information: (1) Nature of procedure; (2) purpose or rationale; (3) benefits; (4) risks; (5) availability of alternatives. 2. Four exceptions to informed consent: (1) emergency; (2) waiver by patient; (3) patient is incompetent; (4) therapeutic privilege (unconscious, confused, physician deprives patient of autonomy in interest of health). 3. Gag clauses that prohibit a physician from discussing treatment options that are not approved violate informed consent and are illegal. 4. Consent can be oral. 5. A signed paper the patient has not read or does not understand does NOT constitute informed consent. 6. Written consent can be revoked orally at any time. Rule #11: Special rules apply with children. 1. Children younger than 18 years are minors and are legally incompetent. 2. Exceptions: emancipated minors—(1) if older than 13 and taking care of self, i.e., living alone, treat as an adult; (2) marriage makes a child emancipated as does serving in the military; (3) pregnancy or having a child, in most cases, does not. 3. Partial emancipation—(1) many states have special ages of consent, generally age 16 and older; (2) for certain issues only: (a) substance drug treatment; (b) prenatal care; (c) sexually transmitted disease treatment; (d) birth control. Rule #12: Parents cannot withhold life- or limb-saving treatment from their children. 1. If parents refuse permission to treat child: (1) if immediate emergency, go ahead and treat; (2) if no immediate, but still critical (e.g., juvenile diabetes), generally the child is declared a ward of the court and the court grants permission; (3) if not life- or limb-threatening (e.g., child needs minor stitches), listen to the parents. 2. Note that the child cannot give permission. A child’s refusal of treatment is irrelevant. Rule #13: Confidentiality is absolute. 1. Physicians cannot tell anyone anything about their patient without the patient’s permission. 2. Getting a consultation is permitted, as the consultant is bound by confidentiality, too. However, watch the location of the consultation. Be careful not to be overheard (e.g., not elevator or cafeteria). 3. If you receive a court subpoena, show up in court but do not divulge information about your patient. 4. If patient is a threat to self or other, the physician MUST break confidentiality: (1) duty to warn and duty to protect; (2) a specific threat to a specific person; (3) suicide, homicide, and abuse are obvious threats; (4) infectious disease should generally be treated as a threat, but be careful. Here issue is usually getting the patient to work with you to tell the person who is at risk; (5)In the case of an STD, the issue is not really whether to inform a sexual partner, but how they should be told. Best advice: have patient and partner come to your office. Rule #14: Patients should be given the chance to state DNR (Do Not Resuscitate) orders, and physicians should follow them. 1. DNR refers only to cardiopulmonary resuscitation. 2. Continue with on-going treatments. 3. Most physicians are unaware of DNR orders. 4. DNR decisions are made by the patient or surrogate. Rule #15: Committed mentally ill patients retain their rights. 1. Committed mentally ill adults legally are entitled to the following: (1) they must have treatment available; (2) they can refuse treatment; (3) they can command a jury trial to determine “sanity”. 2. They lose only the civil liberty to come and go. 3. They retain their competence for conducting business transactions, marriage, divorce, voting, driving. 4. The words “sanity” and “competence” are legal, not psychiatric, terms. They refer to prediction of dangerousness, and medicopsychological studies show that health care professionals cannot reliably and validly predict such dangerousness. Rule #16: Detain patients to protect them or others. 1. Emergency detention can be effected by a physician and/or a law enforcement person for 48 hours, pending a hearing. 2. A physician can detain, only a judge can commit. 3. With children, special rules exist. Children can be committed only if: (1) they are in imminent danger to self and/or others; (2) they are unable to care for their own daily needs; (3) the parents have absolutely no control over the child, and the child is in danger (e.g., fire setter), but not because the parents are unwilling to discipline a child. Rule #17: Remove from patient contact health care professionals who pose risk to patients. 1. Types of risks: (1) infectious disease (TB); (2) substance abuse; (3) depression (or other psychological issues); incompetence. 2. Actions: (1) insist that they take time off; (2) contact their supervisors if necessary. 3. The patient, not professional solidarity, comes first. Rule #18: Focus on what is the best ethical conduct, not simply the letter of law. The best answers are those that are both legal and ethical. (XYS20080919) ◇◇新语丝(www.xys.org)(xys2.dxiong.com)(www.xysforum.org)(xys-reader.org)◇◇