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为什么医生开那么多检查?

更新时间:2020-4-22 7:03:01 来源:本站原创 作者:佚名 浏览:

Why Doctors Order So Many Tests
为什么医生开那么多检查?

One afternoon when I was running later than usual, I recognized a familiar face among the patients waiting to see me. A voluble newspaper fanatic, the gentleman, in his 70s, was usually eager to discuss the latest headlines with me. That day, however, he was remarkably quiet. He was suffering from the flu. "I'm really feeling no good," he rasped.

有天下午,我的门诊时间比往常拖得久了一点。在候诊的病人中,我看到一张熟悉的脸。这位老先生今年70多了,爱看报纸侃大山,平常总是滔滔不绝地跟我讨论新闻热点问题。可那一天,他却明显发蔫儿。流感正折磨着他。“我真的感觉很不舒服,”老先生声音沙哑地说。

After hearing about his symptoms and examining him, I suggested fluids, rest and maybe a cough suppressant and nasal decongestant. I saw the corners of his eyes and mouth fall. I understood.

我听他描述了症状,做了检查,然后给出医嘱:多喝水,多休息,也许可以去药店买点止咳和缓解鼻塞的非处方药。这时,我看见了他翻了个白眼,耷拉下嘴角。我明白了。

He was waiting for me to offer him a prescription, or to order more tests.

他指望我能给他开处方药,要么就再多做几项检查。

I knew that he didn't really need blood drawn or a chest X-ray, and he certainly didn't need antibiotics for the virus that was causing his symptoms. But I also knew what would happen if I took the time to explain why and to answer all the questions that would no doubt follow: irritated looks from other patients, the staff or even my colleagues because of the time I spent with one patient.

我知道他其实真的并不需要抽血化验或是拍X光胸片,而且要对付导致其不适症状的流感病毒,也绝对用不着抗生素。但我也知道,如果我花时间跟他解释,一一回答所有相关问题的话,接下来等着我的会是什么:其他病人、门诊工作人员甚至是同事的冷脸——因为我在一个病人身上花了太多时间。

Offering unnecessary care would, in fact, be faster.

说到底,提供不必要的医疗服务要痛快利索得多了。

Later, when I bumped into a senior colleague and explained my quandary, he simply shrugged. "In training, the most important lesson they teach you is when not to do something," he said. "But in real life, it's all about staying out of trouble and surviving.

后来,我与一位资深同事偶遇,跟他说起了我的两难处境。他只是耸了耸肩。“上学时,他们教给你的最重要的一课是在哪些时候不应做哪些事,”他说:“但在现实生活中,一切都不过是为了别惹麻烦,挺住就是胜利。”

"Even if that means ordering things you might not think necessary," he added with a wink.

他挤挤眼,补充道,“即使这意味着开那些你明知道不必要的检查单和处方。”

I recalled my colleague's words this week when I read a study about the excessive and unnecessary care patients receive and how their doctors feel about it.

这星期,看到一项研究报告时,我立时想起了这位同事的话。该项研究调查了病人所接受的过度和不必要医疗的状况,以及他们的医生对此事的看法。

For several decades now, researchers have pointed to excessive care as an important factor behind spiraling health care costs. Some studies have estimated that up to 30 percent of the care delivered to patients in the United States is unnecessary, and sometimes even harmful. More and more policy makers and insurers have been addressing the overuse problem like a calorie-reduction plan to lose weight, arguing that eliminating excess from our medical diet is critical to streamlining our corpulent health care system.

从几十年前到现在,研究者们一直宣称,过度医疗是导致医疗开支不断急剧上涨的重要潜在原因。据一些研究估测,在美国,患者所接受的医疗服务中,超过30%并无必要,有时候甚至是有害的。越来越多的政策制定者和保险公司开始关注医疗资源滥用的问题。在他们看来,这就像降低卡路里摄入与减肥之间的关系一样,想要精简臃肿不堪的医疗服务体系,关键便在于减少每个人从“医疗大餐”中分一杯羹的机会。

But as anyone who has ever tried to shed pounds knows, deciding to cut extra calories is one thing. What happens at the table is an entirely different matter.

然而,正如每个曾经尝试过瘦身的人都熟知的,决定减少卡路里摄入量是一回事,真坐到餐桌上,那就又是另外一回事了。

This week's Archives of Internal Medicine offers a glimpse of what happens at one "table" of health care: the primary care doctor's office. Researchers analyzed more than 600 responses to a nationwide mail survey that went out to primary care doctors and found that nearly half of them believed that patients in their practice were receiving too much care. Almost a third acknowledged that it wasn't just other providers at fault; it was also their own way of providing care.

本周出版的《内科医学档案》(Archives of Internal Medicine)杂志就医疗服务系统中的一张“餐桌”——基层保健医生的诊室——加以审视。研究人员对全美国范围内的基层保健医生进行了一项邮件问卷调查。对寄回的600多份回复进行分析后,研究者发现,将近半数的被调查者认为,自己接诊的病人接受了过多的医疗服务。近1/3的人承认,这不仅仅是别家医疗机构的问题,他们自己也一样随波逐流。

"Doctors aren't oblivious to what is going on," said Dr. Brenda Sirovich, the lead author and an associate professor of medicine in the Outcomes Group at the White River Junction Veterans Affairs Medical Center in Vermont and at the Dartmouth Institute for Health Policy and Clinical Practice. "They recognize that something is wrong."

“医生们并非对正在发生的事一无所知,他们知道有些事是不对的。”该项研究的主要作者、达特茅斯卫生政策与临床诊疗研究所医学副教授布伦达·希罗维奇(Brenda Sirovich)指出。她还任职于佛蒙特州白河口退伍军人医疗中心(White River Junction Veterans Affairs Medical Center)的医疗产出评估小组(Outcomes Group)。

The doctors surveyed attributed the pressure to overtreat patients primarily to three factors. Almost half believed that inadequate time allotted to patients led them to order more tests or refer to specialists. More than three-quarters also believed that the fear of being sued or perceived as not doing enough put undue pressure on them to order more. A doctor might, for example, order an unnecessary CT scan for a patient who had only a minor forehead bruise from a fall but a perfect neurologic exam.

接受调查的医生们表示,对病人过度治疗的压力主要源自三个因素。近半数人认为,分配到每个病人身上的门诊时间不足导致了基层保健医生多开检查或建议病人去专科医生转诊。超过3/4的人还表示,担心被起诉或是被指责玩忽职守的压力迫使他们要求病人做更多的检查。例如,对于一位因为跌倒而额头略微擦伤的病人,本来常规的神经学检查就已足够,但医生却可能会要求他多做一次没有必要检查的CT扫描。

Most notably, more than half the doctors believed that the current quality measures and clinical guidelines endorsed by health care experts and insurers as a way to rein in excesses were in fact having the opposite effect. The guidelines might, for example, require that patients with high blood pressure and diabetes have a specific blood test every three months and take high blood pressure medications as soon as their blood pressure exceeds 140. Because insurers are increasingly linking payment to these guidelines, physicians must strictly follow the quality measures to be paid, regardless of the patient's specific situation. Ironically, most of these quality measures are based on, well, more testing and treatments.

最值得关注的是,超过半数的医生认为,当前的医疗质量评估标准和临床治疗指南虽然是由医学专家和保险公司出于控制医疗开支的目的而制定的,但它们的实际效果却适得其反。例如,治疗指南可能会要求患有高血压和糖尿病的患者每三个月接受一次特定的血液化验,并且在血压超过140毫米汞柱时立即服用降压药物。由于保险公司越来越多地将医疗保险赔付与这些治疗指南挂钩,医生们必须严格遵守医疗质量评估标准才能拿到钱,而不管病人的具体情况为何。具有讽刺意味的是,大多数医疗质量评估标准都是建立在多检查和多治疗的基础上的。

"Guidelines in general set a bar for not enough care," Dr. Sirovich said. "There aren't any guidelines that set a bar for too much care."

“治疗指南通常只设定治疗不足的标准,没有多少指南为过度治疗设定了标准,”希罗维奇说。

Others have proposed that doctors might prescribe unnecessary care for financial gain, but only 3 percent of doctors in this study believed their decisions were based on a desire to generate extra revenue. Dr. Calvin Chou, author of an editorial accompanying the study and a professor of medicine at the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center, believes that overtreating patients stems not from an active desire to do or gain something, but rather from a sense of overwhelming helplessness.

有些人指出,医生多开没有必要的检查是为了牟利,但在此项研究中,仅有3%的医生认为自己做出的医学决策是建立于想多赚点儿钱的基础上的。加州大学旧金山分校医学教授、旧金山退伍军人医学中心的卡尔文·周(Calvin Chou,音译)医生在这项研究发表时为其撰写评论员文章。他认为,对病人进行过度治疗的根源不在于一定想要做点什么或是捞到点什么,而在于一种压倒一切的无能为力感。

"Many doctors feel like they are on a treadmill and are running scared because of malpractice and having to check off all the checkboxes of quality measures," Dr. Chou said. "They feel like they are in an oppressive situation that they can't do anything about."

“许多医生感觉置身跑步机上,只顾奋力前奔,生怕失职出错,于是恨不得在每一项医疗质量评估标准前面打上对勾,”周医生说,“他们自觉身处弱势但却对此无计可施。”

Nonetheless, there was evidence that doctors were not resigned to their professional plight. Seventy percent of the physicians took the time to answer and return the mailed survey, in part, Dr. Sirovich believes, because "doctors are interested and want to talk about these issues." Moreover, a majority of doctors surveyed acknowledged being curious about how their colleagues practiced; and well over half asked to see a report the researchers offered on how practices in their own communities differed from others. All of this "suggests that doctors are open not only to changes in their own practices, but also to working together to realign the incentives of the system," Dr. Sirovich said.

然而,有证据表明,医生并未屈服于自己的职业困境。在上述研究中,70%的医生花时间回答了调查问卷并将其寄回。在希罗维奇医生看来,其部分原因在于“医生们愿意探讨这些问题”。此外,大部分接受调查的医生表示了对其他同行的临床实践的好奇。超过半数的人要求研究者提供一份关于接受调查者所在社区与其他地区临床实践不同之处的比较报告,供他们参阅。所有这些都“预示着医生们不仅对改变自身临床实践持开明态度,而且愿意同心协力,让医疗体系重新变得具有吸引力,”希罗维奇医生表示。

She added: "It all comes down to doctors and patients sitting in the office and deciding what to do. We are not going to be successful in reducing unnecessary care until physicians are also engaged."

她补充道,“这最终要靠医患双方坐在一起,共同决定何去何从。除非医生也全身心地投入其中,否则削减不必要的医疗服务是不可能获得成功的。”

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