医生，你为什么让病人做那么多检查项目？

译者 flyingheart

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.

　　一天下午，我匆匆走进诊室，但还是较往常晚了一些。我认出了其中一位病人。这位绅士是位喋喋不休的报纸狂人，大约70多岁，通常喜欢和我讨论最新的报纸头条。然而，那天他却非常的安静。他患上了流感。“这次我真得感觉不舒服！”他声音嘶哑地说。

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.

　　在听过他的症状自述并为他做了检查之后，我建议他多吃流食、多休息，同时服用止咳药和鼻血管收缩药。我看到了他的眼神中的渴盼，嘴角也微微在动。我明白了！

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

　　他在等我开处方，或者做下一步的医学检查。

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.

　　我知道他真的不需要验血或者拍X光片，而且他的这个症状也用不着抗生素。但我也很清楚，如果我耐心细致地给他解释的话，接下来会发生什么：其它病人、护士甚至我的同事都会投来恼怒的目光。

Offering unnecessary care would, in fact, be faster.

　　事实上，医生提供不必要的诊疗反而不用多费口舌。

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，当我偶遇一位高级同僚并和他聊起此事时，他优雅地耸耸肩。“上学时，老师教我们的最重要内容就是什么事不可以做，”他说，“但在现实生活中，我们得到的教训就是如何避免遇到麻烦，并在社会上生存下去。”

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

　　“甚至你知道没必要的情况下也可以安排病人做检查，”他俏皮地眨了一下眼。

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.

　　本周，在读一份研究报告时，让我想起了这位医生的话。文章谈到了医生给予患者的过量的和不必要的诊疗以及医生为何这样做的想法。

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.

　　几十年来，一直有研究人员指出过度诊疗是隐藏在节节攀升的医疗费用背后的一个重要因素。一些研究报告估计，在美国，患者承担的医疗费用当中有高达30%是非必须的，有时甚至是有害的。越来越多的决策者和保险公司呼吁重视诸如减肥计划中存在的过度诊疗问题，并声称消灭过度诊疗方案对理顺我们庞大的医疗卫生体系是非常关键的。

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.

　　其实每位试图减肥的人都知道，决定减肥是一回事，到了餐桌旁又完全是另一回事。

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.

　　本周的《内科学文献》上一篇文章向我们展示了在医疗卫生“桌”旁发生的事：初级保健医生的办公室。研究人员分析了一家全国性的邮件调查机构向初级保健医生发出并回收的600多份问卷调查表。调查发现，将近半数的初级保健医生认为患者在诊疗时接受了太多的医疗服务。几乎有1/3的人承认，这并非仅仅是其它医疗机构服务的不到位；这其实就是各家医疗机构提供的通行的诊疗服务方式。

"Doctors aren’t  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.”

　　“医生们并非察觉不到有些（诊疗程序）不适当，”布伦达·西诺维奇医生说。她是报告的首席作者也是设在佛蒙特州White River Junction的退伍军人医疗服务中心内的奥特卡慕斯集团（Outcomes Group ）和的达特茅斯卫生政策和临床实研究所两所医疗机构的医学助理教授。“他们认识到有些是程序是错误的。”

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.

　　接受调查的医生将患者被过度诊疗的压力主要归因于3点因素。几乎有一半的医生认为，诊疗速度（即分配给每位患者的时间）的要求使得他们更多地借助于检测报告或者参考专业医师的意见。有超过3/4的医生认为，如果诊疗过程看起来不到位，很有可能引起患者的疑心甚至遭到患者起诉，所以这种恐惧感也给他们施加了极大压力，让他们不得不给患者多安排些检查项目。例如，一位患者跌了一跤，前额有些许挫伤，常规来讲做一次神经学检查就足够了，但医生也许会再安排一次不必要的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.

　　更为明显的是，有超过一半的医生认为，目前被卫生保健专家和保险公司认可的、被用作严控过度诊疗现象的手段的“标准诊疗措施”和“临床指导意见书”，实际上正在起相反的作用。例如，指导书要求高血压和糖尿病患者每隔3个月要做一次详尽的血液检查，并且一旦血压超过140就应服用高血压药物。由于保险公司越来越多地把医保支付与这些指导书联系起来，因此医生们会不管患者的具体情况如何，只严格按照标准诊疗措施来做。具有讽刺意味的是，大多数标准诊疗措施都是以更多的检查和治疗为基础的。

“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.”

　　“通常临床指导意见书会约束诊疗不到位的行为，”西诺维奇医生说，“但还没看到有哪一份指导书会限制过度诊疗。”

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.

　　其他人提出，医生们也许为了经济上的回报而故意开出非必须的处方，但是在该调查中只有3%的医生认为他们的诊疗过程是基于获得额外收入的愿望。周凯文医生认为患者出现过度诊疗的现象不是源于主动地想做什么或者获得什么的愿望，而是源于一股巨大的无助感。周医生是该报告的执笔作者、加利福尼亚大学和旧金山退伍军人医疗服务中心的医学教授。

“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.”

　　“许多医生感觉自己在做的工作枯燥无味，并因担心误操作而变得神经兮兮，所以总迫使自己将标准诊疗措施的检查项目查个底朝天，”周医生说，“他们感觉自己处于一种难以忍受的情形之下，他们无法根据自己的判断治病救人！”

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.

　　不管怎样，也有证据表明医生们并未屈服于自己的职业困境。有70%的医生抽时间回答并寄回了问卷调查表。西诺维奇医生认为，部分原因是因为“医生们对问卷感兴趣，愿意就这些问题发表意见。”再者，绝大多数接受问卷调查的医生都承认对他们的同行的诊疗习惯感到好奇；同时也有过半的医生希望阅读研究人员提供的一份有关医学界的临床实践与其它社会团体的行为方式何不同的报告。所有这些研究结果都“暗示出医生们不仅对改变自身的临床实践持开放的态度，而且也愿意团结协作、重新调整整个医疗界的行为规范，”西诺维奇医生说。

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.”

　　她继续补充道：“希望医患双方都能放下身段，坐在一起共同决定最恰当的诊疗过程。只有医生们也全身心投入了，我们才能真正成功地减少不必要的诊疗项目。”