医患关系暧昧 怎样避免误诊

A patient with abdominal pain dies from a ruptured appendix after a doctor fails to do a complete physical exam. A biopsy comes back positive for prostate cancer, but no one follows up when the lab result gets misplaced. A child's fever and rash are diagnosed as a viral illness, but they turn out to be a much more serious case of bacterial meningitis.
如果医生没能做好全面身体检查，腹痛病人可能会死于阑尾破裂。前列腺癌活体组织检查结果呈阳性，但却没人跟进，因为实验室结果被弄混了。小孩发烧和出疹被诊断为病毒性疾病，但最后却发现是严重得多的细菌性脑膜炎。

Such devastating errors lead to permanent damage or death for as many as 160,000 patients each year, according to researchers at Johns Hopkins University. Not only are diagnostic problems more common than other medical mistakes -- and more likely to harm patients -- but they're also the leading cause of malpractice claims, accounting for 35% of nearly $39 billion in payouts in the U.S. from 1986 to 2010, measured in 2011 dollars, according to Johns Hopkins.
约翰霍普金斯大学(Johns Hopkins University)研究人员表示，每年有多达16万名病人因此类致命失误而出现永久损伤或死亡。研究人员称，诊断问题比其他医疗失误更为普遍，而且更容易伤害到病人，同时它们也是医疗过失诉讼的主因，按照2011年美元价值计算，它们在1986年至2010年间共计近390亿美元的赔偿额中占35%。

The good news is that diagnostic errors are more likely to be preventable than other medical mistakes. And now health-care providers are turning to a number of innovative strategies to fix the complex web of errors, biases and oversights that stymie the quest for the right diagnosis.
好消息是，误诊比其他医疗失误更容易预防。现在医疗机构开始采用一系列创新措施来纠正失误、偏误和疏忽等妨碍医生做出正确诊断的问题。

Part of the solution is automation -- using computers to sift through medical records to look for potential bad calls, or to prompt doctors to follow up on red-flag test results. Another component is devices and tests that help doctors identify diseases and conditions more accurately, and online services that give doctors suggestions when they aren't sure what they're dealing with.
其中一个解决办法是自动化──用电脑筛查医疗记录从而找出可能的误诊，或提醒医生跟进标有红色警示的检查结果。另一方面是帮助医生更准确诊断疾病和病情的设备和测试，还有在医生对病人病情不确定时给他们建议的网上服务。

Finally, there's a push to change the very culture of medicine. Doctors are being trained not to latch onto one diagnosis and stick with it no matter what. Instead, they're being taught to keep an open mind when confronted with conflicting evidence and opinion.
最后还有推动医疗文化的改革。医生受到的教导是不能抓住一种诊断不放，而是应该在面对相互冲突的证据和观点时保持开放的思想。

'Diagnostic error is probably the biggest patient-safety issue we face in health care, and it is finally getting on the radar of the patient quality and safety movement,' says Mark Graber, a longtime Veterans Administration physician and a fellow at the noNPRofit research group RTI International.
美国退伍军人事务部(Veterans Administration)资深医师、非营利研究机构RTI International研究员马克・格雷伯(Mark Graber)说：“误诊可能是我们在医疗行业面临的最大的病人安全问题，现在终于纳入到了病人诊治质量和管理运动中。”

The effort will get a big boost under the new health-care law, which requires multiple providers to coordinate care -- and help prevent key information like test results from slipping through the cracks and make sure that patients follow through with referrals to specialists.
这些举措在最新的医疗法律下将会得到大大的推进。法规要求多家医疗机构协调护理治疗，并帮助预防检查结果等关键信息被遗漏，确保病人按照医生的推荐去找专家。

There are other large-scale efforts in the works. The Institute of Medicine, a federal advisory body, has agreed to undertake a $1 million study of the impact of diagnostic errors on health care in the U.S.
另外还有一些大规模的举措正在进行中。为美国联邦政府提供咨询的医学研究所(Institute of Medicine)已经同意承担一项100万美元的有关误诊对美国医疗影响的研究。

In addition, the Society to Improve Diagnosis in Medicine, which Dr. Graber founded two years ago, is working with health-care accreditation groups and safety organizations to develop methods to identify and measure diagnostic errors, which often aren't revealed unless there is a lawsuit. In addition, it's developing a medical-school curriculum to help trainees improve diagnostic skills and assess their competency.
此外，格雷伯博士两年前创立的改善医疗诊断协会(Society to Improve Diagnosis in Medicine)正在与医疗认证机构及安全组织合作，研究确定和衡量诊断失误的方法，通常情况下除非有人起诉，否则误诊是不会公之于众的。另外，协会还在设计一个医学院课程表，帮助学员提高诊断技能并对他们的能力进行评估。

Robert Wachter, associate chairman of the department of medicine at the University of California, San Francisco, says defining and measuring diagnostic errors is an important step. 'Right now, none of the incentives for improvement in health care are based on whether the doctor made the correct diagnosis,' Dr. Wachter says. But equally important, he adds, 'we need to nurture bottom-up innovation.'
加州大学旧金山分校(University of California, San Francisco)医药部副主任罗伯特・瓦赫特(Robert Wachter)说，对诊断失误进行确定和衡量是重要的一个步骤。他说：“目前医疗改善的激励措施没有一项是基于医生是否做出了正确诊断的。”不过他又说，同样重要的是，“我们需要鼓励从下至上的创新”。

That's already happening. Large health-care systems are mining their electronic records for missed signals. At the Southern California Permanente Medical Group, part of managed-care giant Kaiser Permanente, a 'Safety Net' program periodically surveys its database of 3.6 million members to catch lab results and other data that might fall through the cracks.
创新已经开始。大型医疗系统正在筛查他们的电子记录以查找误诊的迹象。在管理式医疗行业巨头凯泽永久医疗集团(Kaiser Permanente)旗下的南加州永久医疗机构(Southern California Permanente Medical Group)，其“安全网”(Safety Net)项目会定期对其数据库中360万名会员进行问卷调查，从而捕捉到有可能被遗漏的实验室结果及其他数据。

In one of the first uses of the system, a case manager reviewed 8,076 patients with abnormal PSA test results for prostate cancer, and more than 2,200 patients had follow-up biopsies. From 2006 to 2009, 745 cancers were diagnosed among those patients -- and Kaiser had no malpractice claims related to missed PSA tests.
在首次使用该系统的过程中，一位病例管理员查到8,076名病人的前列腺癌PSA检查结果不正常，2,200多名病人随后有做活体组织检查。2006至2009年，这些病人中有745人被诊断患有癌症，而凯泽并未接到有关遗漏的PSA检查的过失起诉。

The program is also being used to find patients with undiagnosed kidney disease, which is often found via an abnormal test result for creatinine, which should be repeated within 90 days. From 2007 to 2012, the system found 7,218 lab orders placed for patients with an abnormal test that had not been repeated. Of those, 3,465 were repeated within 90 days of a notice to patients that they needed a repeat test, and 1,768 showed abnormal results. The majority, 1,624, turned out to be new cases of the disease.
该项目还被用于查找患有未被诊断的肾脏疾病的病人。肾脏疾病通常是通过异常肌酸酐检查结果发现的，并且应在90天内进行复查。2007年至2012年，系统发现有7,218张做异常检查的实验室检查单未进行复查。其中3,465单在通知病人90天内需要复查后进行了复查，1,768人呈现异常结果。最后大多数人，也就是1,624人被诊断为患有肾脏疾病。

Michael Kanter, regional medical director of quality and clinical analysis, says the system enables clinicians to go back 'as far as is feasible to find all of the errors that we can and fix them.'
负责质量和临床分析的区域医学主任迈克尔・坎特(Michael Kanter)说，该系统使得临床医师能够“尽最大可能回去查找并弥补所有的失误”。

Because the disease is slow moving, Dr. Kanter says, people with a five-year-old undiagnosed case may not have been harmed. Likewise, with many early prostate cancers, 'in many of these cases it doesn't mean harm would have reached the patient,' he says. 'But we don't want patients not to have the information they should have had through some kind of lapse in the system.'
坎特博士说，由于这种病是慢性病，所以五年没有被诊断出来的人可能并不会有大碍。同样的，他说，对于早期前列腺癌来说，“在很多案例中并不意味着病患已经危及到了病人，但我们不想因为系统里的某种过失导致病人对本应知道的信息不知情”。

Electronic records aren't a panacea, of course, and can even lead to information overload. In a survey of Veterans Administration primary-care practitioners reported last March in JAMA Internal Medicine, more than two-thirds reported receiving more patient-care-related alerts than they could effectively manage -- making it possible for them to miss abnormal test results.
当然，电子纪录并非万应良药，而且还有可能导致信息过载。去年3月，在《美国医学会杂志・内科学》(JAMA Internal Medicine)上发表的对美国退伍军人事务部初诊医师所做的一项调查显示，超过三分之二的医师收到的有关看病的通报数量超过了自己所能有效管理的范围──这就有可能导致他们遗漏异常的检查结果。

Some researchers suggest the best solution isn't to flood doctors with information but to provide a second set of eyes to find things they may have missed.
有研究人员表示，最佳的解决办法并不是把海量的信息塞给医生，而是为他们提供第二双眼睛查找他们有可能遗漏的东西。

The focus now is preventing dangerous delays in follow-ups of abnormal test results. In a pilot program, researchers at the Houston VA developed 'trigger' queries -- a set of rules -- to electronically identify medical records of patients with potential delays in prostate and colorectal cancer evaluation and diagnosis. Records included charts that had no documented follow-up for abnormal findings suspicious for cancer after a certain period, according to the research team's leader, Hardeep Singh, chief of health policy and quality at Michael E. DeBakey VA Medical Center in Houston and an assistant professor of medicine at Baylor College of Medicine.
目前的重点在于防止在异常检查结果的跟进过程中出现危险性延误。在一个试点项目中，退伍军人事务部休斯顿分部的研究人员设计出了“触发”查询，这是一套规则，通过计算机确认在前列腺和结肠直肠癌评估和诊断中可能有延误的病人的病历记录。研究小组负责人哈迪普・辛格(Hardeep Singh)表示，记录包括特定时期后对表明有疑似癌症的异常检查结果无正式跟进记载的图表。辛格是休斯顿Michael E. DeBakey VA Medical医学中心医疗政策及质量主任，以及贝乐医学院(Baylor College of Medicine)医药学助理教授。

The queries were run on nearly 600,000 records of patients seen at one VA facility in 2009 and 2010. Dr. Singh says the use of triggers, which helped find abnormal PSA tests and positive fecal occult blood tests, could detect an estimated 1,048 instances of delayed or missed follow-up of abnormal findings annually and 47 high-grade cancers.
2009年和2010年，在退伍军人事务部下属一家医院就诊过病人的近60万份记录得到了这样的查询。辛格博士说，使用“触发”查询帮助找到了异常PSA检查和阳性大便潜血检查，每年可以查到约1,048例异常检查结果的后续跟进被延误或遗漏，以及47例重度癌症。