澳大利亞John Murtagh全科病案研究(五十一)
——連續(xù)性服務(wù)：全科醫(yī)學(xué)的特權(quán)

John Murtagh，Hui Yang

譯者按：有不少人認(rèn)為只有在病人生病并尋求醫(yī)療服務(wù)的時(shí)候，才會(huì)“遭遇”到醫(yī)患關(guān)系，然而這種理解在全科醫(yī)學(xué)中是錯(cuò)誤的。連續(xù)性服務(wù)是全科醫(yī)學(xué)的精髓。全科醫(yī)學(xué)中的醫(yī)患關(guān)系不同于其他臨床?？?，這種關(guān)系是可以跨越時(shí)間的長(zhǎng)期關(guān)系，并非是因某具體疾病的診治才建立起的臨時(shí)關(guān)系。甚至，把對(duì)某慢性疾病的長(zhǎng)期隨訪理解為連續(xù)性，仍不能切實(shí)地解釋這個(gè)詞的完整含義。在全科醫(yī)學(xué)的醫(yī)患關(guān)系中，醫(yī)生可以在不同時(shí)間遇到某病人各種不同的急性或慢性、軀體或心理的健康問(wèn)題，而且醫(yī)患關(guān)系可以牽涉這個(gè)病人的配偶，或上推下移到這個(gè)病人的長(zhǎng)輩和后輩。全科醫(yī)學(xué)中這種獨(dú)特的醫(yī)患關(guān)系，決定了其連續(xù)性服務(wù)的屬性。醫(yī)生不僅能夠全面地理解病人的身心健康，還能理解病人的家庭，以及導(dǎo)致病人和家庭成員生病的各種危險(xiǎn)因素和應(yīng)激原。Murtagh教授在這里通過(guò)2個(gè)親身經(jīng)歷的病案，分析和討論全科醫(yī)學(xué)連續(xù)性服務(wù)的本質(zhì)特征。

回想當(dāng)年，我剛剛開(kāi)始給病人看病的時(shí)候，就知道一位叫梅維斯的病人。當(dāng)年她60歲，是一位農(nóng)民的妻子。她當(dāng)時(shí)找我看病的原因是踝關(guān)節(jié)扭傷。她說(shuō)自己踩在了別人吃過(guò)的口香糖上，結(jié)果腳扭了一下，受了點(diǎn)輕傷。當(dāng)時(shí)檢查時(shí)發(fā)現(xiàn)，她的踝關(guān)節(jié)很纖細(xì)，她說(shuō)很多女性嫉妒她有很漂亮的踝部。幾年后她再來(lái)看病，這次的主訴是背痛，并有輕度的坐骨神經(jīng)痛。檢查發(fā)現(xiàn)，左腿末梢肌肉組織1度無(wú)力，踝關(guān)節(jié)反射減低。我認(rèn)為這是S1神經(jīng)根病導(dǎo)致的。后來(lái)她的疼痛和踝關(guān)節(jié)有所改善。

時(shí)間過(guò)得很快，轉(zhuǎn)眼就是6個(gè)月前發(fā)生的事情了。梅維斯的30歲兒子羅伯特找我看病，主訴他從客貨兩用車后面跳下來(lái)后，出現(xiàn)踝關(guān)節(jié)疼痛?？雌饋?lái)他是一種很普通的受傷，但他出現(xiàn)了腓骨下端骨折，檢查還發(fā)現(xiàn)他的腿肌肉無(wú)力。我觀察到他的踝關(guān)節(jié)部分和他媽媽的踝關(guān)節(jié)一樣細(xì)弱。難道他們母子的情況是有聯(lián)系的嗎？是不是我忽略了遺傳性的疾??？我坐在椅子上，看著他的兩條腿。突然，我明白了！我看到了一雙“倒置的香檳酒瓶樣的腿”。我以前在書(shū)上讀到過(guò)這種生動(dòng)的比喻，可是從來(lái)沒(méi)有見(jiàn)過(guò)。這下我清楚了，他的病的確與他媽媽的病是有聯(lián)系的。

這種病的診斷是腓肌萎縮(peroneal muscular atrophy)，也稱為夏-馬-圖三氏綜合征(Charcot-Marie-Tooth syndrome)。這個(gè)綜合征包括周圍神經(jīng)病變，因此梅維斯的神經(jīng)學(xué)癥狀不是因?yàn)樗巢康膯?wèn)題引起的。這種病很少見(jiàn)，但這也是全科醫(yī)學(xué)的魅力所在。你不知道下一位病人會(huì)給你帶來(lái)什么樣的挑戰(zhàn)?，F(xiàn)在我知道了，應(yīng)該關(guān)注羅伯特的孩子和其他家庭成員是否也有這種病。

從我上面講的這個(gè)臨床故事中，你可以注意到全科醫(yī)學(xué)一些獨(dú)特和優(yōu)秀的特征：連續(xù)性服務(wù)、為家庭服務(wù)、為個(gè)體服務(wù)。監(jiān)測(cè)家庭的遺傳性疾病，是連續(xù)性服務(wù)和家庭服務(wù)的一個(gè)具體層面。案例中的這個(gè)家庭是非常值得分析的，梅維斯是一位喜歡爭(zhēng)論的病人，有一次和我爭(zhēng)論說(shuō)不想支付看病的賬單，因?yàn)槲业闹委煼桨覆荒苤委熕谋惩础?/p>

另外一個(gè)讓我記憶猶新的病人是45歲的奈德，他是一位溫順和溫柔的養(yǎng)雞場(chǎng)場(chǎng)主，他把雞場(chǎng)打理得井井有條。他在當(dāng)?shù)睾苡忻麣?，因?yàn)樗碾u在斗雞比賽中獲勝。有一天他來(lái)看病，說(shuō)是因?yàn)楸孔镜厮ち艘货?，拇指錯(cuò)位了。他看上去病態(tài)明顯、身寬體胖、顏面紅腫、雙眼布滿血絲。我給他做體檢，發(fā)現(xiàn)他肝部中度擴(kuò)大，血壓155/95 mm Hg(1 mm Hg=0.133 kPa)。我懷疑他可能是個(gè)重度酗酒的人，然而當(dāng)我詢問(wèn)他的時(shí)候，他矢口否認(rèn)，“大夫，我只是偶然跟哥們喝點(diǎn)啤酒”。我讓他回來(lái)復(fù)診，結(jié)果他4個(gè)月后才再來(lái)看病。這次他透露說(shuō)自己感覺(jué)不舒服有好長(zhǎng)時(shí)間了，消化不良、胃腸脹氣、勃起功能障礙。這次測(cè)量血壓165/100 mm Hg。我告訴他要采取健康的生活方式、多鍛煉、健康飲食、不喝酒。但他仍然否認(rèn)自己喝酒。下次再來(lái)看病是在預(yù)約日期之前，這次是他的家人帶他過(guò)來(lái)的，家人說(shuō)他發(fā)生了驚恐發(fā)作，“他被電擊了”。他在一個(gè)大鐵皮房子里藏了很多啤酒，自己在里面偷偷喝酒。那天他正在偷偷喝酒的時(shí)候，外面電閃雷鳴下暴雨，一個(gè)閃電擊中外面的一顆大松樹(shù)，樹(shù)攔腰折斷，樹(shù)上的松果如同雹子一樣噼噼啪啪地砸在鐵皮屋頂上。這種令人驚悚的聲音讓他感覺(jué)到是他媽媽在責(zé)備他偷喝酒，怪罪他整天無(wú)所事事。的確，他就是一個(gè)酗酒者，而且血壓增高也是他酗酒的一個(gè)證據(jù)。我再安排他做肝功能檢查，也證實(shí)飲酒導(dǎo)致了肝功能的變化。事實(shí)上，我可以持續(xù)地觀察病人飲酒情況與他血壓和肝功能的關(guān)系。

連續(xù)性服務(wù)是全科醫(yī)學(xué)的精髓。全科醫(yī)學(xué)的醫(yī)患關(guān)系是跨越時(shí)間的長(zhǎng)期關(guān)系，并非是因某具體疾病的診治才建立起的臨時(shí)關(guān)系。在這種關(guān)系中，醫(yī)生可以在不同時(shí)間遇到某病人各種不同的健康問(wèn)題，醫(yī)生不僅能夠全面地理解病人的身心健康，還能理解病人的家庭，以及導(dǎo)致病人和家庭成員生病的各種危險(xiǎn)因素和應(yīng)激原，并掌握病人的工作情況和業(yè)余娛樂(lè)環(huán)境。

無(wú)論是全科醫(yī)生還是在醫(yī)院里照顧病人的各類健康工作人員，都有促進(jìn)連續(xù)性服務(wù)的特權(quán)[1]。在臨床服務(wù)中，有很多促進(jìn)連續(xù)性服務(wù)的策略，比如開(kāi)發(fā)和維護(hù)比較好的病案系統(tǒng)，特別是病人的個(gè)人健康記錄；做好病人登記工作，制作和分發(fā)病人健康資料，維護(hù)和使用病人清單等。上述工作可以通過(guò)計(jì)算機(jī)系統(tǒng)來(lái)完成，但最重要的還在于醫(yī)生要具有與病人良好溝通的技巧，特別是敏銳的觀察力、旺盛的好奇心以及體貼地對(duì)待病人。

1 John Murtagh,Jill Rosenblatt.Murtagh′s general practice[M].Fifth Edition.McGraw Hill:2011.

·WorldGeneralPractice/FamilyMedicine·

Soon after commencing practice I became acquainted with Mavis J,a 60 year old farmer′s wife,when she presented with a sprained ankle.She described a very minor injury as her foot twisted after stepping on a gum nut.I noted her very slim ankles and she commented that they were the envy of many women.A few years later she presented with back pain and mild sciatica.On examination of the left leg there was grade 1 weakness of the distal leg musculature with a reduced ankle reflex.I attributed this to a S1 radiculopathy.Her pain and ankle improved.

Fast forward to six months when her 30 year son Robert presented with a painful ankle after jumping off the back of his utility.A rather innocuous injury but he had a fractured lower fibula and muscle weakness of his leg was also noted.I then observed the same slender lower leg shape as his mother.Was there a connection and was I missing a hereditary disorder? I sat on the chair looking at his legs and then the penny dropped.I was observing ′inverted champagne bottle′ legs-a tantalizing sign that I′d read about but never seen before.Here was a connection with mother.

The diagnosis was peroneal muscular atrophy also known as Charcot-Marie-Tooth syndrome.Peripheral neuropathy is part of the syndrome so Mavis′s neurological symptoms may not have been caused by her back dysfunction.Rare but that′s the fascination of general practice.You never know what challenge the next patient brings and we will now have to be alert to the condition in Robert′s children and all other family connections.

This clinical story highlights some of the unique and wonderful hallmarks of general practice-continuing care (the C word),family care and personal care.Monitoring familial genetic disorders is a special dimension of continuing and family care.The J family was a very interesting one-Mavis the feisty matriarch confronted us once refusing to pay the bill because her back pain had not responded well to my management plan.

Another of my memorable patients was 45 year old Ned-a meek and mild chicken farmer who was famous for his show winning roosters and well managed farm.He presented one day with a dislocated thumb after a rather clumsy fall.I thought that he did not look well.He was overweight and had a red puffy face and blood shot eyes.I examined him and found that he had a moderately enlarged liver and a blood pressure of 155/95 mm Hg.I suspected that he might be a heavy consumer of alcohol but when asked he flatly denied drinking."Just a few beers with the boys occasionally Doc" I asked him to come back for review and he came 4 months later.He confided that he had not been feeling well with bouts of indigestion and erectile dysfunction.His blood pressure was now 165/100 mm Hg.I then talked about lifestyle,exercise,good diet and no alcohol.He still denied drinking.Before his next review he was brought in by his family because he was having a panic attack and said that ′he was suffering from shock′. The amusing story emerged that he had been drinking secretly from his massive cache of beer in his large tin shed when an electrical storm blew in.Lighting stuck the huge pine tree outside-split it down the middle and pine cones rained down on the roof.The frightening noise made him believe that it was his mother in heaven admonishing him for drinking alcohol and lying about it.Yes he was an alcoholic and the evidence was there in his increasing blood pressure.I performed liver function tests which confirmed the effects of alcohol.In fact I could plot the alcohol consumption of my regular patients over time by their blood pressure and liver status.

The essence of general practice is continuing care.The doctor-patient relationship is unique in general practice in the sense that it covers a span in time that is not restricted to a specific major illness.The continuing relationship involving many separate episodes of illness provides an opportunity for the doctor to develop considerable knowledge and understanding of the patient,the family and its stresses,and the patient′s work and recreational environment.

Obviously rural general practitioners and others caring for their patients in hospital are in a privileged position to enhance continuing care[1].Other practical strategies that promote this care are optimal record systems including personal health records,the patient register,patient education material and recall lists.These communication factors have been boosted by improved computerisation of records but the most important of all is good communication skills including sharp observation,curiosity and kindness.

Reference

1 John Murtagh,Jill Rosenblatt.Murtagh′s general practice[M].Fifth Edition.McGraw Hill:2011.