《The Medical Republic》案例分享
——全科醫(yī)生的“一桿進洞”

Leon Piterman，鄭慧敏（譯），黃文靜（譯），楊輝（譯）

“醫(yī)生，只有您在關心我，心血管病專家只關注我的心臟”。貝茜一邊這樣說，一邊自豪地展示著她的獎杯——一個高爾夫球，她在社區(qū)高爾夫球場，在全程130 m、標準桿數(shù)為3桿的第8洞，一桿進洞。對愛好高爾夫的人而言，人生任何階段的一桿進洞都是一項成就。而貝茜的成就則更引人矚目，因為她已經84歲高齡了，而且患有心功能不全、髖膝關節(jié)炎等疾病。

我為貝茜和她已故的丈夫約翰提供診療服務已經20多年了，約翰是在貝茜獲得一桿進洞這項重大成就的前1年去世的。約翰也愛好高爾夫，如果他還在，他一定會為貝茜的成就感到自豪。貝茜患有很多疾病，包括高血壓、缺血性心臟病（已經置入支架）、主動脈瓣狹窄、胃食管反流及髖膝關節(jié)炎。她接受過右髖關節(jié)置換術，并考慮過置換左髖關節(jié)。如果是現(xiàn)在，貝茜可以考慮行經導管主動脈瓣置換術，這樣就可以解決她不耐受開胸手術的問題。但當時她接受了開胸手術，并且因為胸部感染發(fā)生過2次急性肺水腫住院。

約翰去世后，貝茜自己要面對所有和法律、財務相關的事情，這讓她感到不知所措。以前，這些事情都是約翰處理的，約翰是一個食品公司的總經理，退休后就負責起家中的所有財務。盡管貝茜得到了子女的幫助，但她仍覺得自己需要學習一些基本的記賬。因此，她參加了關于記賬和電腦使用的成年人教育課程，這讓她充滿自信，并且增強了她的獨立生活能力。

1年前，貝茜為了照顧病重的約翰放棄了打高爾夫。約翰去世6個月后，貝茜決定重拾興趣。她發(fā)現(xiàn)自己不需要花費太多力氣就可以打到9洞，但她的膝關節(jié)和左髖關節(jié)在完成3洞后就會感到非常疼痛。這讓貝茜身心極受打擊。高爾夫不僅是一項有益的運動，也可以增加社交機會，從而使人身心愉悅、神清氣爽。如果1周不能打1場高爾夫，更別提貝茜想要的1周2場，就意味著她將失去一個主要的快樂源泉，生活質量也會因此下降。

以前，約翰一直服用塞來昔布來治療關節(jié)炎。因此，貝茜也決定在打高爾夫前的1～2 d以及球賽當天服用塞來昔布，這讓她能夠輕松地完成一場高爾夫。但有一次她去心血管病專家處就診時，提到了自己服用塞來昔布的事情，心血管病專家非常生氣，告訴她：“你絕對不能服用塞來昔布，這會升高你的血壓，引起水鈉潴留，并且加重你的心力衰竭，更不用說對你食管反流的影響了。我嚴肅地禁止你使用這個藥”。貝茜對心血管病專家的反應非常驚訝，就好像是他自己在服用一樣。貝茜淚流滿面、心煩意亂地向我訴說著她的困惑，她確信心血管病專家從醫(yī)學角度給了她最好的建議，但同時她也覺得心血管病專家剝奪了她僅存的生活樂趣，因此她來全科診所征詢我的意見。一位滿懷疑惑離開專家診室的患者，來到全科診室尋求咨詢，這是有特殊原因的。

我時常教導我的學生，要使用“生物-心理-社會”的模式去診斷和管理患者，但可惜的是，這種醫(yī)學模式在當下的醫(yī)院培訓中大部分被忽視了，即使沒有被忽視，也會被過度專科化，以致于心血管病專家不再關心患者是一個整體，而僅僅關注某個特定器官或系統(tǒng)。

我十分理解貝茜的困境，知道需要為她最大限度地保留生活樂趣，這就需要在醫(yī)學決策上做出妥協(xié)。我承認塞來昔布可能會給貝茜帶來危險，但這也可以通過控制和合理使用藥量來調整。因此，我建議貝茜在打高爾夫球賽的當天及前2天服藥，同時服用半片呋塞米，并密切關注自身癥狀，監(jiān)測體質量和血壓。如果出現(xiàn)體質量增加超過1 kg，或者血壓超過140/90 mm Hg（1 mm Hg=0.133 kPa），就需要及時聯(lián)系我。同時，我也建議她把打高爾夫的時間從1周2場改為1周1場，或者2周1場。當時，貝茜已經在服用質子泵抑制劑（PPI）類藥物，希望她的胃食管反流能夠得到控制。貝茜同意這個方案，我提醒她需要每個月復診1次。之后，貝茜的高爾夫球技大漲，完成9洞也不再是個挑戰(zhàn)。

3個月后，我聽到了從候診室傳來的笑聲和歡呼聲。是生日慶祝會嗎？不，這是貝茜在展示她的高爾夫球杯。我從未忘記她的話：“醫(yī)生，只有您在關心我，心血管病專家只關注我的心臟”。還原論已經不合適了，現(xiàn)在是迎接全科醫(yī)學的時代！

譯者注：（1）還原論（Reductionism）：是一種理解復雜事物本質的方法，即將復雜事物簡化為其各部分間的相互作用，也可以被描述為一個復雜的系統(tǒng)只不過是其各部分的總和的哲學立場。本文中喻指心血管病專家的思維方式和做法，這與全科醫(yī)生的做法是相反的。（2）社區(qū)高爾夫球場：在澳大利亞的社區(qū)會經常見到高爾夫球場，通常有3種。一種是練習場，供初學者使用；一種是9洞場，以老年人鍛煉身體為主；一種是18洞場，可以兼用于鍛煉和比賽。

志謝：特別感謝原文出版者《The Medical Republic》同意將此文編譯后刊登于《中國全科醫(yī)學》。

"Doctor you look after me. My cardiologist just looks after my heart".

These were the words Bessie uttered as she proudly displayed her trophy——a mounted golf ball with which she scored a hole in one on the par three, 130 m, eighth hole at her local course.

Scoring a hole in one is an achievement for any golfer at any stage in life. What made Bessie's achievement more noteworthy was that she was 84 years old and being treated for cardiac failure and osteoarthritis of her hips and knees.

I had looked after Bessie, as well as her late husband,for more than 20 years. John passed away 12 months before Bessie's momentous achievement. A keen golfer himself, he would have been extremely proud of her achievement.

Bessie had a multitude of complaints which included hypertension, ischaemic heart disease (treated with stents)aortic stenosis, gastro-oesophageal reflux and osteoarthritis of hips and knees. She had a right hip replacement and was contemplating replacement of her left hip.

Had Bessie been alive today, she may well have had her aortic valve replaced though a transcatheter aortic valve implantation which might have overcome the objections that she was medically unfit to survive open heart surgery. As it stood, Bessie had already had two admissions to hospital with acute pulmonary oedema associated with chest infections.

Following John's death, Bessie felt overwhelmed with all the legal and accounting matters that she had to attend to.John had been a chief executive of a large food-distributing company prior to retiring and had always taken care of all financial matters.

Six months after John's death, Bessie decided to start playing golf again, having given it away a year earlier to look after John during his terminal illness. She found herself able to manage nine holes without too much effort from a cardiorespiratory perspective. But her knees and left hip caused considerable pain after three holes.

This was debilitating and depressing. Golf was not only a useful form of exercise, it also was an opportunity for social engagement and was emotionally and spiritually uplifting. Being unable to complete a round once a week,let alone twice, as she had hoped for, meant a major source of enjoyment was gone and the quality of her life was consequently diminished.

John had been taking celecoxib for his joint pains.Bessie decided to try John's celecoxib a day or two before the golf games, and on the morning of the game. She found that she could get through the game comfortably if she did this.

During a visit to her cardiologist she mentioned the celecoxib. He was most upset. "You must never take celecoxib. It will raise your blood pressure, cause fluid retention and worsen your heart failure, not to mention the effect on your reflux. I really forbid you to use it", the cardiologist told her.

Bessie was quite surprised by his reaction. It was as if he was taking it personally.

Bessie was tearful and distraught as she explained her predicament to me. She was sure the cardiologist was acting in her best interests from a medical perspective, but at the same time she felt he was removing one of the few pleasures she had left. She sought my advice-not an unusual reason for a GP consultation following patients leaving specialists'rooms in a confused state.

We teach our medical students to take a bio-psychosocial approach to diagnosis and management. It is a pity that much of this is lost in contemporary hospital training, or if not lost, is compartmentalised so specialists no longer care for the whole person, but for only for a particular organ or system.

Fully appreciating Bessie's dilemma, I felt it was time to compromise on guidelines in the interest of her enjoyment of life. I acknowledged the possible dangers of celecoxib,but felt that these could be modified through controlled and judicious use of the drug. I suggested that on the two or three days she takes celecoxib, that she should take an extra half a furosemide and monitor her symptoms over this period, as well as her weight and blood pressure, using her home blood pressure machine and contact me if she gained a kilogram or more, or if her blood pressure went beyond 140/90 mm Hg.

I also advised her to restrict her golf to one day a week instead of two, or one day a fortnight.

Bessie was already taking a PPI, so hopefully her reflux would be controlled. She agreed to this compromise, and I continued to see her on a monthly basis. Her golf had never been better and nine holes were no longer a challenge.

Three months later I heard laughter and cheering in the waiting room. Was it birthday celebrations, perhaps?

No, it was Bessie showing off her golfing trophy. I have never forgotten her remark: "Doctor you look after me. My cardiologist just looks after my heart".

Surely reductionism has gone too far. It is time to celebrate the generalist.