《The Medical Republic》案例分享
——發(fā)熱管理的文化沖突

Leon Piterman，邱珊嬌（譯），黃文靜（譯），楊輝（譯）

我們生活在一個多元文化的社會，超過四分之一的人口出生在國外，包括我自己。近期的人口普查數(shù)據(jù)顯示，我們的人口組合方式正在發(fā)生改變，越來越多來自中國、印度以及中東的移民抵達澳大利亞的海岸。生活在這里的大部分成年人都體驗到了移民政策帶來的好處，包括文化、美食、時尚等各方面。小的時候，當?shù)夭宛^的菜單上只能看到炸魚、薯條、牛排及雞蛋，但如今，在離我住所幾步遠的距離內，就有來自十幾個國家、萬花筒般多種多樣的餐館和美食可以選擇。

移民也給澳大利亞帶來了各種各樣的健康理念，有的時候這些與病因或疾病管理有關的健康理念，會與傳統(tǒng)的西方教學中傳授的理念發(fā)生沖突。當然，在一個多元文化的社區(qū)中，全科醫(yī)生不可能完全理解每一種文化的健康理念和做法，如被惡魔的眼睛看到、被別人詛咒、被冷風吹著就能使人患病，或者把酒精敷在頸部可以治療呼吸系統(tǒng)感染、拔罐治療、各種草藥治療等。

以患者為中心的全科服務，要求全科醫(yī)生要詢問患者的健康理念，用尊重的態(tài)度聆聽患者的訴求，并根據(jù)自身的專業(yè)知識以及掌握的診斷依據(jù)，為患者提供恰當?shù)闹委熞庖?。不過正如下述這個困擾了我?guī)资甑陌咐故镜哪菢?，說起來容易，做起來并非總是那么簡單。

克里斯托斯的故事

在我剛從事全科醫(yī)療行業(yè)不久，當?shù)氐囊粋€希臘家庭打電話要求我提供家庭訪視服務，因為他們9個月大的嬰兒克里斯托斯出現(xiàn)了發(fā)熱和嘔吐癥狀。我在家門口見到了擔心和流淚的患兒母親，她把我從門口帶進臥室。家人為了給克里斯托斯保暖，在他身上蓋了好幾層毯子。臥室里人很多，有患兒父母，也有患兒的爺爺、奶奶、外公、外婆，他們用充滿疑慮的眼神看著我這位年輕的全科醫(yī)生。

我當時覺得，這是一個展示技術水平的好機會?；純嚎雌饋硇枰禍?，我迅速拿掉了蓋在患兒身上的毯子，讓家屬拿來冷海綿為他降溫，同時進行病史采集，并對赤裸的患兒進行體格檢查。我注意到在我用微溫的海綿給患兒擦身的時候，他的祖父母們面露驚慌，而當我剛做完這些處理時，克里斯托斯就出現(xiàn)了一次抽搐癥狀。突然間，我覺得我面對的不僅是一個病重的嬰兒，還有一屋子會哭泣和尖叫的患兒家屬。毫無疑問，他們認為是我的治療方法引起了孩子抽搐。

抽搐持續(xù)了幾分鐘，但卻讓人覺得似乎非常漫長。在我來之前，患兒是被喂過奶的，而且肯定嘔吐過。但我更擔心接下來的嘔吐和誤吸。當患兒的父親呼叫救護車時，我在患兒旁邊照顧他。抽搐發(fā)作結束后，我鼓起勇氣給他的家屬解釋這可能只是單純的高熱驚厥，但必須排除腦膜炎的可能。

救護車將患兒接走后，我打電話給兒童醫(yī)院的接診醫(yī)生，解釋了剛才出現(xiàn)的問題，并向她尋求對我困境的同情。但不幸的是，沒有人同情我。我備感受創(chuàng)，并且需要找人傾訴。回到診所后，我的同事都已經下班回家了，幸好還有一位年紀較大的接診員在，他給我沖了一杯咖啡。但這個時候，一杯尊尼獲加或許對我更有用。

我一夜無眠，早上一起床就打電話到醫(yī)院。獲悉患兒腰椎穿刺結果無異常，同時長出了皮疹，是典型的麻疹。為什么？為什么早期診斷如此困難？克里斯托斯在醫(yī)院住了3 d，出院時醫(yī)院建議他留在家里并采取隔離措施，由我或另外一位全科醫(yī)生進行復查，2周后回醫(yī)院復診。我有些惶恐地敲開了克里斯托斯的家門。這次，他的祖父母們不在，我想如果他們在的話，是不會允許我進去的。

全科醫(yī)生和專科醫(yī)生一樣，都害怕誤診、誤治，而且會擔心被患者及其家屬投訴，這是醫(yī)生的主要壓力來源。上述案例中，患兒的健康結局是理想的，但實際上這個案例給我個人帶來的影響很大，影響了我之后對患兒的管理方式，特別是那些文化背景不同的患兒。我們都認為醫(yī)生們提供的是循證醫(yī)學服務，但當面對另一種文化的相反證據(jù)時，循證醫(yī)學的實踐往往會遇到障礙。保持寬容和無偏見，這說起來容易，但做起來難。

譯者注：尊尼獲加（Johnny Walker），著名的蘇格蘭威士忌品牌。

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》。

We live in a multicultural society with over a quarter of our population, including me, born overseas. Our recent census data also indicates that the population mix is changing with more migrants coming from China, India and the Middle East, to our shores.

Many of us who have lived here most of our adult life have experienced the benefits of migration. These include culture, cuisine and fashion, to mention just a few.

As a child, the only items I witnessed on the menu at the local restaurant were fish and chips or steak and eggs.I am now presented with a kaleidoscope of restaurants and cuisine choices from a dozen countries within a short walk from where I live.

Migrants to Australia also bring with them a plethora of health beliefs. Occasionally these belief systems around the causation of disease or its management will collide with traditional western teaching.

It is, of course, impossible for GPs practising in a multicultural community to understand every culture's health beliefs and practices, such as diseases caused by the evil eye, a curse, a cold wind, and treatments including alcohol compresses to the neck for respiratory infection, cupping and a range of herbal remedies.

Naturally, being patient-centred requires us to inquire about the patient's health beliefs, to listen respectfully, and,at the same time, express an opinion based on our knowledge and the evidence we have for appropriate treatment.

This is not always simple as the case below, which has troubled me for decades, illustrates.

The Story of Christos

Soon after commencing general practice, I was called to the home of a local Greek family worried about fever and vomiting affecting a nine-month old child. I was met at the door by the tearful and worried mother, who ushered me into the bedroom where baby Christos was concealed under a mountain of blankets designed to keep him warm.

The bedroom was crowded with his parents, and two sets of grandparents, looking very suspiciously at this young GP.

Here was an opportunity to apply my craft. The baby needed to be cooled. I quickly removed the blankets and asked for a cold sponge to cool the baby down while I took a history and conducted a physical examination on the now naked child.

I noted the look of horror on the face of the grandparents as I applied a tepid sponge. No sooner had I done this, than Christos had a convulsion. I was suddenly confronted not only with a very sick infant, but also with a room full of crying and screaming family members. There was no doubt in their mind that my treatment had caused the convulsion.

The convulsion lasted several minutes but, of course, it seemed like an eternity. The baby has been given milk before my arrival which he had duly vomited, but I was concerned about further vomiting and aspiration.

I nursed him on the side while his father called the ambulance.

Once the fitting finished, I tried bravely to explain the likelihood that this was simply a febrile convulsion knowing full well that meningitis needed to be excluded. As things settled and the ambulance took over I phoned the admitting officer at the Children's Hospital and explained the nature of the problem and sought sympathy from her about my predicament.

Sadly, none was forthcoming. I felt traumatised and needed to debrief. By the time I returned to the clinic,all my colleagues had gone home. Fortunately, our senior receptionist was still there and offered a coffee. A measure of Johnny Walker might have been more useful.

After a sleepless night, I phoned the hospital. Lumbar puncture was normal. In the meantime, the baby had developed a rash. Typical measles. Why, oh why, is early diagnosis so difficult? Christos spent three days in hospital and was discharged with instructions to remain isolated at home and to be reviewed by me, or another GP, with a follow up at the hospital two weeks later.

It was with some trepidation that I knocked on the door of the family home. On this occasion, the grandparents were not there. I doubt they would have let me in.

GPs, as well as specialists, are haunted by fear of misdiagnosis and mismanagement which, coupled with fear of litigation, are major stressors.

This case, which in fact had a good outcome, had a considerable impact on me and influenced my management of sick children, particularly those from cultural backgrounds different to mine.

We like to think that we practise evidence-based medicine. Doing so in the face of counter evidence from another culture can be confronting.

Remaining tolerant and non-judgmental can be easier said than done.