醫患關係曖昧 怎樣避免誤診

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.
如果醫生沒能做好全面身體檢查，腹痛病人可能會死於闌尾破裂。前列腺癌活體組織檢查結果呈陽性，但卻沒人跟進，因爲實驗室結果被弄混了。小孩發燒和出疹被診斷爲病毒性疾病，但最後卻發現是嚴重得多的細菌性腦膜炎。

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.
約翰霍普金斯大學(Johns Hopkins University)研究人員表示，每年有多達16萬名病人因此類致命失誤而出現永久損傷或死亡。研究人員稱，診斷問題比其他醫療失誤更爲普遍，而且更容易傷害到病人，同時它們也是醫療過失訴訟的主因，按照2011年美元價值計算，它們在1986年至2010年間共計近390億美元的賠償額中佔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，誤診比其他醫療失誤更容易預防。現在醫療機構開始採用一系列創新措施來糾正失誤、偏誤和疏忽等妨礙醫生做出正確診斷的問題。

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.
其中一個解決辦法是自動化──用電腦篩查醫療記錄從而找出可能的誤診，或提醒醫生跟進標有紅色警示的檢查結果。另一方面是幫助醫生更準確診斷疾病和病情的設備和測試，還有在醫生對病人病情不確定時給他們建議的網上服務。

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.
最後還有推動醫療文化的改革。醫生受到的教導是不能抓住一種診斷不放，而是應該在面對相互衝突的證據和觀點時保持開放的思想。

'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.
美國退伍軍人事務部(Veterans Administration)資深醫師、非營利研究機構RTI International研究員馬克・格雷伯(Mark Graber)說：“誤診可能是我們在醫療行業面臨的最大的病人安全問題，現在終於納入到了病人診治質量和管理運動中。”

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.
這些舉措在最新的醫療法律下將會得到大大的推進。法規要求多家醫療機構協調護理治療，並幫助預防檢查結果等關鍵信息被遺漏，確保病人按照醫生的推薦去找專家。

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.
另外還有一些大規模的舉措正在進行中。爲美國聯邦政府提供諮詢的醫學研究所(Institute of Medicine)已經同意承擔一項100萬美元的有關誤診對美國醫療影響的研究。

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，格雷伯博士兩年前創立的改善醫療診斷協會(Society to Improve Diagnosis in Medicine)正在與醫療認證機構及安全組織合作，研究確定和衡量診斷失誤的方法，通常情況下除非有人起訴，否則誤診是不會公之於衆的。另外，協會還在設計一個醫學院課程表，幫助學員提高診斷技能並對他們的能力進行評估。

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.'
加州大學舊金山分校(University of California, San Francisco)醫藥部副主任羅伯特・瓦赫特(Robert Wachter)說，對診斷失誤進行確定和衡量是重要的一個步驟。他說：“目前醫療改善的激勵措施沒有一項是基於醫生是否做出了正確診斷的。”不過他又說，同樣重要的是，“我們需要鼓勵從下至上的創新”。

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.
創新已經開始。大型醫療系統正在篩查他們的電子記錄以查找誤診的跡象。在管理式醫療行業巨頭凱澤永久醫療集團(Kaiser Permanente)旗下的南加州永久醫療機構(Southern California Permanente Medical Group)，其“安全網”(Safety Net)項目會定期對其數據庫中360萬名會員進行問卷調查，從而捕捉到有可能被遺漏的實驗室結果及其他數據。

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.
在首次使用該系統的過程中，一位病例管理員查到8,076名病人的前列腺癌PSA檢查結果不正常，2,200多名病人隨後有做活體組織檢查。2006至2009年，這些病人中有745人被診斷患有癌症，而凱澤並未接到有關遺漏的PSA檢查的過失起訴。

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.
該項目還被用於查找患有未被診斷的腎臟疾病的病人。腎臟疾病通常是通過異常肌酸酐檢查結果發現的，並且應在90天內進行復查。2007年至2012年，系統發現有7,218張做異常檢查的實驗室檢查單未進行復查。其中3,465單在通知病人90天內需要複查後進行了複查，1,768人呈現異常結果。最後大多數人，也就是1,624人被診斷爲患有腎臟疾病。

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.'
負責質量和臨牀分析的區域醫學主任邁克爾・坎特(Michael Kanter)說，該系統使得臨牀醫師能夠“盡最大可能回去查找並彌補所有的失誤”。

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.'
坎特博士說，由於這種病是慢性病，所以五年沒有被診斷出來的人可能並不會有大礙。同樣的，他說，對於早期前列腺癌來說，“在很多案例中並不意味着病患已經危及到了病人，但我們不想因爲系統裏的某種過失導致病人對本應知道的信息不知情”。

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.
當然，電子紀錄並非萬應良藥，而且還有可能導致信息過載。去年3月，在《美國醫學會雜誌・內科學》(JAMA Internal Medicine)上發表的對美國退伍軍人事務部初診醫師所做的一項調查顯示，超過三分之二的醫師收到的有關看病的通報數量超過了自己所能有效管理的範圍──這就有可能導致他們遺漏異常的檢查結果。

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.
有研究人員表示，最佳的解決辦法並不是把海量的信息塞給醫生，而是爲他們提供第二雙眼睛查找他們有可能遺漏的東西。

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.
目前的重點在於防止在異常檢查結果的跟進過程中出現危險性延誤。在一個試點項目中，退伍軍人事務部休斯頓分部的研究人員設計出了“觸發”查詢，這是一套規則，通過計算機確認在前列腺和結腸直腸癌評估和診斷中可能有延誤的病人的病歷記錄。研究小組負責人哈迪普・辛格(Hardeep Singh)表示，記錄包括特定時期後對錶明有疑似癌症的異常檢查結果無正式跟進記載的圖表。辛格是休斯頓Michael E. DeBakey VA Medical醫學中心醫療政策及質量主任，以及貝樂醫學院(Baylor College of Medicine)醫藥學助理教授。

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，在退伍軍人事務部下屬一家醫院就診過病人的近60萬份記錄得到了這樣的查詢。辛格博士說，使用“觸發”查詢幫助找到了異常PSA檢查和陽性大便潛血檢查，每年可以查到約1,048例異常檢查結果的後續跟進被延誤或遺漏，以及47例重度癌症。The VA has funded a randomized trial to test whether an automated surveillance system of triggers can improve timely diagnosis and follow-up for five common cancers.
退伍軍人事務部資助了一個隨機試驗，測試“觸發”自動化監測系統是否能改善五種常見癌症的及時診斷和跟進。

'This program is like finding needles in a haystack, and we use information technology to make the haystack smaller and smaller so it's easier to find the needles,' Dr. Singh says.
辛格博士說：“這個項目就像是在乾草堆中找針，我們利用信息技術讓乾草堆變得越來越小，這樣就更容易找到針。”

More health-care systems are also turning to electronic decision-support programs that help doctors rank possible diagnoses by likelihood based on symptoms and notes in the medical record. In a study of one such system, called Isabel, researchers led by Dr. Graber found that it provided the correct diagnosis 96% of the time when key clinical features from 50 challenging cases reported in the New England Journal of Medicine were entered into the system. The American Board of Internal Medicine is studying how Isabel could be linked to assessments of physician skill and knowledge.
越來越多的醫療系統也開始採用電子決策支持程序來幫助醫生根據症狀和病歷筆記爲診斷結果的可能性進行排序。在一個名爲“伊莎貝爾”(Isabel)的程序的研究中，由格雷伯博士帶領的研究小組發現，刊登在《新英格蘭醫學雜誌》(New England Journal of Medicine)上的50個疑難案例中的關鍵臨牀特徵輸入系統時，系統96%的情況下都給出了正確的診斷。美國內科學委員會(The American Board of Internal Medicine)正在研究如何將“伊莎貝爾”與醫師技能和知識的評估聯繫起來。

Another system, DXplain, developed at Massachusetts General Hospital in Boston, was shown in a study last year to significantly improve diagnostic accuracy among first-year medical residents.
另外一個名叫DXplain的系統是由波士頓麻省總醫院(Massachusetts General Hospital)開發的。去年的一項研究顯示，該系統能顯著增強第一年住院醫師診斷的準確性。

Edward Hoffer, associate clinical professor at Harvard and senior computer scientist at Mass General who leads the DXplain program, says the aim now is to have DXplain 'push' diagnostic suggestions to physicians through an electronic-medical-records system rather than requiring doctors to initiate a query, which some are still reluctant to do. 'We have to focus our attention on dealing with situations where doctors think they know what the diagnosis is, but they don't,' Dr. Hoffer says.
負責DXplain項目的是哈佛大學(Harvard)臨牀副教授、麻省總醫院高級計算機科學家愛德華・霍弗(Edward Hoffer)，他說，當前的目標是讓DXplain通過電子病例記錄系統向醫生“推送”診斷建議，而不是要求醫生髮起查詢，有些醫生仍然不願意主動查詢。霍弗博士說：“我們要把重點放在處理醫生自以爲知道診斷結果、但事實上不知道的情況。”

New devices also hold promise for confirming a diagnosis and avoiding unnecessary tests. A number of companies are rushing to provide aids such as portable diagnostic equipment and lab tests that can analyze tiny samples of blood and other bodily fluids quickly to detect disease.
新設備也有望對確認診斷和避免不必要的檢查提供幫助。多家公司正加速提供便攜式診斷設備和實驗室結果等援助，可以幫助分析微小的血樣及其他體液，從而迅速發現疾病。

Consider MelaFind, which came to market in the U.S. in 2011. The device allows dermatologists to noninvasively examine moles as deep as 2.5 millimeters beneath the surface to gauge the level of 'disorganization,' an indicator of irregular growth patterns that are a sign of melanoma, among the deadliest cancers.
以2011年進入美國市場的MelaFind爲例。皮膚科醫生可使用該設備無創檢查在皮下深達2.5毫米處的痣，從而檢測“組織破壞”的水平。“組織破壞”的水平可反應不規則生長模式，不規則生長模式是黑色素瘤等最致命癌症的跡象。

New York dermatologist Macrene Alexiades-Armenakas says she uses MelaFind to confirm that a mole is to be removed and prioritize the level of disorganization in multiple abnormal moles. In some cases, when another doctor or the patient has been concerned about a mole, MelaFind supported 'clinical diagnosis of a benign mole, thereby sparing them a biopsy,' she says.
紐約皮膚專家麥克蘭納・亞歷克西亞德斯-阿門內卡斯(Macrene Alexiades-Armenakas)說，她用MelaFind證實某顆痣是否需要去除，以及對多顆異常痣的“組織破壞”水平進行排序。她說，有時候，當其他醫生或病人對某顆痣表示擔心時，MelaFind會支持“良性痣的臨牀診斷，從而讓他們省去了活體組織檢驗的程序”。

But such devices will never replace a thorough physical exam with a trained eye and careful follow-up, says Dr. Alexiades-Armenakas: 'These diagnostic tools are aids to increase our accuracy and adjuncts to good physical diagnosis, not a substitute.'
亞歷克西亞德斯-阿門內卡斯博士說，不過這樣的設備永遠替代不了全面的體檢以及訓練有素的眼睛和仔細的後續跟進。她說：“這些診斷工具是提高準確性和好的檢體診斷的輔助手段，而不是替代手段。”

Some efforts to cut down on errors take a different route altogether -- and try to improve diagnoses by improving communication.
有些嘗試減少失誤的措施則走的是完全不同的路線──嘗試通過改善溝通來改善診斷質量。

For instance, there's a push to get patients more engaged in the diagnostic process, by encouraging them to speak up about their symptoms and ask the doctor, 'What else could this be?' At Kaiser Permanente, a pilot program provides patients with a pamphlet that encourages them to think about and write down their symptoms and what concerns or fears they have, encouraging them to ask specific questions to be sure they understand their diagnosis and the next steps they must take.
例如，有的機構在促使病人在診斷過程中更積極主動，鼓勵病人說出自己的症狀並且詢問醫生：“這還會是什麼病？”凱澤永久的一個試點項目爲病人提供小冊子，鼓勵他們思考並寫下自己的症狀以及他們的擔憂或恐懼，鼓勵他們提出具體的問題，從而確保他們理解自己的診斷結果以及下一步需要採取的步驟。

Medical schools, meanwhile, are teaching doctors to be more receptive to patient input and avoid 'anchoring,' the habit of focusing on one diagnosis and excluding other possible scenarios, and 'premature closure,' not even considering the correct diagnosis as a possibility.
與此同時，醫學院也在教導醫生們更加虛心聽取病人的意見並避免“錨定”，即習慣集中在一種診斷上，不考慮其他可能的情形，還要避免“過早下結論”，即根本不把正確診斷作爲一種可能性進行考慮。

The Critical Thinking program at Dalhousie University in Halifax, Nova Scotia, established last year, aims to help trainees step back and examine how biases may affect their thinking. Developed by Pat Croskerry, a physician known for his research on the role of cognitive error in diagnosis, it uses a list of 50 different types of bias that may lead to diagnostic error.
加拿大新斯科舍省哈利法克斯(Halifax)的達爾豪斯大學(Dalhousie University)去年創立了批判性思考項目。該項目旨在幫助學員退一步思考，審視偏誤會對自己的思維有何影響。該項目由帕特・克羅斯克裏(Pat Croskerry)開發，他是一名以研究診斷過程中認知錯誤的影響而聞名的醫師。項目列出了50種不同種類可能導致診斷失誤的偏誤。

The program is being integrated throughout four years of the medical school. Students study cases such as a psychiatric patient with shortness of breath who was assumed to be merely having an anxiety attack; doctors overlooked that she was a smoker on birth-control pills, a risk for the blood clot that later traveled to her lung and killed her.
該項目被整合到了達爾豪斯大學醫學院的四年制教學中。學生們會學習很多案例，比如呼吸短促的精神病人被認爲只是焦慮發作，醫生沒注意到她是服用避孕藥的吸菸者，這導致她體內產生血塊，隨後血塊到了肺裏，最終令她喪命。

'If we can teach physicians how to think more critically,' Dr. Croskerry says, 'they would be more effective in delivering good care and arriving at the right diagnosis.'
克羅斯克裏博士說：“如果我們教會醫生們如何以更批判性的思維思考，他們就會更有效地給病人看病並做出正確診斷。”