評(píng)論
打印
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(yī)生沒(méi)能做好全面身體檢查，腹痛病人可能會(huì)死于闌尾破裂。前列腺癌活體組織檢查結(jié)果呈陽(yáng)性，但卻沒(méi)人跟進(jìn)，因?yàn)閷?shí)驗(yàn)室結(jié)果被弄混了。小孩發(fā)燒和出疹被診斷為病毒性疾病，但最后卻發(fā)現(xiàn)是嚴(yán)重得多的細(xì)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(xué)(Johns Hopkins University)研究人員表示，每年有多達(dá)16萬(wàn)名病人因此類致命失誤而出現(xiàn)永久損傷或死亡。研究人員稱，診斷問(wèn)題比其他醫(yī)療失誤更為普遍，而且更容易傷害到病人，同時(shí)它們也是醫(yī)療過(guò)失訴訟的主因，按照2011年美元價(jià)值計(jì)算，它們?cè)?986年至2010年間共計(jì)近390億美元的賠償額中占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，誤診比其他醫(yī)療失誤更容易預(yù)防。現(xiàn)在醫(yī)療機(jī)構(gòu)開(kāi)始采用一系列創(chuàng)新措施來(lái)糾正失誤、偏誤和疏忽等妨礙醫(yī)生做出正確診斷的問(wèn)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(gè)解決辦法是自動(dòng)化──用電腦篩查醫(yī)療記錄從而找出可能的誤診，或提醒醫(yī)生跟進(jìn)標(biāo)有紅色警示的檢查結(jié)果。另一方面是幫助醫(yī)生更準(zhǔn)確診斷疾病和病情的設(shè)備和測(cè)試，還有在醫(yī)生對(duì)病人病情不確定時(shí)給他們建議的網(wǎng)上服務(wù)。
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.
最后還有推動(dòng)醫(yī)療文化的改革。醫(yī)生受到的教導(dǎo)是不能抓住一種診斷不放，而是應(yīng)該在面對(duì)相互沖突的證據(jù)和觀點(diǎn)時(shí)保持開(kāi)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(guó)退伍軍人事務(wù)部(Veterans Administration)資深醫(yī)師、非營(yíng)利研究機(jī)構(gòu)RTI International研究員馬克・格雷伯(Mark Graber)說(shuō)：“誤診可能是我們?cè)卺t(yī)療行業(yè)面臨的最大的病人安全問(wèn)題，現(xiàn)在終于納入到了病人診治質(zhì)量和管理運(yùn)動(dòng)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(yī)療法律下將會(huì)得到大大的推進(jìn)。法規(guī)要求多家醫(yī)療機(jī)構(gòu)協(xié)調(diào)護(hù)理治療，并幫助預(yù)防檢查結(jié)果等關(guān)鍵信息被遺漏，確保病人按照醫(yī)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(guī)模的舉措正在進(jìn)行中。為美國(guó)聯(lián)邦政府提供咨詢的醫(yī)學(xué)研究所(Institute of Medicine)已經(jīng)同意承擔(dān)一項(xiàng)100萬(wàn)美元的有關(guān)誤診對(duì)美國(guó)醫(yī)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?jī)赡昵皠?chuàng)立的改善醫(yī)療診斷協(xié)會(huì)(Society to Improve Diagnosis in Medicine)正在與醫(yī)療認(rèn)證機(jī)構(gòu)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(huì)公之于眾的。另外，協(xié)會(huì)還在設(shè)計(jì)一個(gè)醫(yī)學(xué)院課程表，幫助學(xué)員提高診斷技能并對(duì)他們的能力進(jìn)行評(píng)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(xué)舊金山分校(University of California, San Francisco)醫(yī)藥部副主任羅伯特・瓦赫特(Robert Wachter)說(shuō)，對(duì)診斷失誤進(jìn)行確定和衡量是重要的一個(gè)步驟。他說(shuō)：“目前醫(yī)療改善的激勵(lì)措施沒(méi)有一項(xiàng)是基于醫(yī)生是否做出了正確診斷的。”不過(guò)他又說(shuō)，同樣重要的是，“我們需要鼓勵(lì)從下至上的創(chuàng)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(chuàng)新已經(jīng)開(kāi)始。大型醫(yī)療系統(tǒng)正在篩查他們的電子記錄以查找誤診的跡象。在管理式醫(yī)療行業(yè)巨頭凱澤永久醫(yī)療集團(tuán)(Kaiser Permanente)旗下的南加州永久醫(yī)療機(jī)構(gòu)(Southern California Permanente Medical Group)，其“安全網(wǎng)”(Safety Net)項(xiàng)目會(huì)定期對(duì)其數(shù)據(jù)庫(kù)中360萬(wàn)名會(huì)員進(jìn)行問(wèn)卷調(diào)查，從而捕捉到有可能被遺漏的實(shí)驗(yàn)室結(jié)果及其他數(shù)據(jù)。
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(tǒng)的過(guò)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(jié)果不正常，2,200多名病人隨后有做活體組織檢查。2006至2009年，這些病人中有745人被診斷患有癌癥，而凱澤并未接到有關(guān)遺漏的PSA檢查的過(guò)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(xiàng)目還被用于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(guò)異常肌酸酐檢查結(jié)果發(fā)現(xiàn)的，并且應(yīng)在90天內(nèi)進(jìn)行復(fù)查。2007年至2012年，系統(tǒng)發(fā)現(xiàn)有7,218張做異常檢查的實(shí)驗(yàn)室檢查單未進(jìn)行復(fù)查。其中3,465單在通知病人90天內(nèi)需要復(fù)查后進(jìn)行了復(fù)查，1,768人呈現(xiàn)異常結(jié)果。最后大多數(shù)人，也就是1,624人被診斷為患有腎臟疾病。
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(fù)責(zé)質(zhì)量和臨床分析的區(qū)域醫(yī)學(xué)主任邁克爾・坎特(Michael Kanter)說(shuō)，該系統(tǒng)使得臨床醫(yī)師能夠“盡最大可能回去查找并彌補(bǔ)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(shuō)，由于這種病是慢性病，所以五年沒(méi)有被診斷出來(lái)的人可能并不會(huì)有大礙。同樣的，他說(shuō)，對(duì)于早期前列腺癌來(lái)說(shuō)，“在很多案例中并不意味著病患已經(jīng)危及到了病人，但我們不想因?yàn)橄到y(tǒng)里的某種過(guò)失導(dǎo)致病人對(duì)本應(yīng)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(dāng)然，電子紀(jì)錄并非萬(wàn)應(yīng)良藥，而且還有可能導(dǎo)致信息過(guò)載。去年3月，在《美國(guó)醫(yī)學(xué)會(huì)雜志・內(nèi)科學(xué)》(JAMA Internal Medicine)上發(fā)表的對(duì)美國(guó)退伍軍人事務(wù)部初診醫(yī)師所做的一項(xiàng)調(diào)查顯示，超過(guò)三分之二的醫(yī)師收到的有關(guān)看病的通報(bào)數(shù)量超過(guò)了自己所能有效管理的范圍──這就有可能導(dǎo)致他們遺漏異常的檢查結(jié)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，最佳的解決辦法并不是把海量的信息塞給醫(yī)生，而是為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(diǎn)在于防止在異常檢查結(jié)果的跟進(jìn)過(guò)程中出現(xiàn)危險(xiǎn)性延誤。在一個(gè)試點(diǎn)項(xiàng)目中，退伍軍人事務(wù)部休斯頓分部的研究人員設(shè)計(jì)出了“觸發(fā)”查詢，這是一套規(guī)則，通過(guò)計(jì)算機(jī)確認(rèn)在前列腺和結(jié)腸直腸癌評(píng)估和診斷中可能有延誤的病人的病歷記錄。研究小組負(fù)責(zé)人哈迪普・辛格(Hardeep Singh)表示，記錄包括特定時(shí)期后對(duì)表明有疑似癌癥的異常檢查結(jié)果無(wú)正式跟進(jìn)記載的圖表。辛格是休斯頓Michael E. DeBakey VA Medical醫(yī)學(xué)中心醫(yī)療政策及質(zhì)量主任，以及貝樂(lè)醫(yī)學(xué)院(Baylor College of Medicine)醫(yī)藥學(xué)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(wù)部下屬一家醫(yī)院就診過(guò)病人的近60萬(wàn)份記錄得到了這樣的查詢。辛格博士說(shuō)，使用“觸發(fā)”查詢幫助找到了異常PSA檢查和陽(yáng)性大便潛血檢查，每年可以查到約1,048例異常檢查結(jié)果的后續(xù)跟進(jìn)被延誤或遺漏，以及47例重度癌癥。
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(wù)部資助了一個(gè)隨機(jī)試驗(yàn)，測(cè)試“觸發(fā)”自動(dòng)化監(jiān)測(cè)系統(tǒng)是否能改善五種常見(jiàn)癌癥的及時(shí)診斷和跟進(jìn)。
'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(shuō)：“這個(gè)項(xiàng)目就像是在干草堆中找針，我們利用信息技術(shù)讓干草堆變得越來(lái)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(lái)越多的醫(yī)療系統(tǒng)也開(kāi)始采用電子決策支持程序來(lái)幫助醫(yī)生根據(jù)癥狀和病歷筆記為診斷結(jié)果的可能性進(jìn)行排序。在一個(gè)名為“伊莎貝爾”(Isabel)的程序的研究中，由格雷伯博士帶領(lǐng)的研究小組發(fā)現(xiàn)，刊登在《新英格蘭醫(yī)學(xué)雜志》(New England Journal of Medicine)上的50個(gè)疑難案例中的關(guān)鍵臨床特征輸入系統(tǒng)時(shí)，系統(tǒng)96%的情況下都給出了正確的診斷。美國(guó)內(nèi)科學(xué)委員會(huì)(The American Board of Internal Medicine)正在研究如何將“伊莎貝爾”與醫(yī)師技能和知識(shí)的評(píng)估聯(lián)系起來(lái)。
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(gè)名叫DXplain的系統(tǒng)是由波士頓麻省總醫(yī)院(Massachusetts General Hospital)開(kāi)發(fā)的。去年的一項(xiàng)研究顯示，該系統(tǒng)能顯著增強(qiáng)第一年住院醫(yī)師診斷的準(zhǔn)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(fù)責(zé)DXplain項(xiàng)目的是哈佛大學(xué)(Harvard)臨床副教授、麻省總醫(yī)院高級(jí)計(jì)算機(jī)科學(xué)家愛(ài)德華・霍弗(Edward Hoffer)，他說(shuō)，當(dāng)前的目標(biāo)是讓DXplain通過(guò)電子病例記錄系統(tǒng)向醫(yī)生“推送”診斷建議，而不是要求醫(yī)生發(fā)起查詢，有些醫(yī)生仍然不愿意主動(dòng)查詢。霍弗博士說(shuō)：“我們要把重點(diǎn)放在處理醫(yī)生自以為知道診斷結(jié)果、但事實(shí)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(shè)備也有望對(duì)確認(rèn)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(shè)備和實(shí)驗(yàn)室結(jié)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(fā)現(xiàn)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(jìn)入美國(guó)市場(chǎng)的MelaFind為例。皮膚科醫(yī)生可使用該設(shè)備無(wú)創(chuàng)檢查在皮下深達(dá)2.5毫米處的痣，從而檢測(cè)“組織破壞”的水平。“組織破壞”的水平可反應(yīng)不規(guī)則生長(zhǎng)模式，不規(guī)則生長(zhǎng)模式是黑色素瘤等最致命癌癥的跡象。
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(nèi)卡斯(Macrene Alexiades-Armenakas)說(shuō)，她用MelaFind證實(shí)某顆痣是否需要去除，以及對(duì)多顆異常痣的“組織破壞”水平進(jìn)行排序。她說(shuō)，有時(shí)候，當(dāng)其他醫(yī)生或病人對(duì)某顆痣表示擔(dān)心時(shí)，MelaFind會(huì)支持“良性痣的臨床診斷，從而讓他們省去了活體組織檢驗(yàn)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(nèi)卡斯博士說(shuō)，不過(guò)這樣的設(shè)備永遠(yuǎn)替代不了全面的體檢以及訓(xùn)練有素的眼睛和仔細(xì)的后續(xù)跟進(jìn)。她說(shuō)：“這些診斷工具是提高準(zhǔn)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(guò)改善溝通來(lái)改善診斷質(zhì)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(jī)構(gòu)在促使病人在診斷過(guò)程中更積極主動(dòng)，鼓勵(lì)病人說(shuō)出自己的癥狀并且詢問(wèn)醫(yī)生：“這還會(huì)是什么病？”凱澤永久的一個(gè)試點(diǎn)項(xiàng)目為病人提供小冊(cè)子，鼓勵(lì)他們思考并寫下自己的癥狀以及他們的擔(dān)憂或恐懼，鼓勵(lì)他們提出具體的問(wèn)題，從而確保他們理解自己的診斷結(jié)果以及下一步需要采取的步驟。
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(shí)，醫(yī)學(xué)院也在教導(dǎo)醫(yī)生們更加虛心聽(tīng)取病人的意見(jiàn)并避免“錨定”，即習(xí)慣集中在一種診斷上，不考慮其他可能的情形，還要避免“過(guò)早下結(jié)論”，即根本不把正確診斷作為一種可能性進(jìn)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(dá)爾豪斯大學(xué)(Dalhousie University)去年創(chuàng)立了批判性思考項(xiàng)目。該項(xiàng)目旨在幫助學(xué)員退一步思考，審視偏誤會(huì)對(duì)自己的思維有何影響。該項(xiàng)目由帕特・克羅斯克里(Pat Croskerry)開(kāi)發(fā)，他是一名以研究診斷過(guò)程中認(rèn)知錯(cuò)誤的影響而聞名的醫(yī)師。項(xiàng)目列出了50種不同種類可能導(dǎo)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(xiàng)目被整合到了達(dá)爾豪斯大學(xué)醫(yī)學(xué)院的四年制教學(xué)中。學(xué)生們會(huì)學(xué)習(xí)很多案例，比如呼吸短促的精神病人被認(rèn)為只是焦慮發(fā)作，醫(yī)生沒(méi)注意到她是服用避孕藥的吸煙者，這導(dǎo)致她體內(nèi)產(chǎn)生血塊，隨后血塊到了肺里，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.'
克羅斯克里博士說(shuō)：“如果我們教會(huì)醫(yī)生們?nèi)绾我愿行缘乃季S思考，他們就會(huì)更有效地給病人看病并做出正確診斷。”
