澳大利亞John Murtagh全科病案研究(五十一)
——連續性服務：全科醫學的特權

John Murtagh，Hui Yang

譯者按：有不少人認為只有在病人生病并尋求醫療服務的時候，才會“遭遇”到醫患關系，然而這種理解在全科醫學中是錯誤的。連續性服務是全科醫學的精髓。全科醫學中的醫患關系不同于其他臨床專科，這種關系是可以跨越時間的長期關系，并非是因某具體疾病的診治才建立起的臨時關系。甚至，把對某慢性疾病的長期隨訪理解為連續性，仍不能切實地解釋這個詞的完整含義。在全科醫學的醫患關系中，醫生可以在不同時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題，而且醫患關系可以牽涉這個病人的配偶，或上推下移到這個病人的長輩和后輩。全科醫學中這種獨特的醫患關系，決定了其連續性服務的屬性。醫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，以及導致病人和家庭成員生病的各種危險因素和應激原。Murtagh教授在這里通過2個親身經歷的病案，分析和討論全科醫學連續性服務的本質特征。

回想當年，我剛剛開始給病人看病的時候，就知道一位叫梅維斯的病人。當年她60歲，是一位農民的妻子。她當時找我看病的原因是踝關節扭傷。她說自己踩在了別人吃過的口香糖上，結果腳扭了一下，受了點輕傷。當時檢查時發現，她的踝關節很纖細，她說很多女性嫉妒她有很漂亮的踝部。幾年后她再來看病，這次的主訴是背痛，并有輕度的坐骨神經痛。檢查發現，左腿末梢肌肉組織1度無力，踝關節反射減低。我認為這是S1神經根病導致的。后來她的疼痛和踝關節有所改善。

時間過得很快，轉眼就是6個月前發生的事情了。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后，出現踝關節疼痛。看起來他是一種很普通的受傷，但他出現了腓骨下端骨折，檢查還發現他的腿肌肉無力。我觀察到他的踝關節部分和他媽媽的踝關節一樣細弱。難道他們母子的情況是有聯系的嗎？是不是我忽略了遺傳性的疾病？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”。我以前在書上讀到過這種生動的比喻，可是從來沒有見過。這下我清楚了，他的病的確與他媽媽的病是有聯系的。

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)。這個綜合征包括周圍神經病變，因此梅維斯的神經學癥狀不是因為她背部的問題引起的。這種病很少見，但這也是全科醫學的魅力所在。你不知道下一位病人會給你帶來什么樣的挑戰。現在我知道了，應該關注羅伯特的孩子和其他家庭成員是否也有這種病。

從我上面講的這個臨床故事中，你可以注意到全科醫學一些獨特和優秀的特征：連續性服務、為家庭服務、為個體服務。監測家庭的遺傳性疾病，是連續性服務和家庭服務的一個具體層面。案例中的這個家庭是非常值得分析的，梅維斯是一位喜歡爭論的病人，有一次和我爭論說不想支付看病的賬單，因為我的治療方案不能治療她的背痛。

另外一個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雞場場主，他把雞場打理得井井有條。他在當地很有名氣，因為他的雞在斗雞比賽中獲勝。有一天他來看病，說是因為笨拙地摔了一跤，拇指錯位了。他看上去病態明顯、身寬體胖、顏面紅腫、雙眼布滿血絲。我給他做體檢，發現他肝部中度擴大，血壓155/95 mm Hg(1 mm Hg=0.133 kPa)。我懷疑他可能是個重度酗酒的人，然而當我詢問他的時候，他矢口否認，“大夫，我只是偶然跟哥們喝點啤酒”。我讓他回來復診，結果他4個月后才再來看病。這次他透露說自己感覺不舒服有好長時間了，消化不良、胃腸脹氣、勃起功能障礙。這次測量血壓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。但他仍然否認自己喝酒。下次再來看病是在預約日期之前，這次是他的家人帶他過來的，家人說他發生了驚恐發作，“他被電擊了”。他在一個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候，外面電閃雷鳴下暴雨，一個閃電擊中外面的一顆大松樹，樹攔腰折斷，樹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到是他媽媽在責備他偷喝酒，怪罪他整天無所事事。的確，他就是一個酗酒者，而且血壓增高也是他酗酒的一個證據。我再安排他做肝功能檢查，也證實飲酒導致了肝功能的變化。事實上，我可以持續地觀察病人飲酒情況與他血壓和肝功能的關系。

連續性服務是全科醫學的精髓。全科醫學的醫患關系是跨越時間的長期關系，并非是因某具體疾病的診治才建立起的臨時關系。在這種關系中，醫生可以在不同時間遇到某病人各種不同的健康問題，醫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，以及導致病人和家庭成員生病的各種危險因素和應激原，并掌握病人的工作情況和業余娛樂環境。

無論是全科醫生還是在醫院里照顧病人的各類健康工作人員，都有促進連續性服務的特權[1]。在臨床服務中，有很多促進連續性服務的策略，比如開發和維護比較好的病案系統，特別是病人的個人健康記錄；做好病人登記工作，制作和分發病人健康資料，維護和使用病人清單等。上述工作可以通過計算機系統來完成，但最重要的還在于醫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.