澳大利亚John Murtagh全科病案研究(五十一)——连续性服务：全科医学的特权

John Murtagh，Hui Yang

译者按：有不少人认为只有在病人生病并寻求医疗服务的时候，才会“遭遇”到医患关系，然而这种理解在全科医学中是错误的。连续性服务是全科医学的精髓。全科医学中的医患关系不同于其他临床专科，这种关系是可以跨越时间的长期关系，并非是因某具体疾病的诊治才建立起的临时关系。甚至，把对某慢性疾病的长期随访理解为连续性，仍不能切实地解释这个词的完整含义。在全科医学的医患关系中，医生可以在不同时间遇到某病人各种不同的急性或慢性、躯体或心理的健康问题，而且医患关系可以牵涉这个病人的配偶，或上推下移到这个病人的长辈和后辈。全科医学中这种独特的医患关系，决定了其连续性服务的属性。医生不仅能够全面地理解病人的身心健康，还能理解病人的家庭，以及导致病人和家庭成员生病的各种危险因素和应激原。Murtagh教授在这里通过2个亲身经历的病案，分析和讨论全科医学连续性服务的本质特征。

回想当年，我刚刚开始给病人看病的时候，就知道一位叫梅维斯的病人。当年她60岁，是一位农民的妻子。她当时找我看病的原因是踝关节扭伤。她说自己踩在了别人吃过的口香糖上，结果脚扭了一下，受了点轻伤。当时检查时发现，她的踝关节很纤细，她说很多女性嫉妒她有很漂亮的踝部。几年后她再来看病，这次的主诉是背痛，并有轻度的坐骨神经痛。检查发现，左腿末梢肌肉组织1度无力，踝关节反射减低。我认为这是S1神经根病导致的。后来她的疼痛和踝关节有所改善。

时间过得很快，转眼就是6个月前发生的事情了。梅维斯的30岁儿子罗伯特找我看病，主诉他从客货两用车后面跳下来后，出现踝关节疼痛。看起来他是一种很普通的受伤，但他出现了腓骨下端骨折，检查还发现他的腿肌肉无力。我观察到他的踝关节部分和他妈妈的踝关节一样细弱。难道他们母子的情况是有联系的吗？是不是我忽略了遗传性的疾病？我坐在椅子上，看着他的两条腿。突然，我明白了！我看到了一双“倒置的香槟酒瓶样的腿”。我以前在书上读到过这种生动的比喻，可是从来没有见过。这下我清楚了，他的病的确与他妈妈的病是有联系的。

这种病的诊断是腓肌萎缩(peroneal muscular atrophy)，也称为夏-马-图三氏综合征(Charcot-Marie-Tooth syndrome)。这个综合征包括周围神经病变，因此梅维斯的神经学症状不是因为她背部的问题引起的。这种病很少见，但这也是全科医学的魅力所在。你不知道下一位病人会给你带来什么样的挑战。现在我知道了，应该关注罗伯特的孩子和其他家庭成员是否也有这种病。

从我上面讲的这个临床故事中，你可以注意到全科医学一些独特和优秀的特征：连续性服务、为家庭服务、为个体服务。监测家庭的遗传性疾病，是连续性服务和家庭服务的一个具体层面。案例中的这个家庭是非常值得分析的，梅维斯是一位喜欢争论的病人，有一次和我争论说不想支付看病的账单，因为我的治疗方案不能治疗她的背痛。

另外一个让我记忆犹新的病人是45岁的奈德，他是一位温顺和温柔的养鸡场场主，他把鸡场打理得井井有条。他在当地很有名气，因为他的鸡在斗鸡比赛中获胜。有一天他来看病，说是因为笨拙地摔了一跤，拇指错位了。他看上去病态明显、身宽体胖、颜面红肿、双眼布满血丝。我给他做体检，发现他肝部中度扩大，血压155/95 mm Hg(1 mm Hg=0.133 kPa)。我怀疑他可能是个重度酗酒的人，然而当我询问他的时候，他矢口否认，“大夫，我只是偶然跟哥们喝点啤酒”。我让他回来复诊，结果他4个月后才再来看病。这次他透露说自己感觉不舒服有好长时间了，消化不良、胃肠胀气、勃起功能障碍。这次测量血压165/100 mm Hg。我告诉他要采取健康的生活方式、多锻炼、健康饮食、不喝酒。但他仍然否认自己喝酒。下次再来看病是在预约日期之前，这次是他的家人带他过来的，家人说他发生了惊恐发作，“他被电击了”。他在一个大铁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时候，外面电闪雷鸣下暴雨，一个闪电击中外面的一颗大松树，树拦腰折断，树上的松果如同雹子一样噼噼啪啪地砸在铁皮屋顶上。这种令人惊悚的声音让他感觉到是他妈妈在责备他偷喝酒，怪罪他整天无所事事。的确，他就是一个酗酒者，而且血压增高也是他酗酒的一个证据。我再安排他做肝功能检查，也证实饮酒导致了肝功能的变化。事实上，我可以持续地观察病人饮酒情况与他血压和肝功能的关系。

连续性服务是全科医学的精髓。全科医学的医患关系是跨越时间的长期关系，并非是因某具体疾病的诊治才建立起的临时关系。在这种关系中，医生可以在不同时间遇到某病人各种不同的健康问题，医生不仅能够全面地理解病人的身心健康，还能理解病人的家庭，以及导致病人和家庭成员生病的各种危险因素和应激原，并掌握病人的工作情况和业余娱乐环境。

无论是全科医生还是在医院里照顾病人的各类健康工作人员，都有促进连续性服务的特权[1]。在临床服务中，有很多促进连续性服务的策略，比如开发和维护比较好的病案系统，特别是病人的个人健康记录；做好病人登记工作，制作和分发病人健康资料，维护和使用病人清单等。上述工作可以通过计算机系统来完成，但最重要的还在于医生要具有与病人良好沟通的技巧，特别是敏锐的观察力、旺盛的好奇心以及体贴地对待病人。

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.