《The Medical Republic》案例分享——为什么全科医生需要时刻保持警惕？WhyGPsNeedtobeEverVigilant?

，邱珊娇(译)，黄文静(译)，杨 辉(译)

·世界全科医学工作瞭望·

《The Medical Republic》案例分享
——为什么全科医生需要时刻保持警惕？WhyGPsNeedtobeEverVigilant?

LeonPiterman1，邱珊娇(译)2，黄文静(译)2，杨 辉(译)1

全科医生；精神分裂症，偏执型

General practitioners;Schizophrenia,paranoid

PITERMAN L.为什么全科医生需要时刻保持警惕？[J]. 邱珊娇，黄文静，杨辉，译.中国全科医学，2017，20(25)：3072-3074.[www.chinagp.net]

PITERMAN L.Why GPs need to be ever vigilant?[J]. QIU S J,HUANG W J,YANG H,translators.Chinese General Practice，2017，20(25)：3072-3074.

全科医生需要为患者诊治各种各样的疾病，我们从不挑选疾病和患者。

在全科医学的定义中包含了综合性服务(comprehensive care)的概念。即使部分全科医生仍有自己的专科兴趣，我们仍期望我们所服务的人群是未经过挑选的，是不分性别、器官系统或病种的。因此，在我们的服务人群中，也包括了慢性心理疾病的患者，如精神分裂症、双相情感障碍、边缘性人格障碍等。

我所在的诊所安排了周末值班，每位医生每5周都会轮到一次周六、日全天值班。这就是所谓的“24 h全科诊所”的雏形，包括个别用大钢琴装饰的诊所。我第一次见到珍妮，就是在我当班的某个周末。珍妮45岁左右，比当时的我年长约10岁，是一位优雅、打扮精心、穿戴奢华的女士。珍妮已经离婚了，当时和她年迈的父亲居住在一起，她的两个孩子已经成年，在外独立生活。她的住址信息显示，她住在城市的富人区。

珍妮的疾病看起来似乎很简单，当时正值“流感季节”，她的症状和体征符合流行性感冒。我给她做出了诊断，而且无论是否管用，给她开了一些抗生素。她想了解我是不是新来的医生，还有是不是打算继续做下去。珍妮走之前的最后一句话让我感到很奇怪，直到我有机会看到了她的病历，才真正理解了那句话的含义。她说：“我希望你不会和比尔医生做同样的事”。

我找出珍妮的病历放在手边，午休的时候开始仔细查看。病历封面上很显眼地写着一行字：“永远不找比尔看病”。比尔是一位与我共事的、经验丰富的全科医生，看上去诚实、博学、敬业、关心他人，简单地说，比尔应该是患者理想的全科医生。为什么要拒绝比尔的服务呢？当我阅读完珍妮的病历，就一切都明白了。珍妮有长期的精神分裂症病史，典型临床表现是被害妄想(encapsulated delusion)。珍妮认为比尔曾经强奸过她，而且认为比尔还会一次又一次地试图潜入她壁垒森严的豪宅去强奸她。我迫不及待地和比尔讨论了珍妮的病情，进一步了解到的情节让人感到悲伤和烦扰。大约是在我给珍妮看病的10年前，比尔给珍妮做了一次巴氏涂片检查。幸运的是，鉴于珍妮有心理健康问题，做检查时请了诊所的护士在场。随后，珍妮向医学委员会举报比尔强奸她。比尔只好在委员会为自己做辩护，这绝不是惬意的经历。珍妮的举报很快就理所应当地被驳回了，但比尔感觉自己遭到了重创、身心俱疲。之后珍妮仍然处于被害妄想之中，她没有接受自己精神分裂症的诊断，拒绝治疗，也不想按照医学委员会的任何决定做出改变。

大约1年以后，我被要求去珍妮家做家庭访视，当我知道我要访视的患者是珍妮的父亲、85岁的布鲁斯时，我松了一口气。布鲁斯一直在接受慢性心力衰竭的治疗。在通过珍妮家前门保安系统的时候，珍妮喝住了流着口水狂吠的德国牧羊犬，我被带进前门，然后上楼梯进入布鲁斯的卧室。走上楼梯的时候，我看到了一把刻意放置在楼梯口的猎枪。在这个人口稠密的近郊，猎杀狐狸和兔子似乎是不可能的。我随口问珍妮，是不是怀疑可能会有入侵者。珍妮说：“就是比尔医生”。她的话让我脊柱僵直、胃肠痉挛。

布鲁斯的卧室非常闷热，我注意到墙上的通风口被报纸盖住了。布鲁斯小声地嘀咕到：“这是为了挡住比尔医生，珍妮真的需要帮助，你了解的”。布鲁斯病得不轻，存在呼吸困难等多种临床症状，表明他的症状加重了，需要住院治疗。我给布鲁斯做了解释，也下楼给等在那里的珍妮做了解释。我联系好当地的一家私立医院，叫了急救车，然后建议珍妮在急救人员到来之前把猎枪收起来。

给布鲁斯做完访视离开珍妮家的时候，我感到既忧心又担心。很显然，珍妮是存在心理健康问题的，是需要帮助的，之前为她做的各种治疗都失败了。同时，我也很担心比尔医生。在一些公众案例中，曾经有偏执型(妄想型)精神障碍患者射杀或刺伤医生的情况。精神分裂症也有很高的自杀危险，虽然珍妮没有表现出抑郁症状，但她幻听到的声音很可能会指导她结束自己的生命。

我和比尔以及诊所的其他同事讨论了我的思考困境，是保护珍妮隐私，还是因为面对迫在眉睫的伤他危险而报告警方。最终，我认为应该向警方报告珍妮的情况，希望警医可以介入，将珍妮强制性地收入当地精神病院进行治疗。警方迅速地采取了行动，收缴了未经注册的非法枪支，然后警医给珍妮安排住院进行精神病学评估。珍妮在精神病院住院治疗4个星期，然后带着抗精神病药物按计划出院。我接到的精神病院报告上写到：虽然珍妮平静了很多，但她丝毫没有改变自己的执念，坚信比尔医生有邪恶行为。深藏的妄想是很难改变的。

值得注意的是，大多数精神分裂症患者是非暴力的，是不会置医生或其他医疗行业人员于危险境地的。然而，目前关于医疗行业人员被袭击的案件数量呈不断上升趋势，尤其是针对急诊科和急诊过程中的医护人员。在我写这篇文章的时候，墨尔本博山医院的一名医生因为在急诊科外遭到袭击而正处于昏迷状态。在此类袭击中，毒品发挥了驱动作用，特别是甲基苯丙胺(冰毒)。因此，我们必须提高警惕，不要使自己暴露于不必要的危险之中。

译者注：被害妄想——妄想是精神疾病患者的一项重要症状，表现为多疑、多虑、胡乱推理和判断、思维障碍，可能伴有幻觉。被害妄想是妄想的常见类型，患者毫无根据地坚信某人(或团体)对自己(或亲人、家庭)进行监视、攻击、迫害(非议、诬陷、暗算、抢劫、强奸等)。患者处于恐惧状态，因此处处防备、生活极度谨慎，对外界极度不信任。因担心被害，患者的生活和社交受到严重影响。被害妄想者可能存在自杀和谋杀企图，这可能受到幻听的指引，因此及时的诊断和治疗非常必要。

志谢：特别感谢原文出版者《The Medical Republic》同意将此文编译后刊登于《中国全科医学》。

GPs care for patients with a range of maladies.We do not pick and choose.

Comprehensive care is embodied in the definition of our discipline,and while some of us have special interests,the expectation is that we will care for an unselected population of patients not defined by gender,organ system or disease.Included in that population are patients with chronic mental illnesses,such as schizophrenia,bipolar disorder or borderline personality disorder.

Our practice ran a weekend roster where one in five weekends someone worked all day Saturday and Sunday.This was before the advent of the so-called "24 hour clinics",including those occasional ones adorned with grand pianos.

It was during one of these weekends that I first met Jenny.She was an attractive,well-groomed,expensively dressed woman in her mid-40s,which was 10 years older than me at that time.She was divorced and lived with her elderly father.Her two adult children lived independently.Her address indicated her abode was in the expensive end of town.

The consultation seemed very straightforward.It was the "flu season" and she had a full house of flu-like symptoms and signs.I offered a diagnosis and,for better or worse,prescribed some antibiotics.She wanted to know if I was new to the clinic and whether or not I intended to stay.Jenny then ended with a remark that I thought strange at the time,but only understood the significance of later when I had time to read through her file.She said:"I hope you don′t go the same way as Dr Bill."

I set her file aside and during the lunch break began to delve into it.Boldly inscribed on the front of the file was a message:"Never to see Dr Bill".Bill was my senior colleague.He seemed honest,knowledgeable,dedicated and caring.In short,he seemed a patient′s ideal GP.

Why would someone be deprived of his services? All was revealed as I read through the notes.Jenny had a long history of schizophrenia.A particular feature of her illness was an encapsulated delusion that Bill had raped her and that he was trying to do this again and again by gaining entry into her well-protected mansion.I could hardly wait until Monday to discuss this case with Bill.

What followed was a sad and disturbing tale.Some 10 years earlier Bill had done a Pap smear on Jenny,fortunately in the presence of the clinic nurse,given the nature of Jenny′s mental-health problems.She subsequently reported him to the Medical Board for raping her.Bill had to defend himself before the board.Never an enjoyable experience.

Naturally,the case was summarily dismissed.But Bill felt traumatised and scarred.And Jenny′s delusions continued.She had never accepted the diagnosis of schizophrenia,had refused treatment and was not going to be influenced by any decisions of a Medical Board to change.

About 12 months later I was asked to do a home visit at Jenny′s place.I was relieved to hear that the patient was Bruce,her 85-year-old father,who had been treated for chronic heart failure.Having worked my way through the security system at the front gate while Jenny restrained a barking,salivating German shepherd dog,I was ushered past the front door and upstairs to Bruce′s bedroom.

I left Jenny′s home deeply worried and concerned.She was clearly mentally unwell and needed help.

As I reached the top of the stairs I noticed a strategically placed shotgun.Shooting foxes and rabbits seemed an unlikely past time in this heavily populated suburb.I flippantly asked Jenny if she was expecting any intruders.She responded,"Only Dr Bill".This sent a shiver down my spine and sparked my irritable bowel into action.

Bruce′s bedroom seemed very stuffy.I noticed the air vents in the walls had been covered over with newspaper.Bruce whispered to me:"It′s to keep Dr Bill out.She really needs help,you know."

Bruce was unwell.He was short of breath and clinical signs were compatible with exacerbation of heart failure.He needed hospital admission.I explained this to him and to Jenny who was waiting downstairs.I arranged this at the local private hospital,called an ambulance and suggested to Jenny that she might remove the shotgun when the ambulance was in attendance.

I left Jenny′s home deeply worried and concerned.She was clearly mentally unwell and needed help.Efforts to convince her of this in the past had failed.

I was just as concerned for the wellbeing of my colleague Dr Bill.There is a history of paranoid patients shooting or stabbing their doctors with some well-publicised cases.Schizophrenia also carries a high risk of suicide,and although Jenny did not appear depressed,voices might have instructed her that she should take her own life.

I discussed my dilemmas with colleagues at the clinic and with Dr Bill,and felt that I needed to report this to the police in the hope that the police surgeon might become involved and Jenny would be compelled to be admitted to the local psychiatric facility.

The police acted quickly,removing the shotgun,which was unlicensed.The police surgeon in attendance arranged for admission for psychiatric assessment.Jenny then spent the next four weeks in hospital and was discharged on antipsychotic medication.The report I received indicated that although she was much calmer,her belief in Dr Bill′s nefarious activities had not changed.Encapsulated delusions are hard to shift.

It is important to remember that most schizophrenic patients are not violent and do not pose a risk to doctors or other health professionals.

We are,however,experiencing record numbers of assaults directed at health professionals,particularly in emergency departments and towards paramedics on the road.

As I write this piece,a surgeon in Melbourne is in a coma,having been assaulted outside the emergency department at Box Hill hospital in Melbourne.

Many of these attacks are fuelled by drugs.In particular,methamphetamine.To be effective,we must remain vigilant and not expose ourselves to unnecessary risk.

(本文编辑：王凤微)

R 749.3

A

10.3969/j.issn.1007-9572.2017.25.002

2017-06-05)

【编者按】 澳大利亚的全科医生具有行业自律性，体现在其自行制定行业标准、自主进行资质考核及自主执业等方面，也体现在《The Medical Republic》这一共享平台上。Leon Piterman是医学学士，医学博士，教育学硕士，英国医生学会会员，澳大利亚全科医生学会会员，Monash University副校长、全科医学教授，从事全科医学临床服务近40年；研究兴趣为慢性病管理、心理健康、医学教育；曾获澳大利亚勋章，医学部医学教育奖，澳大利亚全科医生学会研究奖，香港全科医生学会研究奖等；获多项澳大利亚卫生和医学研究理事会等大型研究项目，发表科学文章和著作章节120余篇，是《全科医学中的精神病学》合作著者。Piterman教授建议我国的全科医生应培养“共和”思想，以为全科医学领域提供更多的平等交流机会。目前Piterman教授定期为《The Medical Republic》撰写文章，本刊深受“医学共和”思想的启发，特邀本刊编委Monash University杨辉教授对Piterman教授的文章进行编译，并进行连载刊登！本期Piterman教授为我们讲述了一例精神分裂症患者的临床处理经过，该例患者有着较为严重的被害妄想，经全科医生充分考虑后，最终借助警察和警医的力量帮助其接受了强制治疗，避免了自杀和他杀事件的发生。Piterman教授提醒全科医生，在临床上为存在精神障碍的患者提供服务时，应提高警惕，如有需要应及时采取强制措施为患者提供治疗，敬请关注！

1.3168MonashUniversity,Melbourne,Australia

2.518003 广东省深圳市，罗湖医院集团黄贝岭社区健康服务中心

注：本文首次刊登于《TheMedicalRepublic》