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从“医者仁心”看中美医疗体系的一些异同
1. On DNR, DNI:
At the beginning of the show, Dr. Zhong encountered a pt. who appears that may have signed up DNR and DNI (Do not resuscitate and Do not intubate). This is often seen here in the U.S. Once those end stage patient or their proxy or Power of Attorney (POA) made the decision with the treating physician, we must follow the order and will not resuscitate. However, that does not mean DO NOT Treat. If any difficult situation arise, there is usually a Ethic Committee in house on call or obtain a court order to proceed in some extreme conditions.
At the end of the show, on Dr. Ding's death, it seems that the doctors observed the wishes of his DNI and DNR.
2. Close to the end of the show, Dr. Wu Mingxun asked why Dr. Zhong not dating his patient (develop a romance relationship with his patient). In the U.S., this is against the code of conduct of physicians set out by AMA (American Medical Association). It is considered unethical to develop a romance with his or her patients due to unequal power. There is considerable involvement of trust, intimacy, and emotional dependence from the patient towards the doctors and not mention that the doctor has the detailed personal information of the patient which is not fair at all in a relationship from the beginning. This is not fair for the patient and will potentially compromise the care of the patient.
3. In the E.R.: We have hospital security team usually quite efficient and very effective in dealing with the kind of chaos that may arise. This is not only for the security of the medical staff but also for all the patients in the E.R. to ensure they are treated promptly and equally according to the urgency nature of patient's condition.
4. In the O.R.: it seems that Chinese surgeons at least in this show (except Wu Mingxun who wears a eye goggle at all his surgeries)are lacking of protection during the operation: no face shield or eye protection wear at least. The splash of blood, deris, or body fluid places surgeons in considerable risk of communicable disease. Also, the surgeons are still wearing slippers in the O.R. with barefoot without protection. I did not see a "time out" (verification of the surgery right before operation start) before each operation either. (do not know if it is the case now in China)
5. On the Floor: In the U.S. hospitals, there are a whole team of supportive faculties assisting postop rehab and discharge of the patients. No only nurse, each patient case is assigned to a case manager in dealing with payment, insurance , dispo issues. Also, there are social workers, physical therapist and occupational therapist, some time speech therapist to make sure the patient is properly discharged and followed up. I do not know if that would be the case in China now.
6. On Communication:
In the practice guidelines of U.S. medical professions, the best way to avoid law suit is COMMUNICATION, COMMUNICATION AND COMMUNICATION. Without proper consent, we are not allowed to operate on the patient. All encounters, phone calls are documented.
1.有关DNR, DNI:
在片子开头,钟立行的美国病人可能是预先有DNR 和 DNI (Do not resuscitate and Do not intubate 不复苏以及不插管)。 这在美国医院中会常有遇到。一般为末期病人本人或法律上的代理执行人向医生要求并决定。 医生写下医嘱后,医疗团队必须照此执行。但是,DNR 和 DNI 并不等同于不治疗。不排斥合理的和符合病人最佳利益的治疗。另外,每个医院有一个伦理委员会,有24 小时值班人员,对于难于处理的个案提供指导。或者,有时求助于法院机构介入医疗决定如果时间允许的话。
在此剧最后,丁院长的去世,遵从了他的愿望。不知道一般的病人是否一样。
2. 在片中,将近最后。武院长问钟为何不与他的病人谈恋爱。在美国医生医生协会行为准则中明确规定医生和他的或她的病人发生的亲密关系是违反医生道德伦理的。发生关系的双方在起初就处在不对等的起点。病人对于医生的信任,隐私,和情感上的依赖有可能被滥用。这被认为是不符合伦理的和会对病人的治疗带来可能的不良后果。
3. 在急诊,美国医院都有院内安保人员防止混乱以及暴力的发生。通常运作十分有效和及时。不光保障医疗人员安全而且更重要的是所有病人的安全。优良的次序从而保证及时的根据病情轻重而得到及时的救治。
4. 在手术室,国内的医生开上去疏于自我保护。除了武明训一人每台手术都戴护目镜外, 其他大多人员没有面罩和最起码的眼睛保护。手术中的血液,体液,和组织残物多是可能的疾病传染源。另外,我所知的大多医院还是赤脚穿拖鞋的吧。手术前,除了主治医生谈话,签名,证人签名,表明手术部位之外,在美国的所有外科手术实施之前,有一项规程叫"time out" :手术室所有成员停下进程,由一个手术巡回护士宣读手术同意书上所写的手术并在全体人员认可后才可继续进行手术。不知国内是否有类似方法。 其目的在于即可能的减少医疗失误。
5. 再病房中,不光是医生和护士,在美国的医院中有一个团队在为每一个病人的术后康复和出院作出一个尽量合理的安排。团队包括病案经理(case manager)处理协调费用和保险, 社会工作者(social worker指有社会工作专业学历的执照人员)协调出院后事项, 理疗师(physical therapist)和职业治疗师(occupational therapist,)保障和测定病人的自理康复需求和有时语言治疗师共同参与病人的出院康复。
6. 有关沟通:
在美国医疗相关指导原则中,最为重要的防止医疗官司的方法是及时有效的沟通,沟通,再沟通。没有详尽的解释何同意,医生是一般不会开展进一步的治疗的。所有的对话,电话,每一次的病人接触都会记录下来。
有时去治愈;常常去帮助;总是去安慰。
在纽约东北部的撒拉纳克湖畔长眠着一位名不见经传的特鲁多医生,但他的墓志铭却久久流传于人间,激励着一代又一代的行医人。“To Cure Sometimes, To Relieve Often, To Comfort Always.”中文翻译简洁而富有哲理:“有时,去治愈;常常,去帮助;总是,去安慰。”有时、常常、总是,像三个阶梯,一步步升华出三种为医的境界。 |
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