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怎样避免误诊

更新时间:2013-12-10 21:16:22 来源:华尔街日报中文网 作者:佚名

The Biggest Mistake Doctors Make
怎样避免误诊

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.

如果医生没能做好全面身体检查,腹痛病人可能会死于阑尾破裂。前列腺癌活体组织检查结果呈阳性,但却没人跟进,因为实验室结果被弄混了。小孩发烧和出疹被诊断为病毒性疾病,但最后却发现是严重得多的细菌性脑膜炎。

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.

约翰霍普金斯大学(Johns Hopkins University)研究人员表示,每年有多达16万名病人因此类致命失误而出现永久损伤或死亡。研究人员称,诊断问题比其他医疗失误更为普遍,而且更容易伤害到病人,同时它们也是医疗过失诉讼的主因,按照2011年美元价值计算,它们在1986年至2010年间共计近390亿美元的赔偿额中占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,误诊比其他医疗失误更容易预防。现在医疗机构开始采用一系列创新措施来纠正失误、偏误和疏忽等妨碍医生做出正确诊断的问题。

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.

其中一个解决办法是自动化──用电脑筛查医疗记录从而找出可能的误诊,或提醒医生跟进标有红色警示的检查结果。另一方面是帮助医生更准确诊断疾病和病情的设备和测试,还有在医生对病人病情不确定时给他们建议的网上服务。

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.

最后还有推动医疗文化的改革。医生受到的教导是不能抓住一种诊断不放,而是应该在面对相互冲突的证据和观点时保持开放的思想。

'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.

美国退伍军人事务部(Veterans Administration)资深医师、非营利研究机构RTI International研究员马克·格雷伯(Mark Graber)说:“误诊可能是我们在医疗行业面临的最大的病人安全问题,现在终于纳入到了病人诊治质量和管理运动中。”

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.

这些举措在最新的医疗法律下将会得到大大的推进。法规要求多家医疗机构协调护理治疗,并帮助预防检查结果等关键信息被遗漏,确保病人按照医生的推荐去找专家。

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.

另外还有一些大规模的举措正在进行中。为美国联邦政府提供咨询的医学研究所(Institute of Medicine)已经同意承担一项100万美元的有关误诊对美国医疗影响的研究。

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,格雷伯博士两年前创立的改善医疗诊断协会(Society to Improve Diagnosis in Medicine)正在与医疗认证机构及安全组织合作,研究确定和衡量诊断失误的方法,通常情况下除非有人起诉,否则误诊是不会公之于众的。另外,协会还在设计一个医学院课程表,帮助学员提高诊断技能并对他们的能力进行评估。

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.'

加州大学旧金山分校(University of California, San Francisco)医药部副主任罗伯特·瓦赫特(Robert Wachter)说,对诊断失误进行确定和衡量是重要的一个步骤。他说:“目前医疗改善的激励措施没有一项是基于医生是否做出了正确诊断的。”不过他又说,同样重要的是,“我们需要鼓励从下至上的创新”。

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.

创新已经开始。大型医疗系统正在筛查他们的电子记录以查找误诊的迹象。在管理式医疗行业巨头凯泽永久医疗集团(Kaiser Permanente)旗下的南加州永久医疗机构(Southern California Permanente Medical Group),其“安全网”(Safety Net)项目会定期对其数据库中360万名会员进行问卷调查,从而捕捉到有可能被遗漏的实验室结果及其他数据。

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.

在首次使用该系统的过程中,一位病例管理员查到8,076名病人的前列腺癌PSA检查结果不正常,2,200多名病人随后有做活体组织检查。2006至2009年,这些病人中有745人被诊断患有癌症,而凯泽并未接到有关遗漏的PSA检查的过失起诉。

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.

该项目还被用于查找患有未被诊断的肾脏疾病的病人。肾脏疾病通常是通过异常肌酸酐检查结果发现的,并且应在90天内进行复查。2007年至2012年,系统发现有7,218张做异常检查的实验室检查单未进行复查。其中3,465单在通知病人90天内需要复查后进行了复查,1,768人呈现异常结果。最后大多数人,也就是1,624人被诊断为患有肾脏疾病。

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.'

负责质量和临床分析的区域医学主任迈克尔·坎特(Michael Kanter)说,该系统使得临床医师能够“尽最大可能回去查找并弥补所有的失误”。

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.'

坎特博士说,由于这种病是慢性病,所以五年没有被诊断出来的人可能并不会有大碍。同样的,他说,对于早期前列腺癌来说,“在很多案例中并不意味着病患已经危及到了病人,但我们不想因为系统里的某种过失导致病人对本应知道的信息不知情”。

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.

当然,电子纪录并非万应良药,而且还有可能导致信息过载。去年3月,在《美国医学会杂志·内科学》(JAMA Internal Medicine)上发表的对美国退伍军人事务部初诊医师所做的一项调查显示,超过三分之二的医师收到的有关看病的通报数量超过了自己所能有效管理的范围──这就有可能导致他们遗漏异常的检查结果。

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.

有研究人员表示,最佳的解决办法并不是把海量的信息塞给医生,而是为他们提供第二双眼睛查找他们有可能遗漏的东西。

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.

目前的重点在于防止在异常检查结果的跟进过程中出现危险性延误。在一个试点项目中,退伍军人事务部休斯顿分部的研究人员设计出了“触发”查询,这是一套规则,通过计算机确认在前列腺和结肠直肠癌评估和诊断中可能有延误的病人的病历记录。研究小组负责人哈迪普·辛格(Hardeep Singh)表示,记录包括特定时期后对表明有疑似癌症的异常检查结果无正式跟进记载的图表。辛格是休斯顿Michael E. DeBakey VA Medical医学中心医疗政策及质量主任,以及贝乐医学院(Baylor College of Medicine)医药学助理教授。

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,在退伍军人事务部下属一家医院就诊过病人的近60万份记录得到了这样的查询。辛格博士说,使用“触发”查询帮助找到了异常PSA检查和阳性大便潜血检查,每年可以查到约1,048例异常检查结果的后续跟进被延误或遗漏,以及47例重度癌症。

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.

退伍军人事务部资助了一个随机试验,测试“触发”自动化监测系统是否能改善五种常见癌症的及时诊断和跟进。

'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.

辛格博士说:“这个项目就像是在干草堆中找针,我们利用信息技术让干草堆变得越来越小,这样就更容易找到针。”

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.

越来越多的医疗系统也开始采用电子决策支持程序来帮助医生根据症状和病历笔记为诊断结果的可能性进行排序。在一个名为“伊莎贝尔”(Isabel)的程序的研究中,由格雷伯博士带领的研究小组发现,刊登在《新英格兰医学杂志》(New England Journal of Medicine)上的50个疑难案例中的关键临床特征输入系统时,系统96%的情况下都给出了正确的诊断。美国内科学委员会(The American Board of Internal Medicine)正在研究如何将“伊莎贝尔”与医师技能和知识的评估联系起来。

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.

另外一个名叫DXplain的系统是由波士顿麻省总医院(Massachusetts General Hospital)开发的。去年的一项研究显示,该系统能显著增强第一年住院医师诊断的准确性。

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.

负责DXplain项目的是哈佛大学(Harvard)临床副教授、麻省总医院高级计算机科学家爱德华·霍弗(Edward Hoffer),他说,当前的目标是让DXplain通过电子病例记录系统向医生“推送”诊断建议,而不是要求医生发起查询,有些医生仍然不愿意主动查询。霍弗博士说:“我们要把重点放在处理医生自以为知道诊断结果、但事实上不知道的情况。”

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.

新设备也有望对确认诊断和避免不必要的检查提供帮助。多家公司正加速提供便携式诊断设备和实验室结果等援助,可以帮助分析微小的血样及其他体液,从而迅速发现疾病。

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年进入美国市场的MelaFind为例。皮肤科医生可使用该设备无创检查在皮下深达2.5毫米处的痣,从而检测“组织破坏”的水平。“组织破坏”的水平可反应不规则生长模式,不规则生长模式是黑色素瘤等最致命癌症的迹象。

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.

纽约皮肤专家麦克兰纳·亚历克西亚德斯-阿门内卡斯(Macrene Alexiades-Armenakas)说,她用MelaFind证实某颗痣是否需要去除,以及对多颗异常痣的“组织破坏”水平进行排序。她说,有时候,当其他医生或病人对某颗痣表示担心时,MelaFind会支持“良性痣的临床诊断,从而让他们省去了活体组织检验的程序”。

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.'

亚历克西亚德斯-阿门内卡斯博士说,不过这样的设备永远替代不了全面的体检以及训练有素的眼睛和仔细的后续跟进。她说:“这些诊断工具是提高准确性和好的检体诊断的辅助手段,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.

有些尝试减少失误的措施则走的是完全不同的路线──尝试通过改善沟通来改善诊断质量。

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,有的机构在促使病人在诊断过程中更积极主动,鼓励病人说出自己的症状并且询问医生:“这还会是什么病?”凯泽永久的一个试点项目为病人提供小册子,鼓励他们思考并写下自己的症状以及他们的担忧或恐惧,鼓励他们提出具体的问题,从而确保他们理解自己的诊断结果以及下一步需要采取的步骤。

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.

与此同时,医学院也在教导医生们更加虚心听取病人的意见并避免“锚定”,即习惯集中在一种诊断上,不考虑其他可能的情形,还要避免“过早下结论”,即根本不把正确诊断作为一种可能性进行考虑。

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)的达尔豪斯大学(Dalhousie University)去年创立了批判性思考项目。该项目旨在帮助学员退一步思考,审视偏误会对自己的思维有何影响。该项目由帕特·克罗斯克里(Pat Croskerry)开发,他是一名以研究诊断过程中认知错误的影响而闻名的医师。项目列出了50种不同种类可能导致诊断失误的偏误。

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.

该项目被整合到了达尔豪斯大学医学院的四年制教学中。学生们会学习很多案例,比如呼吸短促的精神病人被认为只是焦虑发作,医生没注意到她是服用避孕药的吸烟者,这导致她体内产生血块,随后血块到了肺里,最终令她丧命。

'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.'

克罗斯克里博士说:“如果我们教会医生们如何以更批判性的思维思考,他们就会更有效地给病人看病并做出正确诊断。”

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