介於神與人之間的行業：醫療！醫師！

1. 介於神與人之間的行業：醫療！醫師！ 演講人：楊秀儀 演講日期：2005/1/27 演講對象：北市衛生局

2. 演講大綱 • 病人診斷醫師─好醫師的要素 • 病人是人─「告知後同意」與「新醫病關係」 • 醫師也是人─「醫療錯誤」與「病人安全」 • 結語：醫德與專業倫理

3. 病人診斷醫師

4. Anatole Broyard, Intoxicated By My Illness 我對這位醫師打一開始便無好感。 他看來乏味無趣，恐怕 既無精力亦無意願征服 像疾病這樣強猛邪惡的 東西。

5. - • 我看不出他 對生命有何悲憫之情，也 沒有強烈的意志要對抗命運

6. 我面前這一位完全凡骨俗胎的醫師!!! • -

7. ─ • 我希望我的醫師除醫療能力外還要有魔法，能起死回生、化險為夷。我在此細述病人的狂想，讓大家看出在這處境下的人多麼不講道理。 • 我希望我的醫師仔細審視我的病，在用藥上多推敲、再斟酌 • 我希望醫師不僅是個有天分的醫師，還帶點哲學家的味道，如此既能醫身體，也能治靈魂

8. 我願我的醫師具備權威與魅力，幫助我保得靈魂不失我願我的醫師具備權威與魅力，幫助我保得靈魂不失 -

9. ─ 照我無知的看法，實際的診斷工作主要是技術員作的。 技術員拿來素 材，醫師把他 們寫成診斷詩。 因此我想要 一位纖細敏感 的醫師

10. - • 我的醫師沒理由也不需要愛我， • 我也不指望他陪我受苦， • 我並不想多費他的時間， • 只希望他能靜心專注在我的病情上5分鐘；只要一次，他把全心放在我身上，與我短暫交會，細究我的靈魂與肉體，探觸我的病。 • 每個人病的方式都不一樣。

11. 病人是人！ • Jay Katz, The Silent World of Doctor and Patient (1984) • 新醫學倫理觀─尊重病人自主權 • 新醫療法律─告知後同意法則 • 法律要的醫病關係─空虛的自主還是溫暖的父權？

12. 醫師也是人！ • IOM, “ To Err is Human”, 1999 • 醫學的目的不在開啟廣大的智慧之門，而在為無窮的錯誤設下界線 • 無意義的怪罪無濟於事，如果不能找出錯誤背後的制度性因素，錯誤將會一再發生！ • 認錯─通報─分析─改善

13. 第一個難題：認錯 • 歸咎文化使得認錯比文過飾非更困難 • The old paradigm of blaming and punishing individuals led to overreliance on flawless personal performance and to the hiding of mistakes out of shame and fear if they occurred. Albert Wu conducted an anonymous study of 114 house officers regarding their most significant mistakes. Only 54% had discussed their mistake with their attending physician, and only 24% told the patients and families. • Wu AW. Do house officers learn from their mistakes? JAMA. 1991, 265: 2089-2094

14. 第二個難題：通報 • 醫界的沈默密碼─沈默的共犯 • AMA Code of Ethics • Principles of medical ethics • I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. • II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

15. 問Why?而不問Who? • 是否林醫師因為過長的工時而過度疲倦？ • 林醫師是否有充分的訓練？ • 急診室是否有收治受虐兒童的標準作業流程？ • 急診室是否人力不足，因此造成輕率的服務？ • 當時是否急診室已經收治了太多的病人，而導致人員無法應付？ • 為何護士沒有辦法找到林醫師親自來看病人？ • 為何林醫師沒有及時的被通知急診有一名非常嚴重的病患，而且一看就知道是家庭暴力的受害者？ • 醫院平常有提供家庭暴力防治的訓練給他的員工嗎？ • 是否住院醫師有定期接受如何避免醫療錯誤，以及一旦發生錯誤後，應該如何應對的教育訓練嗎？（而且最好是以工作坊的形式進行）。

16. 最困難的課題：落實改善方案 • 經營管理者要願意付出成本來落實改善方案。 • 「等真的有人跌倒了再說！」

17. 病人安全運動成果一： 美國規定縮短年輕住院醫生的工作時數 （中央社記者鍾行憲華盛頓2002年 6月13日專電）鑑於日增的證據顯示每週工作多達 120小時對年輕醫生有害，監督美國醫生訓練的研究生醫學教育鑑定委員會昨天宣布，它將對住院醫師的工作時數加以嚴格的新限制。 根據這個委員會採取的新規定，住院醫師正常的每週工作時數不得超過80小時，值班之後必須休息10小時，每週休息 1天。兼差也受到限制。 華盛頓郵報今天報導，美國首次對年輕醫生值班時間訂定全國標準，是由於接受訓練的醫生長時間工作早已讓人擔心危及病人的照料。每年有數以千計病患由於醫療錯誤而喪生的報導，則使前述問題重新受到注意。代表大約 1萬 2千名加入工會住院醫師的實習醫生及住院醫師委員會讚揚此一決定。該委員會主席波蒂(Ruth Potee)說：「在我們一次值班36小時、一星期工作120小時的時候，可能發生太多的錯誤。」

18. Young Doctors Working Too Many HoursPublished: January 12, 2004, New York Times • Medical experts say most residency programs comply with the new work-hour rules adopted last July. But the medical community almost universally acknowledges that some programs still overwork young doctors. • Justin Wood, a spokesman for the union Committee for Residents and Interns, said a common story he hears is residents are told "more or less explicitly" to falsify time sheets.

19. F.D.A. 要求藥廠所有藥品都要有條碼 • 有鑑於日益增多的醫療錯誤，美國FDA於日前宣布(2003/03/13)其將要求所有的藥品均有條碼，因此醫院可以透過條碼掃瞄來確定病患得到正確的藥品及劑量。 • As for bar-coded dispensing, the Veterans Health Administration is a pioneer. • Dr. Jonathan B. Perlin, an official of the agency, said some of its 150 hospitals now had "virtually no dispensing errors". • The V.A. prints its own bar codes, but that would be too expensive for most hospital pharmacies. The F.D.A., will order the pharmaceutical companies to come up with codes identifying each drug and dosage. The FDA estimated that it would cost pharmaceutical companies $50 million to put bar codes on every product and that hospitals would spend over $7 billion on scanners and computers.

20. 佛羅里達州立法規定醫師開立處方的寫作方式By Damon Adams, AMNews staff. Aug. 4, 2003. • 新法在2003年7月1日生效，佛州是美國第二個針對醫師的手寫處方立法規範的州。(華盛頓州在2000年通過類似的法案）Florida Senate Bill 2084, which became law, in pdf (www.flsenate.gov/data/session/2003/senate/bills/billtext/pdf/s2084er.pdf) • 禁止用阿拉伯數字寫月份。 • It requires that the quantity of the drug be written in text and number • 處方要用大寫體或打字。 • "It's an added 10 seconds, but multiply that by dozens of prescriptions a day and that's a serious annoyance," Dr. Van Durme said. "But it's hard to argue against something that's going to lead to safer care."

21. Hospital injuries have high added costs,2003 Oct. 8 • Injuries during hospitalization resulted in an estimated 32,591 patient deaths, $4.6 billion in additional national healthcare expenditures and 2.4 million in added hospital days in 2000, according to a federal study in this week's Journal of the American Medical Association.

22. Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization, JAMA. 2003;290:1868-1874. • Design, Setting, and Patients The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) were used to identify medical injuries in 7.45 million hospital discharge abstracts from 994 acute-care hospitals across 28 states in 2000 in the AHRQ Healthcare Cost and Utilization Project Nationwide Inpatient Sample database.

23. Results  • Excess length of stay attributable to medical injuries ranged from 0 days for injury to a neonate to 10.89 days for postoperative sepsis; • excess charges ranged from $0 for obstetric trauma (without vaginal instrumentation) to $57 727 for postoperative sepsis; • excess mortality ranged from 0% for obstetric trauma to 21.96% for postoperative sepsis (P<.001). • Following postoperative sepsis, the second most serious event was postoperative wound dehiscence, with 9.42 extra days in the hospital, $40 323 in excess charges, and 9.63% attributable mortality. Infection due to medical care was associated with 9.58 extra days, $38 656 in excess charges, and 4.31% attributable mortality.

24. . • Among 18 types of injuries, postoperative bloodstream infections had the most serious consequences; they extended hospital stays an average of nearly 11 days and increased patients' risk of death 21.9%, or about 3,000 deaths per year. The excess charges associated with such infections were $57,727 per case. • The next most serious event was postoperative reopening of a surgical incision, which increased risk of death 9.6%, or 405 deaths annually, while adding 9.4 days per stay and $40,323 in charges per case. • In contrast, birth and obstetric trauma resulted in little or no added length of stay, cost or risk of death, the researchers said.

25. 醫德（medical ethics)與專業倫理(professionalism) • 倫理不是八股教條！ • 倫理是在道德兩難的情境下作決定！ • 仁愛醫院事件並沒有出現道德兩難，而是整個專業失去了專業的理想與熱忱。 • 我心中的理想模式