Are Good Doctors Bad for Your Health?
NOV. 21, 2015
http://nyti.ms/1kO5UDB很有趣的文章，作者說到他常接到朋友的緊急電話，詢問「要找最好的心臟科醫師，來治療親人的心臟病」這種事我們當醫生的，一定常接到。
然而，找到最好的心臟科醫師，結果是最好的嗎？
今年初，JAMA文章，
LESS IS MORE
Mortality and Treatment Patterns Among Patients Hospitalized With Acute Cardiovascular Conditions During Dates of National Cardiology Meetings
JAMA Intern Med. 2015;175(2):237-244
這文章收集了，美國醫學中心，教學醫院，近10萬的病例，10年的時間，發現30天內的心衰竭，AMI住院死亡率，在心臟科醫師們年會時，這死亡率可以下降達1/3。心臟科醫師不在醫院時，心臟病人活得更好？這種反直覺的研究結果，真是令人驚訝。
As the article concludes, high-risk patients with heart failure and cardiac arrest, hospitalized in teaching hospitals, had lower 30-day mortality when cardiologists were away from the hospital attending national cardiology meetings. And the differences were not trivial — mortality decreased by about a third for some patients when those top doctors were away.
另外，這報告額外的告訴我們，在"teaching hospitals"教學醫院的醫療結果，還是比"community hospitals"社區醫院好，所以作者說，可以的話，還是選教學醫院吧。
為什麼資深的心臟科醫師不在醫院時，病人的死亡率會較低，研究提出可能的解答：資深醫師專長是研究，臨床處置還是年輕醫師較強。另外，就是資深醫師可能會試較多新的醫療處置，因此增加了病人風險。
One possible explanation is that while senior cardiologists are great researchers, the junior physicians — recently out of training — may actually be more adept clinically. Another potential explanation suggested by the data is that senior cardiologists try more interventions. When the cardiologists were around, patients in cardiac arrest, for example, were significantly more likely to get interventions, like stents, to open up their coronary blood vessels.
作者也提到以色列的研究，發現醫師們多開了5-7種不必要的藥物給患者，把這些藥停掉後，病人也沒有不良後果。
We — both physicians and patients — usually think more treatment means better treatment. We often forget that every test and treatment can go wrong, produce side effects or lead to additional interventions that themselves can go wrong.
沒錯，病人和患者仍然覺得，「多還是好」，不是「Less is More」，藥物不夠大包、不夠多顆，藥效就不夠好，不排個檢查就是醫療沒有到位。雖然醫師們都知道， “First, do no harm” 。
最後，作者教大家，當醫師們建議一個新的檢查或是治療時，要問4個問題？1) 這檢查能改變什麼？2) 這改變，可以延長生命？減少心臟病風險嗎？ 3) 副作用有多大 ？4) 這裡是教學醫院嗎？這4個問題，比開口要找最有名的醫師還重要。
So when your mother is being rushed to the hospital, it might be best not to seek the most famous senior doctor, but to ask those four questions.
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Ezekiel J. Emanuel is an oncologist and a vice provost at the University of Pennsylvania.
