Why Doctors Don’t Take Sick Days、生而平等、醫生為何不請病假？

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Why Doctors Don’t Take Sick Days

Why Doctors Don’t Take Sick Days http://nyti.ms/1dyBb3I

Topos Graphics

By DANIELLE OFRI

Published: November 15, 2013

這文章真是敲到我心裡，「醫生為何不請病假？」

為什麼醫生生病了，不管是感冒或是腸胃炎，吐得亂七八糟，還是堅持上班？吞顆藥，甚至打點滴後再上？（我之前就曾發生一邊滴點滴，一邊值住院醫師班的事）

看著作者寫著，他手上打著點滴，一邊指揮fellow作醫療處理，一邊電話order 小姐抽血，一邊做medication renew，等著天亮白班來交班。之後，回家洗澡，睡幾小時，然後晚上10點，再來繼續上班。

為什麼作者不請病假呢？

醫師長久以來就是被認為是最糟糕的病人，最不合作，或是最不聽醫囑。也許是因為從醫學教育啟蒙的一開始，請病假就被當作是「肉腳」會作的事（因為老師們也都常抱病上班？）

¶"From day one in medical training, the unspoken message is that calling in sick is for wimps."

因為一旦請假了，你的工作就是分配給同事們，也不會有突然增加的人力幫忙，就是原來的那些工作人員減你一個，這樣，誰敢輕易請假？誰也不想增加別人的負擔。

所以醫師們請是拖著，直到嚴重到「要住院，躺到對面那病床上了？」才肯請病假就醫。（這就讓我想到幾位因為癌症過逝的前輩醫師們，都太晚發現病症了。）

90年代英國的一項調查發現，87%的一般科醫師就算嚴重的感冒也不請病假（相較於一般大眾，32%的人，就願意請病假了）挪威2001年的調查，80%的醫師，若是和他們醫師一樣嚴重病情的大眾，他一定護民眾居家休息，而醫師自己卻不休息。

除了不想增加同事們的負擔外，一部份是醫師們的心理。醫師認為他是處理或是說可以戰勝病症的人，而不是被病症所擊倒的人。

¶"But another part is how we see ourselves. Illness is what we do, not who we are. We define ourselves by vanquishing illness, not succumbing to it."

作者提到，他25年來第一次請病假，是他女兒突然在上班前發燒，他必須請「病假」照顧女兒。（我行醫以來唯一次請病假在家是開業前幾年，長水痘了，沒辦法，一定要隔離一週）

¶作者希望，當然最好能有個機制，讓醫師們可以有空間，可以突發性的請病假，然而他也知道，這是很困難時，因為找不到備用醫師可以隨時支援。然而，至少在醫學教育時，就讓下一代醫學生知道，醫生和患者是一樣的，一樣都會生病，一旦有病症，還是要請病假或是就醫。

¶An associate professor of medicine at New York University, the editor of the Bellevue Literary Review and the author of “What Doctors Feel: How Emotions Affect the Practice of Medicine.”

最後，祝大家醫師節快樂！身體健康。

102年度台灣基層透析協會會員大會暨學術研討會、內科醫學會

上週日上台北參加內科醫學會，其實更重要的是參加「 102年度台灣基層透析協會會員大會暨學術研討會」，醫師要面對健保局或是處理攸關自己權利的事時，常常是不知情或是不知如何爭取。基層透析腎臟科醫師能有這個協會來幫大家把關，實在是很幸運的事。所以一定要來參加一下會員大會，壯大聲勢一下。

最新消息：

☆Final Call 各位基層同仁，本週日(11/24)邀請健保署醫務管理組林阿明副組長

  列席座談，他是目前健保署透析醫療政策最重要的幕僚，多項透析政策是由他

  草擬，要來聽聽基層的聲音，這是我們表達意見最好的機會，請大家務必出席！

  102年度台灣基層透析協會會員大會暨學術研討會

時間：102年11月24日(星期日)上午9：30-12：40

   地點：台北市公園路15-2號1樓

                           (台大景福館，捷運台北站M8出口)

議          程	Speaker	Moderator
09:10~09:30  報到及聯誼
09:30~10:00  Non-metal based phosphate binder in CKD 10:00~10:10  Q & A	盧國城主任 台北耕莘醫院腎臟科	鄭集鴻醫師
10:10~10:40  肝素之臨床使用及研究分享 10:40~10:50   Q & A	陳金順主任 三軍總醫院腎臟科	顏大翔醫師
10:50~11:30  洗腎給付座談：              ‧基層的努力方向                ‧腎臟科的努力方向              ‧如何做才能維持給付	鄭集鴻醫師 李素慧醫師 林阿明副組長列席指導	楊孟儒醫師
11:30~12:10  洗腎診所經營座談：              ‧如何增加腎友來源              ‧如何提升醫療品質              ‧如何做護理人員訓練              ‧腎友接送問題	楊孟儒醫師 呂國樑醫師 蔣榮福醫師	李少瑛醫師
12:10~12:40  會員大會              ‧會員年費修訂              ‧推派代表參加腎臟醫學會                  理監事選舉	全體會員	鄭集鴻醫師

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在內科醫學會會場，去聽了SLE的topic，主講者展示了幾張照片，問大家SLE的皮膚表現，真是隔行如隔山，這malar rash，就可以讓不同科醫師選錯了（有人就選右邊這張照片），所以不是本科的的病症，還是應該找專家才對。為什麼是左邊照片，因為「Classical feature is the malar (butterfly) rash: often precipitated by sunlight. ... It spares the naso-labial folds」

以下這位聽說是歌手，Seal (discord rash): Celebrities With Lupus

嘔吐 Angioedema ACEI

THINK LIKE A DOCTOR NOVEMBER 7, 2013, 8:00 AM 307 Comments

Think Like a Doctor: Gut Feeling

Think Like a Doctor: Gut Feeling http://nyti.ms/17GGGPC

By LISA SANDERS, M.D

The red line indicates the amount of swelling in the colon.

這是一個困難的病例，一位47歲的女性患者，高血壓、糖尿病，近2年來一直為偶發性的嚴重的嘔吐所擾，遍尋名醫，也找不出為什麼，後來找出答案了，把這病史貼在New York Times 網站考一下大家（美國的大眾真是強？）不過答對的人，大多是醫療背景者，有些是住院醫師等。

突發嚴重嘔吐，白血球稍高，胃鏡無異常，後來做到腹部的CT和大腸鏡，看到腸道水腫（還被疑是Crohn's disease），外科醫師做了剖腹探查（negative！真是白痛了）。治療上，給予抗生素和點滴，感覺和台灣也是一樣。

在一次的再度住院時會診，腸胃科fellow（是fellow沒錯！）建議再做一次abdominal CT with contrast（上次做是36小時前在ER做的，若是在台灣健保下，36小時後，再做另一次abdominal CT，這個腸胃科醫師真是有GUTS）。

為什麼要立即再F/U abdominal CT？因為患者住院後1天後，症狀立即改善了，GI man想了解腸道是否有變化（水腫消失了嗎？），結果，如上二張CT圖比較，右圖後來F/U的，腸道水腫快速消失。

原因？是她拿來治高血壓的藥，lisinopril所引起的angioedema。

以下原文，讓大家參考這個不常見的名詞angioedema，但是我想，有這些症狀的患者，應該也在台灣存在，會不會被當作精神病患者或是情勢障礙啊？

The correct diagnosis is…

Intestinal angioedema, triggered by lisinopril, the ACE inhibitor the patient took for her high blood pressure.

The Diagnosis:

Angioedema is a localized type of swelling usually involving the mouth, tongue or upper airways. It can be part of a typical allergic reaction, with hives and itching, or it can be isolated, with swelling as the only notable finding. While there is an inherited form of this disease, most cases are acquired. And medications are the most common cause of this form of the syndrome.

The class of high blood pressure drugs known as ACE inhibitors is the most common medication linked to angioedema. This patient was taking lisinopril, one of the most widely prescribed drugs of these drugs. Although angioedema usually arises when the medication is first started, it can occur at any point during a patient’s treatment.

African Americans are at a particularly high risk of this strange drug reaction. Up to one in 30 African Americans who take an ACE inhibitor will develop angioedema at some point. Women are also at somewhat higher risk than men.

And it’s not just this class of medication. Painkillers such as ibuprofen and certain antibiotics are also listed as relatively frequent causes of angioedema. Indeed, there’s a whole long list of drugs that have been linked to this unusual reaction.

A Rare Gut Problem:

Usually the swelling of angioedema is seen in the face: the lips, tongue or throat. And the swelling can be quite dramatic, occasionally completely blocking the upper airways.

However, this patient had a rare form of the problem that arose not in the face but in the intestine. When swelling occurs in the gut, it can block off the intestinal lumen and bring digestion to a screeching halt, causing the terrible pain and vomiting this patient experienced.

Remarkably, no matter where in the body the swelling occurs, or how severe it gets, it always resolves quickly – often within hours – even if the patient continues to take the medication.

When the angioedema happens in the G.I. tract, the diagnosis can be delayed for months or years because so many doctors don’t know that this kind of reaction is even possible. When the medication is stopped, the episodic reaction also finally stops.

How the Diagnosis Was Made:

It was both the rapid resolution of the patient’s symptoms and CT scan abnormalities that provided the essential clue in this case. Dr. Ajaypal Singh was the G.I. fellow who was consulted to help figure out the cause of the patient’s pain. Once he saw the repeat CT scan, which — much to his astonishment — was nearly normal, the diagnosis was rapid. There are simply not very many diseases that will turn around this fast.

Dr. Singh immediately called Dr. Poonam Merai, the resident on call that day at the University of Chicago Medical Center, and told her that he thought this was a reaction to the patient’s blood pressure medication.

He also recommended that the patient be tested for the inherited version of the disease. If the patient had this unusual genetic disorder, stopping the medications would not prevent the attacks of pain and vomiting. Those tests were normal.

The patient was amazed to hear that this pill she’d been taking for years was the cause of her pain. Once the doctors explained it to her, though, a light went off and the intermittent nature of her attacks suddenly made sense.

You see, one thing she hadn’t told any of her doctors was that she often stopped that medication when her blood pressure seemed O.K. She had a blood pressure cuff at home and monitored it closely. She exercised regularly — she knew that brought her blood pressure down. And she tried to follow a low sodium, high potassium diet. When she did both, her blood pressure was usually well under the 140/90 measurement she knew was her target.

And she always restarted the drug when her blood pressure started to go up. That was usually predictable, occurring when she “fell off the wagon” and stopped her exercise and diet routine. Now that she thought about it, most of these episodes arose weeks after restarting her lisinopril.

How the Patient Is Doing:

The patient was given an alternative blood pressure medication and happily stopped taking her lisinopril forever. It has been six months now, and so far, so good. She is keeping her fingers crossed, but at this point it looks like a remarkably simple solution to a terribly painful problem.

還我尊嚴、醫療崩壞

近日看了一則新聞，是大陸浙江溫嶺的第一人民醫院，ENT主任醫師被疑似精神病人殺死，另有二人重傷。更令人不解的是，政府當局為了塑造一個太平盛世，竟然要快速的把遺體火化，讓這事情淡化，而引發了醫護人員的不滿。

November 1, 2013, 2:46 am

Chinese Doctors Becoming the Targets of Patients’ Anger

Chinese Doctors Becoming the Targets of Patients' Anger http://nyti.ms/16rjotR

By DIDI KIRSTEN TATLOW

Jin Yunguo/Agence France-Presse — Getty ImagesHospital workers protesting attacks on medical staff members outside the No. 1 People’s Hospital in Wenling, Zhejiang Province, where a man stabbed three doctors, killing one. The large sign, left, reads “Give My Dignity Back,” and the small sign, right, reads “Defend Justice.” 
逾千醫生抗議同仁被殺 轟官員下台 全國聲援 | 溫嶺 | 醫院 | 血案 | 大紀元 http://www.epochtimes.com/b5/13/10/28/n3997248.htm組圖-逾千醫生抗議同仁被殺-轟官員下台-全國聲援.html
「27日晚，王雲傑的遺體在醫院解剖後，院方未徵得死者家屬同意，企圖將王雲傑遺體送往殯儀館火化，遭到死者家屬及醫護人員集體阻攔，當局派出大批特警維穩，欲搶屍迅速火化。直到今天早上5點半，王雲傑的家屬被逼同意火化。」
對應在台灣的醫療現況，兩岸的部份人民，對待醫療人員的態度倒是相當一致，這是「醫療崩壞」的前夕嗎？ 
醫勞盟
非政府組織 （NGO）醫勞盟官方網站：http://TMAL911.org/

論理、不要「隱惡揚善」？

論理、不要「隱惡揚善」？Talking with Patients about Other Clinicians' Errors — NEJM http://nej.md/1dW0TT0
N Engl J Med 2013; 369:1752-1757October 31, 2013

Talking with Patients about Other Clinicians’ Errors.

這期的NEJM有篇文章吸引我注意，當我們發現同事在醫療上有錯誤時，應該怎麼做？

這是一位神內的醫師收了一個腦中風的病人，發現病人之前有2張心電圖就有atrial fibrillation (Af)，而他的家庭醫師並沒有注意到。當這位神內的醫師告訴患者的家庭醫師時，那家醫醫師還推說是因為心電圖機比較老舊，訊號干擾，不是Af。而神內的醫師拿心電圖請教心內的二位醫師時，心內的醫師異口同聲的說是：Af，這時該怎麼辦？(註：這個家庭醫師之前也轉了不少的病人給這神內的醫師)

以下摘錄部份文字

You are a young neurologist practicing in a small hospital. You admit a 55-year-old woman with hypertension and type 2 diabetes mellitus who had an embolic stroke at home. On reviewing the patient's medical record, you notice that she appears to have been in atrial fibrillation during two electrocardiographic (ECG) tests during visits to the office of her primary care physician (PCP) for palpitations. Her PCP, an internist who provides many of your referrals, read both ECGs as normal and attributed her palpitations to “probable mitral-valve prolapse and anxiety.” The patient is currently in normal sinus rhythm. You show the internist the ECGs and express concern that they indicate atrial fibrillation. He politely disagrees and says you are confused by noise from his old ECG machine. However, when you ask two cardiologists to look at the ECGs, both immediately say “A-fib.” The internist requests that you transfer the patient to his service (see the video, available with the full text of this article at NEJM.org).

是的，當這情況發生時，文章中也提到醫生們多數不知道該怎麼辦，因為前輩老師們也都沒教導。然而，文章中也提到，雖然指出同事的錯誤可能會損壞同事之間的關係，但是給病人最誠實的資訊，這件事也是相當的重要的。

Patients and Families Come First

Although anxieties about damaging collegial relationships loom large in situations of potential error involving other clinicians, a patient's right to honest information shared with compassion about what happened to him or her is paramount.

接下來該怎麼做呢？這位處於尷尬位置的神內醫師，他先告訴那位家庭醫師，他將安排患者做心臟的會診，當有了心臟檢查的背書後，他再來和這家庭醫師溝通日後的處置。若是這家庭醫師仍然拒絕患者以上這心臟檢查，則神內醫師打算上報醫院高層來處理。

WHAT SHOULD THE NEUROLOGIST DO?

The neurologist in our case is in an awkward position. She is confident that the patient's internist did not diagnose atrial fibrillation, that this error probably contributed to the patient's stroke, and that disclosure to the patient is vital. The internist has rebuffed her without assuaging her concerns. The neurologist's next step should be to tell the internist she plans to request a formal cardiology consultation. With the diagnosis firmly in hand, she should communicate the findings to the internist and attempt to formulate a joint disclosure strategy. If the internist declines or objects to the cardiology consult, the neurologist should seek assistance from the institution's medical director or other senior administrative leader. The neurologist would be well served by support from a disclosure coach.

以上這流程可給大家參考。

註：洗腎的病人有Atrial fibrillation也不少，要小心，只是這麼慎重告知的，也不多。