tag:blogger.com,1999:blog-75357875337597423542024-03-05T07:32:18.878-08:00我是黃致翰Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.comBlogger505125tag:blogger.com,1999:blog-7535787533759742354.post-13186230763804175512020-10-08T11:27:00.004-07:002020-10-08T11:27:40.090-07:00如何治療診斷不明確的病人<p> </p><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both;"><br /></div><div class="separator" style="clear: both; text-align: left;">首先,列出病人可能的鑑別診斷,例如A疾病跟B疾病。</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">再來,列出這些鑑別診斷的所有治療選項,例如A疾病的治療選項有a1、a2,B疾病的治療選項有b1、b2。</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTXSuqXvvSGOgs_Xw5yHxMX9jITlrMMj-oEIVt5dJuXXgX9O0obHvGlrm9O-VUxx89uI7gehyVMCOIFypxNFBF_CwB5v81A9FOvBiXTuGIil3BYt51MYyRUxwHClretHA7l-oVkErzDP1r/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="321" data-original-width="514" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTXSuqXvvSGOgs_Xw5yHxMX9jITlrMMj-oEIVt5dJuXXgX9O0obHvGlrm9O-VUxx89uI7gehyVMCOIFypxNFBF_CwB5v81A9FOvBiXTuGIil3BYt51MYyRUxwHClretHA7l-oVkErzDP1r/" width="320" /></a></div><br /></div><div class="separator" style="clear: both; text-align: left;">接下來,開始在腦中做思想實驗。</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">從治療選項a1開始考慮,先想像這個病人最後的診斷是B,那麼問自己一個問題:「如果最後診斷是B,我現在給他a1這個治療,會有甚麼害處?」</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">如果答案是沒甚麼害處,那就給予a1的治療。</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">如果答案是有害處,那再問自己一個問題:「如果最後診斷是A,我沒有及時在現在給他a1這個治療,會有什麼害處?」</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">接著比較這兩個問題的害處,決定(或與病人及家屬討論)要不要在現在給予a1的治療。</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">剩下的治療選項以此類推。</div><div style="text-align: left;"><br /></div></div><div class="separator" style="clear: both; text-align: left;"><br /></div><br /><br /><p></p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-42693709849192431032019-08-16T11:02:00.002-07:002019-08-16T11:02:26.862-07:00為何績效制度持續存在?<div style="background-color: white; color: #1d2129; font-family: Helvetica, Arial, sans-serif; font-size: 15px; margin-bottom: 6px;">
我一直有個疑問,雖然自己已經有了初步答案,但始終仍然是個還有待探索與尋求各種解答的問題。<br />那就是為何我看過的管理學的書(印象中十幾二十本),幾乎每一本的結論都是,績效管理制度在大部分的情況下,都會傷害組織的績效(當然我幾乎不看二十年以前寫的缺乏實證的老派管理學書籍);但績效制度卻仍然這麼氾濫,為何沒有被市場機制淘汰呢?<br />這幾年下來我有幾個推測的假說答案。</div>
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第一,最簡單的解釋當然就是,有些管理階層很久(或從來)沒讀書了,他們真心以為績效管理制度能提升組織績效。這個解釋雖然簡單,但我覺得大概可以解釋一半以上的組織之所以存在績效管理制度。</div>
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第二,其實管理階層根本就不是為了提升組織績效而使用績效制度啦。否則,怎麼會搞到大部分的組織的大部分的員工,都不清楚知道自己的績效成果(績效獎金、PPF)是怎麼算出來的呢?如果要用績效制度來激勵員工,怎麼會蠢到不說清楚遊戲規則,讓員工知道怎麼做才會增加自己的收入,就覺得能達到效果呢?(這裡先不去管根據我一開頭所說的管理學結論,就算說清楚遊戲規則也大概會得到反效果)。</div>
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第三,乍看之下,第一點跟第二點有些矛盾。如果一半以上的組織使用績效制度的原因是因為真心以為績效制度有用,那麼怎麼會大部分組織的員工不知道自己的績效成果怎麼來的呢?其實你如果用一個富有邏輯的人類大腦來思考,當然會覺得矛盾。但組織並不是一顆大腦。大部分時候組織裡「想要推動」績效制度來提升組織績效的人,並不是「實際執行」績效制度的人。而「實際執行」績效制度的人,其實也沒有想要提升組織績效,他就只是想要好好「執行」績效制度而已。而績效制度究竟會不會達到推動者「想要」的那個目的,其實執行者並不在意。</div>
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第四,上述第三點可以部份解釋組織「不為了提升組織績效而執行績效制度」的現象。但還有其他因素可以解釋這樣的現象。首先就是「以績效制度為名目,行轉嫁組織財務風險之實」。這樣的解釋是被一本我買回來之後還沒看過的叫做《風險大轉移》(The Great Risk Shift The New Economic Insecurity and the Decline of the American Dream)的書所啟發的。實行績效制度的組織在理論上會讓盈餘與人事支出成正相關(當然我們都知道出於各種原因,實際上常常不是這樣)。因此雖然在組織發大財的時候發得少一點,但卻受益於在虧大錢的時候將部分虧損轉嫁到員工身上。因此雖然在管理學上績效制度有損於組織績效,但就像你買保險需要花錢一樣,組織將績效制度當作一種轉移財務風險的保險所得到的好處,或許有可能大於績效制度所帶來的減損平均績效的壞處。更何況(正如同我們常常看到的)組織還可以將績效制度設計為組織的盈餘與人事支出的不對稱非線性回歸,意思就是組織發大財的時候給員工一些殘羹冷炙,組織虧大錢的時候大家一起「共體時艱」。而這一點也可以解釋為何大部分的組織都「違反績效制度根本邏輯地」不讓員工清楚績效究竟是如何計算的。</div>
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第五點則是第四點的延伸,只是又更腹黑了一點。如果員工根本不清楚績效如何計算,那麼組織就很容易神不知鬼不覺地單方面對員工的薪酬做不利益之變更。儘管這違反勞基法,但在資訊不對稱的條件下,勞工有發現權益受損就不錯了,更遑論討回自己受損的權益。<br />第六,縱使績效制度有損組織績效,但因為在許多情境下市場機制並不完美,因而無法淘汰使用績效制度的組織,甚至反淘汰不使用績效制度的組織。寫到這裡讓我想到納西姆塔雷伯的《不對稱陷阱》一書。金融界的管理制度我並不熟悉,但塔雷伯在書中提到每天在自由市場上廝殺競爭的許多金融界組織的內部管理,其實是相當共產主義的。這實在是相當有趣的現象。</div>
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第六則是因為「烏比岡湖效應」(Lake Wobegon effect),意思就是大部分的人都覺得自己比別人厲害,這樣一個在邏輯上根本矛盾的心理學現象。這也是被直銷商利用來吸引人投入直銷的人性弱點。因為覺得自己比別人厲害,因此大部分的人都喜歡績效制度,因為幻想中自己能賺得大把鈔票;儘管大量管理學與心理學的研究都告訴我們,處於績效管理制度下的工作者,不但績效比較差,內心也比較不快樂不幸福。這也是為何就算哈佛大學的社會流行病學家河內一郎早就使用實證資料證明一件違反大家直覺的事情(但其實你看了夠多現代管理學與心理學的書就不會覺得違反直覺),那就是美國職棒大聯盟裡,隊內薪資差距越大的球隊,成績越差;但球隊卻沒有為了提升戰績而互相競爭讓薪資差距越來越小,反而大聯盟的薪資差距越來越大。這部份原因就是雖然薪資差距小對球隊戰績有利,但球員卻渴望薪資差距越大越好。這一方面是因為職業運動「薪資身價等於對實力的肯定」之文化,一方面則是高估自己獲得高薪機率的「烏比岡湖效應」。當然,我舉這個大聯盟的例子講的並不是績效制度本身,而是以「薪資差距」這件事作為績效制度的類比,解釋「烏比岡湖效應」讓組織必須用績效制度來吸引根本就喜歡績效制度而不在乎組織績效的勞工。有趣的是,大聯盟球隊的管理者其實相當精明於管理學,儘管用鉅額薪資來競爭球星,但卻鮮少使用績效制度來激勵球員場上的表現。因為他們都明白這絕對會弄巧成拙。</div>
Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com1tag:blogger.com,1999:blog-7535787533759742354.post-91564017565030943792019-02-04T16:38:00.002-08:002019-02-04T16:43:19.472-08:00如何寫好Progress Note(兼論如何下住院/出院診斷)<br />
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<span lang="en-US" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫不好的幾個因素</span></h1>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">在說明怎麼寫好</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">之前,先說明一下造成</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫不好的幾個因素,恐怕更能幫助大家寫出好的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第一個造成</span><span lang="en-US" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫不好的因素是,不論是在學校還是醫院,師長在教寫</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候,幾乎總是用「從症狀到診斷」的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">來舉例,例如:</span></div>
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S:</div>
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cough
with sputum for 2 days, fever with chills for 1 day, shortness of breath for 1
day</div>
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O:</div>
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Consciousness:
drowys, GSC E4V4M6</div>
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Vital
signs: T/P/R 38.2/110/32, BP 89/43</div>
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Lungs:
rapid respiration without accessory muscle use, crackles over right chest,
dullness to percussion over right<span style="mso-spacerun: yes;"> </span>lower
chest</div>
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Abdomen:
soft, no tenderness, no costovertebral<span style="mso-spacerun: yes;">
</span>knocking pain, no Murphy's sign</div>
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Skin: no
rash or wound</div>
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A:</div>
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pneumonia
with septic shock</div>
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P:</div>
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IV fluid
resuscitation</div>
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collect
sputum culture, draw blood culture</div>
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IV
meropnem 500 mg q8h&st</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這樣的</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">當然沒甚麼問題,問題在於「用這樣的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">來當教寫</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的教材」。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">為什麼呢?因為百分之九十九點九要寫</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候,你遇到的都不是這種情境,也就是「從症狀到診斷」的情境。反之,大部分你在寫</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候,都是「病人已經有診斷了」的情境。當然,診斷可能會輕微修正,甚至完全翻盤;或者也可能有新的症狀產生新的診斷,但這都是奠基於一個已經有某些診斷的情境下所寫的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">而至少在我個人的經驗中,從來沒有人(但可能只是剛好我沒遇到)教過我怎麼針對一個已經有診斷,正處在治療過程中的病人,寫他的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">因為這樣一個「從症狀到診斷」的</span><span lang="en-US" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的模板已經深深烙印在大家心中了,導致在面對一個已經有診斷,正處在治療過程中的病人時,便不自覺套用這樣的格式來寫</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。殊不知這時應該用另一套模式來寫</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">才恰當。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第二個造成</span><span lang="en-US" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫不好的因素則是,把「</span><span lang="x-none" style="font-family: "calibri";">Problem-oriented medical record</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」跟「</span><span lang="x-none" style="font-family: "calibri";">SOAP</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」成是兩種「擇一即可」的書寫</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的格式。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">我們現在都會說發明</span><span lang="x-none" style="font-family: "calibri";">SOAP</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的是</span><span lang="x-none" style="font-family: "calibri";">Lawrence Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">醫師,但事實上,他發明的是</span><span lang="x-none" style="font-family: "calibri";">Problem-oriented
medical record</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span><span lang="x-none" style="font-family: "calibri";">SOAP</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">應該是後來的人從他的文章中歸納出來的格式。事實上在</span><span lang="en-US" style="font-family: "calibri";">Lawrence Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的原始論文中所展示的病歷也並不是</span><span lang="x-none" style="font-family: "calibri";">SOAP</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,因為他並沒有</span><span lang="x-none" style="font-family: "calibri";">A</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="x-none" style="font-family: "calibri";">assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">),反而是多了一個</span><span lang="x-none" style="font-family: "calibri";">Rx</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(目前處置)的項目。例如下面一段是從</span><span lang="en-US" style="font-family: "calibri";">Lawrence Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">最知名的那篇</span><span lang="en-US" style="font-family: "microsoft jhenghei";">1968</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">年刊登在</span><span lang="x-none" style="font-family: "calibri";">NEJM</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="x-none" style="font-family: "calibri";">278:593-600, 652-657</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)的文章所節錄的病歷:</span></div>
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#7
Arthralgia:</div>
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<span style="mso-spacerun: yes;"> </span>Sx - comes and goes but essentially about
the same overall.</div>
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<span style="mso-spacerun: yes;"> </span>A.M. hand stiffness seems to be her
biggest complaint.</div>
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<span style="mso-spacerun: yes;"> </span>Obj - joint films --> osteoarthritis
changes in elbows and hands</div>
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<span lang="x-none" style="font-size: 11.0pt;"><span style="mso-spacerun: yes;"> </span>Rx - </span><span lang="en-US" style="font-size: 12.0pt;">ō</span><span lang="x-none" style="font-size: 12.0pt; font-weight: bold;"> </span><span lang="x-none" style="font-size: 11.0pt;">- heat, rest, ASA</span></div>
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<span style="mso-spacerun: yes;"> </span>Plan - continue above</div>
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<a href="https://www.blogger.com/blogger.g?blogID=7535787533759742354" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=7535787533759742354" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=7535787533759742354" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=7535787533759742354" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0nlEYE85shduLrX_rVBr9KJrcFUtO_8TCUC76A1CyFjxwRQLaZPpyIeYo3u1r7cW9vlJaw-vmPdiiP-t2wvzjtjwuQAxlbMNWm95sS4rQyqgTpGuDvo1VgruCYmonbCSy9xCBD3S-B3eT/s1600/3.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="209" data-original-width="911" height="73" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0nlEYE85shduLrX_rVBr9KJrcFUtO_8TCUC76A1CyFjxwRQLaZPpyIeYo3u1r7cW9vlJaw-vmPdiiP-t2wvzjtjwuQAxlbMNWm95sS4rQyqgTpGuDvo1VgruCYmonbCSy9xCBD3S-B3eT/s320/3.png" width="320" /></a></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">事實上真正造成現代醫學史上病歷記載大革命的,,也是</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">要寫得好最需要把握的,是</span><span lang="x-none" style="font-family: "calibri";">Lawrence
Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">所發明的</span><span lang="en-US" style="font-family: "calibri";">Problem-oriented medical record</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,而非</span><span lang="x-none" style="font-family: "calibri";">SOAP</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。當然</span><span lang="x-none" style="font-family: "calibri";">SOAP</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">也是一個很好的補充,特別是</span><span lang="en-US" style="font-family: "calibri";">A</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="en-US" style="font-family: "calibri";">assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)的部分。我可以說,一份好的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,最重要的部分就是</span><span lang="x-none" style="font-family: "calibri";">Problem
list</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,再來是</span><span lang="en-US" style="font-family: "calibri";">A</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="en-US" style="font-family: "calibri";">assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">),再來是</span><span lang="x-none" style="font-family: "calibri";">P</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="x-none" style="font-family: "calibri";">Plan</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)。至於</span><span lang="x-none" style="font-family: "calibri";">S</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="x-none" style="font-family: "calibri";">Subjective</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)跟</span><span lang="x-none" style="font-family: "calibri";">O</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="x-none" style="font-family: "calibri";">Objective</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">),甚至在很多情況下我認為不用寫都可以。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第三個造成</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫不好的因素,則是有一種「字數越多代表我越認真」的執念。再加上從醫學生到醫生的養成過程中,一路上遇到各式各樣的主治醫師,對於</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">也是有各式各樣合理或不合哩,有些還彼此矛盾的要求。例如一定要有</span><span lang="x-none" style="font-family: "calibri";">vital<span style="mso-spacerun: yes;">
</span>signs</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">、一定要有身體檢查等等。這些因素造成</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">充滿太多雜訊,導致真正重要的訊息被淹沒,甚至常常寫了一堆沒意義的雜訊之後,就想說「哇字數看起來已經夠了」,反而真正重要的東西就不寫了。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">有人將這樣的現象都怪罪於病歷電子化,但我也經歷過手寫病歷的年代,這樣的現象並不會比較少;反而因為手寫太麻煩,很多重要的資訊省略得更嚴重(例如需要常常修改的</span><span lang="x-none" style="font-family: "calibri";">Problem list</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,這個後面會講),病歷品質更差。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">要改善</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">雜訊太多的現象,首先當然是醫學生或住院醫師自己要突破「字數越多代表我越認真」的心魔;再來當然是要學會哪些資訊才是重要的;最後,可能也是最重要的,則是主治醫師也應該拋棄「用病歷字數來評價醫學生或住院醫師認真程度」這樣的錯誤觀念。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第四個造成</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫不好的因素,則是太羞於寫中文。羞於寫中文本身並不是甚麼問題,但如果羞於寫中文的同時,英文程度又不是很好,那就很容易造成</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">內容空泛了。因為英語並不是我們的母語,而我們用非母語思考及表達的能力,絕對不及用母語表達,這也就造成</span><span lang="en-US" style="font-family: "calibri";">A</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="en-US" style="font-family: "calibri";">assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)的部分很難寫好。其實我們根本不需要羞於寫中文,因為我們在病歷裡寫的那些美國人也不一定看得懂的語言,與其說是英文,不如說是類似</span><span lang="x-none" style="font-family: "calibri";">Singlish</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的「</span><span lang="x-none" style="font-family: "calibri";">Taiglish</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」吧!</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">講完了</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫不好的因素,接下來講如何寫好</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">一篇好的</span><span lang="en-US" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的</span><span lang="en-US" style="font-family: "calibri";">Gold Standard</span></h1>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">當然我接下來會提出一些寫好</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的準則,然而,最重要的是一定要知道,這些準則的出發點都為了達到一個目的:</span></div>
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「讓值班的醫師(最重要)、接班的醫師、來看會診的醫師、其他醫療團隊的成員(護理師、營養師、呼吸治療師等等)等等,能在一分鐘之內了解這個病人的主要問題、重要病史、目前主要處置、住院期間的重要事件、疾病嚴重程度與發展趨勢,以及治療計畫」。</div>
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具體而言,要檢視自己的病歷有沒有達成上述目標,有幾個思想測試可以做。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第一,想像自己從來沒照顧過這個病人,他的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">也不是自己打的,今天病人忽然</span><span lang="x-none" style="font-family: "calibri";">CPR</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">了,你主導</span><span lang="x-none" style="font-family: "calibri";">CRP</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的過程,趁空檔翻開最後一篇</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,能在一分鐘內知道那些「你想知道的事情」嗎?</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第二,想像自己休假一個月,回來補</span><span lang="x-none" style="font-family: "calibri";">Discharge Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,你能光憑著出院那天的</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,就生出一篇言簡意賅的</span><span lang="x-none" style="font-family: "calibri";">Discharge Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">嗎?</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第三,想像你今天要跟人交班,你能憑著今天的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,順暢地交班,而不需要再另外打交班單嗎?</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第四,你的</span><span lang="x-none" style="font-family: "calibri";">P</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">rogress </span><span lang="x-none" style="font-family: "calibri";">Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">有超過一頁嗎?(沒超過才合格)</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">心中有這樣的對於好的</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的想像,是很重要的。因為唯有如此,才能在每一次寫病歷的時候,都產生自我反饋,隨著經驗而越寫越好。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">接下來,就說明一下我如何寫</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span></div>
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開場白</h1>
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首先,我會用幾個關鍵字湊成一個非正式的短句作開場白。</div>
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這個短句的格式式這樣的:</div>
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[age] yo
[gender], to ED on [date], admitted on [date] (via OPD), [admission reason],
[transfer history]</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">其中的</span><span lang="x-none" style="font-family: "calibri";">admission
reason</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,就是病人來住院的原因,常常是一個主訴(</span><span lang="x-none" style="font-family: "calibri";">chief complaint, CC</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">),例如:</span></div>
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79 yo
woman, to ED on 2018/12/13, admitted on 2018/12/15, CC: shortness of breath for
2 days, transferred to ICU due to respiratory failure on 2018/12/18</div>
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但並不限於主訴,例如病人可能是癌症住院來打常規化療:</div>
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<span lang="en-US">45
yo man, admitted on 2018/12/15 </span><span lang="x-none">via OPD for
chemotherapy for his colon cancer</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">順帶一提的是,因為一些大老莫名的偏執,江湖上有個傳言是</span><span lang="x-none" style="font-family: "calibri";">admission note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面</span><span lang="x-none" style="font-family: "calibri";">chief
complaint</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的部分一定要寫一個症狀,而不能寫像是</span><span lang="x-none" style="font-family: "calibri";">admitted for chemotherapy</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">這樣的住院理由。這其實是一個有礙於病歷資訊正確性的非必要的偏執。當然,「</span><span lang="en-US" style="font-family: "calibri";">admitted for chemotherapy</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」之類的「住院理由」並不是一個「</span><span lang="x-none" style="font-family: "calibri";">complaint</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」沒錯,然而該做的應該是把病歷標題的「</span><span lang="en-US" style="font-family: "calibri";">chief complaint</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」改為「</span><span lang="en-US" style="font-family: "calibri";">chief complaint</span><span lang="en-US" style="font-family: "microsoft jhenghei";">/</span><span lang="x-none" style="font-family: "calibri";">admission reason</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」,而非削足適履。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這樣的開場白並不在傳統</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的模式當中,但卻為原本單調平面的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">帶來一種「故事感」。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">雖然傳統</span><span lang="x-none" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的寫法能夠迅速抓住病人當下最重要的問題,但缺點是少了「時間感」(後面會說明如何改善這點)以及「故事感」。</span></div>
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要帶給人故事感,最重要的就是讓人腦中可以浮現一個具體的病人;而要達成這樣的目的,「年齡」、「性別」,以及「住院原因」(「主訴」或其他住院原因),就是最重要的三項資訊。一旦給人這三項資訊,腦中便會自然浮現一個病人大概的形象了。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這也就是為什麼洪瑞松老師教我們報病例的投影片首頁標題一定是「</span><span lang="x-none" style="font-family: "calibri";">A XX-year-old Woman/man with [chief complaint]</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">其實這點也不是什麼了不起的秘密,大概九成以上的醫生交班第一句也是用「這個病人是</span><span lang="x-none" style="font-family: "calibri";">89</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">歲的阿嬤啦,喘三天進來的</span><span lang="en-US" style="font-family: "microsoft jhenghei";">...</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」、「這個病人是</span><span lang="en-US" style="font-family: "calibri";">38</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">歲的先生啦,</span><span lang="x-none" style="font-family: "calibri";">colon
cancer</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">進來打化療的</span><span lang="en-US" style="font-family: "microsoft jhenghei";">...</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」來開頭。</span></div>
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把病歷寫好真的沒什麼訣竅,說穿了就是把你跟別人交班的時候想知道的事情寫進去而已。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">當然,如果你醫院的電腦系統夠先進,會在</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的頁面自動顯示病人的年齡、性別,以及住院日期,那麼你就不用額外花時間在開場白手動寫入這三個資訊(這能稱得上先進嗎?)。很可惜,敝院的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">頁面只會顯示病人的性別。</span></div>
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事實上,我認為這樣個完全就是由參數所組成的開場白,應該要是病歷書寫系統自動帶入的才對。有的大老會很排斥病歷系統有自動帶入參數的功能,甚至連複製貼上的功能都想要砍掉(其實根本是想恢復手寫病歷吧),但這根本是毫無意義的堅持。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">事實上,</span><span lang="en-US" style="font-family: "calibri";">Lawrence
Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">在他</span><span lang="en-US" style="font-family: "microsoft jhenghei";">1968</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">年的論文中,就非常推崇病歷醫囑系統的電子化!並認為電腦應該協助</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的自動生成,例如假設若病人是40歲以上女性,則電腦自動在</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">加入一個「</span><span lang="x-none" style="font-family: "calibri";"># </span><span lang="en-US" style="font-family: "microsoft jhenghei";">40</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">歲以上女性」的</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,提醒醫師做子宮頸抹片篩檢:</span></div>
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<span style="font-family: "microsoft jhenghei";">「</span><span style="font-family: "calibri";">When large amounts of demographic data are
developed, by means of the computer, a system could be developed whereby input
of certain vital statistics on any patient would automatically result in an
immediate print-</span></div>
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<span lang="zh-TW" style="font-family: "calibri";">out of his main demographic problems along with the current
approaches </span><span lang="en-US" style="font-family: "calibri";">to their
management.</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」(</span><span lang="x-none" style="font-family: "calibri";">Weed, NEJM 1968</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">當初我看到這段的時候真的是嚇到眼鏡掉到地上。</span><span lang="en-US" style="font-family: "microsoft jhenghei";">1968</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">年電腦發明了嗎?我還馬上去</span><span lang="x-none" style="font-family: "calibri";">google</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">了一下電腦發明的時間。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">他甚至跟他老婆一起開發了世界上第一個</span><span lang="en-US" style="font-family: "calibri";">PROMIS</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">系統,藉由護理師、病人,及醫學生或住院醫師所輸入到電腦裡的資料,自動產生</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">及</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="x-none" style="font-family: "calibri";">Wright et al., JAMA 2014</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)。</span></div>
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<span lang="zh-TW">沒想到一個</span><span lang="en-US">1960</span><span lang="zh-TW">年代的醫師這麼高瞻遠矚,而</span><span lang="en-US">2019</span><span lang="zh-TW">年的我所在的醫院還在用手寫醫囑。真是慚愧慚愧。</span></div>
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<h1 lang="en-US" style="color: #1e4e79; font-family: Calibri; font-size: 16.0pt; margin: 0in;">
Problem List</h1>
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<span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,是</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡最重要的部分。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">用</span><span lang="en-US" style="font-family: "calibri";">Lawrence Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="x-none" style="font-family: "calibri";">NEJM 1968</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)自己的話來說,</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">包括:</span></div>
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<br /></div>
<ol style="direction: ltr; font-family: "Microsoft JhengHei"; font-size: 11.0pt; font-style: normal; font-weight: normal; margin-bottom: 0in; margin-left: .375in; margin-top: 0in; unicode-bidi: embed;" type="1">
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;" value="1"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt; font-style: normal; font-weight: normal;">已經確立的診斷</span></li>
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">還無法用一個明確的診斷來解釋的臨床發現</span></li>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="zh-TW" style="font-family: "calibri";">both clearly
established diagnoses and all other unexplained findings that are not yet clear
manifestations of a specific diagnosis, such as abnormal physical findings or
symptoms</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)(</span><span lang="x-none" style="font-family: "calibri";">Weed, NEJM 1968</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)</span></div>
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<h2 style="color: #2e75b5; font-family: "Microsoft JhengHei"; font-size: 14.0pt; margin: 0in;">
診斷越精確越好</h2>
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其中在寫「已經確立的診斷」的時候,有個非常重要的重點,而且這個重點同樣適用於下住院診斷跟出院診斷。</div>
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這個重點就是,要搞清楚「診斷」跟「疾病分類」的不同。</div>
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所謂「診斷」,是針對『個別病人』量身打造,目的是用來概括解釋病人的臨床表現,提供預後資訊,以及作為決定治療計畫的基礎。</div>
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至於「疾病分類」,則是為了「公共衛生」以及臨床研究,以及現實中可能更重要的「保險申報」。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">臨床上千萬不可以把「下診斷」跟「疾病分類」(</span><span lang="x-none" style="font-family: "calibri";">coding</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">出一個</span><span lang="x-none" style="font-family: "calibri";">ICD code</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)畫上等號。(可以注意到</span><span lang="x-none" style="font-family: "calibri";">ICD</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">事實上是</span><span lang="x-none" style="font-family: "calibri";">international classification of disease</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的縮寫,那個</span><span lang="x-none" style="font-family: "calibri";">D</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">並不是</span><span lang="x-none" style="font-family: "calibri";">diagnosis</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的意思。)</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">用風濕免疫科醫師</span><span lang="en-US" style="font-family: "calibri";">Josef S
Smolen</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">等人的話來說就是:</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">「</span><span lang="en-US" style="font-family: "calibri";">...c</span><span lang="zh-TW" style="font-family: "calibri";">lassification is not synonymous </span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "calibri";">with diagnosis. Whereas diagnosis has the ultimate goal of being
correct at the level of the individual patient, classification aims to maximise
homogeneous populations for study purposes, but can be used to support
diagnosis.</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」(</span><span lang="en-US" style="font-family: "calibri";">Smolen et al., Lancet, 2016</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">(非常遺憾的,敝院身為全台灣最後一間在2019年仍維持手寫醫囑,以及病歷仍然要印出來的醫學中心,居然要在即將推出的電子醫囑及病歷系統中,強制規定醫囑及入出院病歷的「診斷」只能輸入</span><span lang="x-none" style="font-family: "calibri";">ICD</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">這樣的疾病分類碼,而不能輸入真正的診斷,這真是非常可笑。)</span></div>
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所以,診斷應該盡可能地針對個別病人達到最精確的程度。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">例如,不要只寫一個</span><span lang="x-none" style="font-family: "calibri";">coronary
artery disease</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。比較好的診斷應該是:</span></div>
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#
coronary artery disease, asymptomatic, double-vessel disease (left anterior
descending [60% stenosis], right<span style="mso-spacerun: yes;">
</span>coronary [70% stenosis]), diagnosed on 2019/01/03 by coronary
angiography without intervention, without history of myocardial infarction</div>
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或者:</div>
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<span lang="x-none" style="font-family: "calibri";"># ischemic heart disease, with stable angina, diagnosed on
2019/01/08 by </span><span lang="en-US" style="font-family: "calibri";">thallium-201</span><span lang="x-none" style="font-family: "calibri";"> myocardial perfusion scan<span style="mso-spacerun: yes;"> </span></span><span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="x-none" style="font-family: "calibri";">(ischemia in the LAD territory, % LV
ischemia = 25%), without history of myocardial infarction</span></div>
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或者:</div>
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<span lang="x-none">#
non-ST-elevation myocardial infarction on 2019/01/30, Killip IV, </span><span lang="en-US">TIMI Risk Score for UA/NSTEMI</span><span lang="x-none"> = 5, status
post percutaneous coronary intervention with stenting (drug-eluting) to left
anterior descending artery (culprit) and right coronary artery (non-culprit) on
2019/01/31, with concurrently diagnosed coronary artery disease, double-vessel
disease (right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">我故意舉這三個例子,是因為常常看到這些病人的病歷的診斷性</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">就通通都只是一個非常不精確的「</span><span lang="x-none" style="font-family: "calibri";">coronary
artery disease</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">如果像上面三個例子一樣寫出精確的診斷性</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,那光是看到診斷</span><span lang="en-US" style="font-family: "microsoft jhenghei";">/</span><span lang="en-US" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,你的心中就應該跳出這個病人該用的藥物,然後再去檢視目前的醫囑,是否有些該用的藥物沒用的,如此一來便能提高照護品質。</span></div>
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<span lang="x-none" style="font-family: "calibri";">Problem-oriented medical record</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">對於醫療品質的提升,事實上是有研究證據支持的。研究發現對於同樣心臟衰竭的病人來說,若其病歷中的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">有記載心臟衰竭這個問題,則這個病人被處方相對應治療藥物的比例比較高(</span><span lang="x-none" style="font-family: "calibri";">Hartung, Journal of General Internal
Medicind 2005</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">由上面三個例子應該看得出來,一個完善的診斷性</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">應該盡可能包含:</span></div>
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<ol style="direction: ltr; font-family: "Microsoft JhengHei"; font-size: 11.0pt; font-style: normal; font-weight: normal; margin-bottom: 0in; margin-left: .375in; margin-top: 0in; unicode-bidi: embed;" type="1">
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;" value="1"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt; font-style: normal; font-weight: normal;">診斷核心概念</span></li>
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">嚴重度</span></li>
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">發生/診斷時間</span></li>
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">診斷依據</span></li>
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">症狀(或沒症狀)</span></li>
</ol>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">當然,診斷性</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫這麼精確也不是沒有缺點,其中最重要的缺點有兩個。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第一,很花時間,特別是用手寫的時候。因此,我非常反對用手寫</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,因為用手寫你不可能有這樣的恆心毅力與時間,寫出這麼精確的診斷性</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。當然,改善這個缺點的做法是在病歷前面夾一張</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,而不用每天重複抄寫一樣的內容。但事實上後面會說明,一個好的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,是要即時修改的,經驗上可能一到三天就會修改一次,所以在病歷前面擺一張</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的作法,只會導致兩個結果,要不是被改成一張沒人看得懂的鬼畫符(這很少見),就是剛住院的時候寫好的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">就再也沒人改他(這最常見),而這也就失去了後面會詳述的</span><span lang="en-US" style="font-family: "calibri";">Problem-oriented medical record</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">最重要的精神——「即時修改」。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">因此,</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">最好是用電子病歷系統打(還記得嗎,這也是</span><span lang="en-US" style="font-family: "microsoft jhenghei";">1960</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">年代</span><span lang="en-US" style="font-family: "calibri";">Lawrence Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的主張),而且絕對不要犯蠢封鎖複製貼上的功能——這只會讓病歷的品質更差!</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">如果用電子病歷系統打</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,而且擁有自動複製上之前的</span><span lang="x-none" style="font-family: "calibri";">Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的功能的話,寫出精確的</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">並且即時修改,就再也不是一件很花時間的事情。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">診斷性</span><span lang="en-US" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫得精確的第二個缺點是,資訊量太大,讓人無法一眼抓住重點。</span></div>
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要改善這個缺點,可以透過排版技巧來達成。</div>
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<h2 style="color: #2e75b5; font-size: 14.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的排版技巧</span></h2>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第一個技巧是關於問題清單(</span><span lang="x-none" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)排列的技巧。首先,我想應該不會有人把一個個問題清單頭尾相連寫成一個不分行的段落,例如:</span></div>
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<span lang="x-none" style="font-family: "calibri";">acute kidney injury; ST-elevation myocardial infarction; diabetes
millitus</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">;</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">而是至少會每次遇到要寫下一個</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候,強制換行書寫,例如:</span></div>
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<span lang="x-none"># </span><span lang="en-US">acute kidney injury</span></div>
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<span lang="x-none">#</span><span lang="en-US"> ST-elevation myocardial infarction</span></div>
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<span lang="x-none">#</span><span lang="en-US"> diabetes millitus</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這樣子的做法,是一個能減輕視覺負擔的排版技巧,也試APA所認可的正式寫作格式——是的,你也可以(而且我推薦)這樣寫</span><span lang="x-none" style="font-family: "calibri";">Admission Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面的</span><span lang="x-none" style="font-family: "calibri";">Present Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,例如:</span></div>
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This
85-year-old man has a history of:</div>
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<span style="mso-spacerun: yes;"> </span># diabetes millitus, type 2;</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># hypertension; and</div>
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<span style="mso-spacerun: yes;"> </span># chronic kidney disease, stage 3.</div>
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有些大老看到這樣的句子會不開心,但你可以拿出APA的手冊告訴他,這句話不但文法正確,還是APA所認可的寫作格式,特別適用於當你所列舉的清單項目比較多、比較長的時候,有助於減輕閱讀者的認知負擔。</div>
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<span lang="zh-TW">然而,真對這種強制換行的清單列舉格式,</span><span lang="en-US">APA</span><span lang="zh-TW">推薦兩種做法,分別試用不同的情境。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第一是像我上面舉的例子一樣,以項目符號開頭。最常用的項目符號是「•」,但以醫學上的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">而言,通用的項目符號是「</span><span lang="x-none" style="font-family: "calibri";">#</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」,這不但通用,還具有歷史傳承的意義。我們來看出自</span><span lang="en-US" style="font-family: "calibri";">Lawrence Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(</span><span lang="en-US" style="font-family: "calibri";">NEJM 1968</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)原始論文裡的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">實例:</span></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1OBwEjmaJdA16tqzqi0HZnS-LJYic84WrGL6jtAi3K5_nzN_MLspwfcpp4sWqNTuIXaBN3YaAS8BFMOb-AK2wNUffPQArtYSnB7NiMmHasVZwBKx93psGiMWAGu-O2wYDHr3nswfgXQ8l/s1600/1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="599" data-original-width="587" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1OBwEjmaJdA16tqzqi0HZnS-LJYic84WrGL6jtAi3K5_nzN_MLspwfcpp4sWqNTuIXaBN3YaAS8BFMOb-AK2wNUffPQArtYSnB7NiMmHasVZwBKx93psGiMWAGu-O2wYDHr3nswfgXQ8l/s320/1.png" width="313" /></a></div>
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<br />
第二種列舉清單的作法則是給予編號作開頭,例如:</div>
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<span lang="x-none">1.
</span><span lang="en-US">acute kidney injury</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none">2.
</span><span lang="en-US">ST-elevation myocardial infarction</span></div>
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<span lang="x-none">3.</span><span lang="en-US"> diabetes millitus</span></div>
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<span lang="en-US">APA</span><span lang="zh-TW">手冊指出,這種以「編號」作開頭的清單格式,特別適用於清單項目彼此有輕重緩急或時間順序等關係,不同的排序具有不同的意義的情境;相對而言,以「項目符號」作開頭,則適用於清單項目彼此的地位是對等,可以隨意排列的情境。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">而醫學上病歷的</span><span lang="x-none" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">中的各個問題,絕對是具有不同的重要程度的。因此,理論上比較適用以編號作開頭的清單格式。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">我們再回頭看</span><span lang="en-US" style="font-family: "calibri";">Lawrence
Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">論文中的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,也是以編號作開頭(他編號前面所加的「</span><span lang="x-none" style="font-family: "calibri";">#</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」並不是項目符號,而是從十九世紀就被使用加在編號前面的「</span><span lang="x-none" style="font-family: "calibri";">number sign</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」)。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">那麼,為什麼我上面的例子,以及我實際在臨床書寫病歷上,都是單純使用「</span><span lang="x-none" style="font-family: "calibri";">#</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」作為項目符號,而不加以數字編號呢?</span></div>
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<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這是因為,敝院的病歷系統沒有</span><span lang="x-none" style="font-family: "microsoft jhenghei";">像</span><span lang="x-none" style="font-family: "calibri";">Word</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">一樣自動編號的功能。所以,每當你調整原有問題的順序,或者加入新的問題,或者刪除已有問題,就需要同時手動更改其他問題的編號。而手動更改編號有兩個討人厭的地方,第一就是容易出錯或漏改,第二則是很花時間很麻煩。</span></div>
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「容易出錯或漏改」就不用多說了,不要小看「很花時間很麻煩」這樣的問題,覺得只是無病呻吟在抱怨而已。從人性與實際的角度來看,改編號很花時間很麻煩,只會造成一個結果,那就是讓人不想修改問題的順序;以及在新增問題的時候,不權衡所新增問題的重要程度,將之插入適當的序號,而是直接將新問題放在舊的問題後面,讓人以為新的問題最不重要。</div>
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而這將嚴重影響病歷的品質。</div>
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因此,兩相權衡之下,我覺得確實即時更新問題的排序更重要,因此選擇使用項目編號。</div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">當然,數字編號還有一個好處,那就是在針對各個問題寫</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候,可以直接用那個問題的編號來省略代表那個問題。</span></div>
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病歷的目的,在於傳達資訊;傳達資訊的要點,在於從資訊接收者的角度出發,藉由認知心理學的技巧,減輕資訊接收者的認知負擔。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">所以,在寫</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候,最好是遵守兩個原則:</span></div>
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原則一,最重要的擺最上面,</div>
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比較不重要的擺比較下面。</div>
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原則二,最重要的擺最前面(最左邊),比較不重要的擺比較後面(比較右邊)。</div>
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舉個例子:</div>
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<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<2019/01/31
Progress Note></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "calibri";">79 y</span><span lang="x-none" style="font-family: "calibri";">o woman, to
ED and admitted on 2019/01/30, CC:</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">胸坎實實三小時</span></div>
<div lang="en-US" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
#
non-ST-elevation myocardial infarction on 2019/01/30, Killip IV, TIMI Risk
Score for UA/NSTEMI = 5, status post percutaneous coronary intervention with
stenting (drug-eluting) to left anterior descending artery (culprit) and right
coronary artery (non-culprit) on 2019/01/31, with concurrently diagnosed
coronary artery disease, double-vessel disease (right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none">#</span><span lang="en-US"> diabetes millitus</span><span lang="x-none">, type 2, diagnosed on
2019/01/30 with HbA1c 7.6</span></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">以寫病歷的時間而言,這個病人最主要的問題顯而易見是剛做完導管的</span><span lang="x-none" style="font-family: "calibri";">NSTEMI</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,因此應該列為第一個問題。至於這次住院當天新診斷的</span><span lang="en-US" style="font-family: "calibri";">HbA1c 7.6</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的糖尿病,則應該列在第二個問題。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">再來,第一個問題之中,最重要的當然是</span><span lang="en-US" style="font-family: "calibri";">non-ST-elevation myocardial infarction</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">這個診斷的核心概念,因此應該放在句子的最前面。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第二個問題也是一樣,比起</span><span lang="x-none" style="font-family: "calibri";">type
2 diabetes millitus</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,我會比較喜歡</span><span lang="en-US" style="font-family: "calibri";">diabetes
millitus, type 2</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的寫法,因為診斷的核心概念擺前面,後面才補充分類,可以減輕閱讀者的認知負擔。當然,這個診斷很短,兩種寫法差別可能不大。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">以上說明了關於問題清單(</span><span lang="en-US" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)排列的技巧。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第二個</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的排版技巧,則是強制換行,將每個問題的第一行只用來凸顯最重要的資訊。這個技巧還得同時配合「凸排」的排版技巧。此外,如果病歷系統有粗體字功能的話,最好也是配合使用(敝院沒有)。要注意的是,如果病歷系統不是像</span><span lang="x-none" style="font-family: "calibri";">W</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">ord一樣有可以設定多個層次的自動凸排的功能的話,就得手動凸排(就像敝院一樣);同時,若病歷系統讓你很難捉摸何時會自動換行的話(就像敝院一樣),最好是在每次強制換行的時候,句首加上連字號「</span><span lang="en-US" style="font-family: "microsoft jhenghei";">-</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」,以方便標示說這行的第一個單字並不是接續上一行的句末但被自動換行。</span></div>
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<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
例如:</div>
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<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<2019/01/31
Progress Note></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "calibri";">79 y</span><span lang="x-none" style="font-family: "calibri";">o woman, to
ED and admitted on 2019/01/30, CC:</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">胸坎實實三小時</span></div>
<div lang="en-US" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"># non-ST-elevation myocardial infarction</span> on
2019/01/30,</div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- Killip IV,
TIMI Risk Score for UA/NSTEMI = 5,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- status
post percutaneous coronary intervention with stenting (drug-eluting) to left
anterior descending artery (culprit) and right coronary artery (non-culprit) on
2019/01/31,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- with
concurrently diagnosed coronary artery disease, double-vessel disease
(right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-weight: bold;">#</span><span lang="en-US" style="font-weight: bold;"> diabetes millitus</span><span lang="x-none">, type 2,</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="en-US" style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>-
</span><span lang="x-none" style="font-family: "calibri";">diagnosed on 2019/01/30
with HbA1c 7.6</span></div>
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<a href="https://www.blogger.com/blogger.g?blogID=7535787533759742354" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=7535787533759742354" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=7535787533759742354" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">加上這些排版之後,</span><span lang="x-none" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">是不是在詳細卻實的同時,又更富層次感,減少你閱讀的認知負擔,讓你一眼就抓到重點了呢?</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">再回頭看看</span><span lang="en-US" style="font-family: "calibri";">Lawrence
Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,其實早就用了上述其中一些排版技巧了呢。</span></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCYLYy3463h-QP8PEUsUD90SMeA_UKV8OxdiUKK9p0i3bDRj07dVWTIpREDbervCJvrv7LckT2i6GSSAngghRsdljjCz49pciQZHeS8bM7Bm59LY3a1JdWsh-NVNELl7DhZs7SqwF7hf0E/s1600/2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="504" data-original-width="784" height="205" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCYLYy3463h-QP8PEUsUD90SMeA_UKV8OxdiUKK9p0i3bDRj07dVWTIpREDbervCJvrv7LckT2i6GSSAngghRsdljjCz49pciQZHeS8bM7Bm59LY3a1JdWsh-NVNELl7DhZs7SqwF7hf0E/s320/2.png" width="320" /></a></div>
<br />
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<h2 style="color: #2e75b5; font-family: "Microsoft JhengHei"; font-size: 14.0pt; margin: 0in;">
<span lang="zh-TW">寫出一份具有</span><span lang="en-US">3D</span><span lang="zh-TW">感的</span><span lang="en-US">Problem List</span></h2>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">有些人可能從我剛剛一些</span><span lang="x-none" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的例子,就發現我非常注重「日期」。不論是診斷的日期,還是檢查(</span><span lang="x-none" style="font-family: "calibri";">CT</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">、抽血數據)的日期,都最好</span><span lang="x-none" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">中寫清楚。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這樣做的原因,是為了彌補</span><span lang="en-US" style="font-family: "calibri";">Problem-oriented
medical record</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的最大缺陷——太平面了,缺乏時間感(故事性)。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這樣的缺陷在問題只有一兩個的時候可能還不明顯,但一旦問題多了起來,甚至是住院中產生新的問題,這時就算你的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">是依照問題的重要性依序排列,但你一眼望去,還是會覺得雜亂無章,抓不到重點。因為不論怎麼依照重要性排序,</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">依然是一個缺乏時間感(故事性)的平面;而人類最習慣的是透過時間軸來理解事情(故事)。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
例如上述心肌梗塞的病人,假設住院五天之後,心臟狀況都穩定了,卻忽然發生肺炎,這時最重要的問題當然變成了肺炎,應該挪到第一個問題;但如果你的病歷是這樣寫:</div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<2019/02/06
Progress Note></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "calibri";">79 y</span><span lang="x-none" style="font-family: "calibri";">o woman, to
ED and admitted on 2019/01/30, CC:</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">胸坎實實三小時</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri"; font-weight: bold;">#</span><span lang="en-US" style="font-family: "microsoft jhenghei"; font-weight: bold;"> </span><span lang="x-none" style="font-family: "calibri"; font-weight: bold;">Pneumonia</span></div>
<div lang="en-US" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"># non-ST-elevation myocardial infarction</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-weight: bold;">#</span><span lang="en-US" style="font-weight: bold;"> diabetes millitus</span><span lang="x-none">, type 2</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
便會讓人摸不著頭緒,這個肺炎是他住院的原因嗎?還是後來發生的院內型肺炎呢?心肌梗塞會不會是肺炎所誘發的呢?當然我有寫了那句開場白,會比較好一點,但那個胸坎實實三小時,是不是也可能是肺炎所導致呢?</div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">如果我們加上時間,甚至加上「</span><span lang="en-US" style="font-family: "calibri";">hospital-accquired</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」,整個感覺就會不一樣了,充滿了故事性:</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<2019/02/06
Progress Note></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "calibri";">79 y</span><span lang="x-none" style="font-family: "calibri";">o woman, to
ED and admitted on 2019/01/30, CC:</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">胸坎實實三小時</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-weight: bold;"># Pneumonia</span><span lang="x-none">,
hospital-accquired, diagnosed on 2019/02/03</span></div>
<div lang="en-US" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"># non-ST-elevation myocardial infarction</span> on
2019/01/30,</div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- Killip IV,
TIMI Risk Score for UA/NSTEMI = 5,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- status
post percutaneous coronary intervention with stenting (drug-eluting) to left
anterior descending artery (culprit) and right coronary artery (non-culprit) on
2019/01/31,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- with
concurrently diagnosed coronary artery disease, double-vessel disease
(right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-weight: bold;">#</span><span lang="en-US" style="font-weight: bold;"> diabetes millitus</span><span lang="x-none">, type 2,</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="en-US" style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>-
</span><span lang="x-none" style="font-family: "calibri";">diagnosed on 2019/01/30
with HbA1c 7.6</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<h2 style="color: #2e75b5; font-size: 14.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">區分</span><span lang="en-US" style="font-family: "calibri";">Active/Inactive Problems</span></h2>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">再來,若這個病人的心臟及血糖部分的治療與臨床表現都穩定了,我們最好將其列入「</span><span lang="x-none" style="font-family: "calibri";">Inactive Problems</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」當中,而且最好也是註明列入</span><span lang="x-none" style="font-family: "calibri";">Inactive
Problems</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時間,以增加病歷的「</span><span lang="en-US" style="font-family: "microsoft jhenghei";">3D</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">感」(雖然說加上時間軸應該是</span><span lang="en-US" style="font-family: "microsoft jhenghei";">4D</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">才對,但這裡的3D只是比喻,用來凸顯沒有時間軸的病歷是平面的)。</span><span lang="x-none" style="font-family: "calibri";">Active Problems</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">我就不特別註明</span><span lang="x-none" style="font-family: "calibri";">Active</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">了,因為本來預設就是</span><span lang="x-none" style="font-family: "calibri";">Active</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,當然你要註明也可以。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<2019/02/06
Progress Note></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "calibri";">79 y</span><span lang="x-none" style="font-family: "calibri";">o woman, to
ED and admitted on 2019/01/30, CC:</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">胸坎實實三小時</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-weight: bold;"># Pneumonia</span><span lang="x-none">,
hospital-accquired, diagnosed on 2019/02/03</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;">INACTIVE:</span></div>
<div lang="en-US" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"># non-ST-elevation myocardial infarction</span> on
2019/01/30,</div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- Killip IV,
TIMI Risk Score for UA/NSTEMI = 5,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- status
post percutaneous coronary intervention with stenting (drug-eluting) to left
anterior descending artery (culprit) and right coronary artery (non-culprit) on
2019/01/31,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- with
concurrently diagnosed coronary artery disease, double-vessel disease
(right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="x-none" style="font-family: "calibri";">*</span><span lang="en-US" style="font-family: "calibri";"> </span><span lang="x-none" style="font-family: "calibri";">2019/02/04
became inactive</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-weight: bold;">#</span><span lang="en-US" style="font-weight: bold;"> diabetes millitus</span><span lang="x-none">, type 2,</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="en-US" style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>-
</span><span lang="x-none" style="font-family: "calibri";">diagnosed on 2019/01/30
with HbA1c 7.6</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="x-none" style="font-family: "calibri";">*</span><span lang="en-US" style="font-family: "calibri";"> </span><span lang="x-none" style="font-family: "calibri";">2019/02/02
became inactive</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">又過了幾天,這個病人的肺炎(一個可以治癒的急性疾病)抗生素療程結束了(但中間又出現了</span><span lang="x-none" style="font-family: "calibri";">DKA</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的問題,所以繼續住院),這時可將之歸入</span><span lang="x-none" style="font-family: "calibri";">Resolved Problems</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">:</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<2019/02/11
Progress Note></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "calibri";">79 y</span><span lang="x-none" style="font-family: "calibri";">o woman, to
ED and admitted on 2019/01/30, CC:</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">胸坎實實三小時</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"># diabetic ketoacidosis</span>, diagnosed on
2019/02/08</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;">RESOLVED:</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-weight: bold;"># Pneumonia</span><span lang="x-none">,
hospital-accquired, diagnosed on 2019/02/03</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span>= IV Tazocin [2019/02/03-09]</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span>* 2019/02/09 -> resolved</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;">INACTIVE:</span></div>
<div lang="en-US" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"># non-ST-elevation myocardial infarction</span> on
2019/01/30,</div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- Killip IV,
TIMI Risk Score for UA/NSTEMI = 5,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- status
post percutaneous coronary intervention with stenting (drug-eluting) to left
anterior descending artery (culprit) and right coronary artery (non-culprit) on
2019/01/31,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- with
concurrently diagnosed coronary artery disease, double-vessel disease
(right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="x-none" style="font-family: "calibri";">*</span><span lang="en-US" style="font-family: "calibri";"> </span><span lang="x-none" style="font-family: "calibri";">2019/02/04
-> inactive</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-weight: bold;">#</span><span lang="en-US" style="font-weight: bold;"> diabetes millitus</span><span lang="x-none">, type 2,</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="en-US" style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>-
</span><span lang="x-none" style="font-family: "calibri";">diagnosed on 2019/01/30
with HbA1c 7.6</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="x-none" style="font-family: "calibri";">*</span><span lang="en-US" style="font-family: "calibri";"> </span><span lang="x-none" style="font-family: "calibri";">2019/02/02<span style="mso-spacerun: yes;"> </span>-><span style="mso-spacerun: yes;">
</span>inactive</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這樣的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">看似繁雜,但其實一眼看去就你就知道只要專注在</span><span lang="x-none" style="font-family: "calibri";">active problem DKA</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">上就好了,其他都不用處理。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">但很重要的是在此同時,你也把住院發生的所有故事都記錄下來了,不但交班方便,接班的人甚至不需要當面交班,自己看最後一天的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">就能了解這個病人了。此外,你要寫出出院病摘的時候,住院治療經過也只要把最後一天的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">改成正式的文章就可以了。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">至於出院診斷則更簡單,直接複製貼上最後一天的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,再刪除一些多餘的註解就好了。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這邊更凸顯了</span><span lang="x-none" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">處處壓上(診斷)日期的重要性。因為你今天下的出院診斷,就是別人明天看的過去病史。而這邊剛好順便說明一下怎麼樣寫病人的過去病史,以及如何下入院及出院診斷。這是我認為目前的病歷品質最需要提升的一塊(而不是什麼</span><span lang="x-none" style="font-family: "calibri";">Review of Systems</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,拜託請把這塊沒有</span><span lang="x-none" style="font-family: "calibri";">evidence base</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的病歷區塊拿掉!)。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<h1 style="color: #1e4e79; font-size: 16.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";">如何寫過去病史</span><span style="font-family: "calibri";">/</span><span style="font-family: "microsoft jhenghei";">入院診斷</span><span style="font-family: "calibri";">/</span><span style="font-family: "microsoft jhenghei";">出院診斷</span></h1>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">過去病史,我以及很多人是用來作為</span><span lang="x-none" style="font-family: "calibri";">Present Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的開場白:</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";">This 84-year-old woman </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(對,就是上面</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面那位心肌梗塞的老太太五年後又住院了)</span><span lang="x-none" style="font-family: "calibri";"> has a history of:</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># diabetes millitus, type 2;</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># non-ST-elevation myocardial infarction</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># coronary artery disease;</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># hypertension; and</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># chronic kidney disease, stage 3a.</div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">順帶一提,</span><span lang="x-none" style="font-family: "calibri";">Admission
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面</span><span lang="x-none" style="font-family: "calibri";">Present Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">下一個欄位是</span><span lang="x-none" style="font-family: "calibri";">Personal History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,其中又包含</span><span lang="x-none" style="font-family: "calibri";">Past History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。就資訊管理的角度而言,同樣的資訊不該有兩處不會自動同步的來源,因為這樣不但在輸入</span><span lang="x-none" style="font-family: "calibri";">Past History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">這個資訊的時候要輸入兩次,而且很容易產生不一致的現象(下次住院複製上次的住院病歷,但只更新了</span><span lang="x-none" style="font-family: "calibri";">Present Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面的</span><span lang="x-none" style="font-family: "calibri";">Past History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">解決這個問題的方法有三個,第一,</span><span lang="x-none" style="font-family: "calibri";">Present Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">不要寫到</span><span lang="x-none" style="font-family: "calibri";">Past
History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。這個方法會導致寫出來的病歷不切合醫學上的診斷推理過程,也不符合投稿學術期刊的個案報告格式。因為我們總是先了解病人的資本資料、主訴、過去病史(這三個重要程度幾乎相當),才進一步了解現在病史,最後則是身體及其他檢查,最終得出可能的診斷。因此這個方法不可行。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第二,</span><span lang="x-none" style="font-family: "calibri";">Past History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">單純寫在</span><span lang="x-none" style="font-family: "calibri";">Present History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">就好,把</span><span lang="x-none" style="font-family: "calibri";">Past History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的獨立欄位取消掉。這個方法還算可以,但也有缺點。因為</span><span lang="x-none" style="font-family: "calibri";">Present Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">並不總是把所有的</span><span lang="x-none" style="font-family: "calibri";">P</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">ast </span><span lang="x-none" style="font-family: "calibri";">History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫出來,特別是</span><span lang="x-none" style="font-family: "calibri";">Past History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">一大堆(二十個診斷),或者有些對於本次住院不重要的小毛病(痔瘡)的時候。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">第三個方法,也是我自己使用的方法。我會將重要的</span><span lang="x-none" style="font-family: "calibri";">Past History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫在</span><span lang="x-none" style="font-family: "calibri";">Present
Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">中;至於</span><span lang="x-none" style="font-family: "calibri";">Personal History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面的</span><span lang="x-none" style="font-family: "calibri";">Past History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">欄位,我會寫上「</span><span lang="x-none" style="font-family: "calibri";">as Present Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」;若有</span><span lang="x-none" style="font-family: "calibri";">Present Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">沒寫到的過去病史,我就補充在</span><span lang="en-US" style="font-family: "calibri";">Personal History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面的</span><span lang="en-US" style="font-family: "calibri";">Past History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">欄位中。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">回歸主題,在寫</span><span lang="x-none" style="font-family: "calibri";">Present
Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候,要注意的重點,其實跟上述寫</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候差不多。但其中針對過去病史的書寫,特別需要強調的守則有兩個:</span><span lang="x-none" style="font-family: "calibri";">1) </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">依照重要程度排序,以及</span><span lang="x-none" style="font-family: "calibri";"> 2) </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">押上診斷日期。</span></div>
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依照重要程度排序這個不用多說,也是為了減輕閱讀者的認知負載。</div>
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過去病史/診斷押上日期的重要性與訣竅</h2>
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過去病史要押上診斷日期的道理也不難理解。五歲診斷的糖尿病跟七十歲診斷的糖尿病,意義絕對不同。一年的糖尿病跟二十年的糖尿病,意義也當然不同。其他像是COPD、心肌梗塞、氣喘、癌症......等等,幾乎你想得到的疾病,不同的診斷年紀,或不同的罹病時間,都有不同的意義。</div>
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這也就是為什麼過去病史押上診斷日期非常重要。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">有一種給過去病史(間接)押上診斷日期的方法是這樣的:</span><span lang="x-none" style="font-family: "calibri";">has a history of type 2 diabetes millitus for 5 years</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">、</span><span lang="x-none" style="font-family: "calibri";">had ischemic stroke 4 years ago</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">我非常不推薦這種方法,因為這種方法常常導致一個不該出現的現象:八年之後這個病人又住院了,病歷裡還是一樣寫著</span><span lang="en-US" style="font-family: "calibri";">has a history of type 2 diabetes
millitus for 5 years</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">、</span><span lang="x-none" style="font-family: "calibri";">had ischemic
stroke 4 years ago</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">——因為是複製貼上的嘛。</span></div>
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我前面已經說過,我非常讚賞複製貼上的功能,因為這可以節省醫師花在文書作業的時間,增加與病人互動的時間,增進工作效率,減少職業倦怠。把複製貼上的功能鎖起來是非常愚蠢的因噎廢食的行為。</div>
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但是,因為大老對複製貼上有太多的偏見與無謂的排斥,導致醫界不願正視複製貼上的存在。沒正視問題,當然也就無法解決問題。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">要解決上面那個「萬年五年糖尿病」的問題非常簡單,就是要培養一個文化,讓所有的病歷書寫者能養成一個「以複製為導向」的病歷寫作模式(</span><span lang="x-none" style="font-family: "calibri";">copy-oriented medical record, COMR</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,讀作</span><span lang="x-none" style="font-family: "calibri";">come ar</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">[來啊])。</span></div>
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所謂「以複製為導向」的病歷寫作模式,就是要盡一切力量避免出現那些「被別人複製貼上後會產生矛盾或錯誤」的病歷片段。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">例如一個</span><span lang="en-US" style="font-family: "microsoft jhenghei";">84</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">歲的女性病人,在</span><span lang="en-US" style="font-family: "microsoft jhenghei";">2019</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">年的時候「</span><span lang="en-US" style="font-family: "calibri";">has a history of type 2 diabetes
millitus for 5 years</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」,其中的「</span><span lang="x-none" style="font-family: "calibri";">for 5
years</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」,就應寫成「</span><span lang="x-none" style="font-family: "calibri";">, diagnosed in 2014</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」,或「</span><span lang="en-US" style="font-family: "calibri";">, diagnosed in </span><span lang="x-none" style="font-family: "calibri";">her 79 years of age</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」(用年齡還是年份視情況而定)。使用這樣的絕對時間參數,不管怎麼複製都不會出錯。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">此外,每當你押上任何一個日期的時候,請不要只寫月份日期,請一定要加上年份。道理很簡單,也是</span><span lang="x-none" style="font-family: "calibri";">COMR</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">原則,不要讓三年後複製你病歷的人還要想你的</span><span lang="en-US" style="font-family: "microsoft jhenghei";">09/01</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">到底是哪一年,還是說是</span><span lang="en-US" style="font-family: "microsoft jhenghei";">2009</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">年01月?還是說試</span><span lang="en-US" style="font-family: "microsoft jhenghei";">2001</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">年09月?只要在寫病歷的時候拋棄以自我為中心,就不會忽略這些小細節。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">此外,我在寫病歷的時候日期格式統一用</span><span lang="x-none" style="font-family: "calibri";">yyyy/mm/dd</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(個位數月份或日期則在十位數補</span><span lang="x-none" style="font-family: "calibri";">0</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">),也方便有的時候需要上下行對齊日期。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">其他的例子還有,不要在</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡寫抗生素打了幾天(除非是在你停掉抗生素的那天),而要寫從幾月幾號開始打的;不要在</span><span lang="en-US" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡寫手術後第幾天,而要寫是幾月幾號手術的;寫</span><span lang="x-none" style="font-family: "calibri";">Off Service</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候要想像你是在寫出院病摘,不要寫</span><span lang="x-none" style="font-family: "calibri";">I</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(第一人稱單數)要寫</span><span lang="x-none" style="font-family: "calibri";">We</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">(第一人稱複數),不要出現未來式等等,都是貼心的</span><span lang="x-none" style="font-family: "calibri";">COMR</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">模式,有待您用心慢慢摸索體會。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">理解了寫過去病史的兩個重點(依重要程度排序、押上日期[</span><span lang="x-none" style="font-family: "calibri";">COMR</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">模式]),我們可以將上面的例子改寫為:</span></div>
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This
84-year-old woman has a history of:</div>
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<span lang="x-none"><span style="mso-spacerun: yes;"> </span># non-ST-elevation myocardial infarction</span><span lang="en-US"> on 2019/01/30,</span><span lang="x-none"> </span><span lang="en-US">status
post percutaneous coronary intervention with stenting (drug-eluting) to left
anterior descending artery (culprit) and right coronary artery (non-culprit) on
2019/01/31, with concurrently diagnosed coronary artery disease, double-vessel
disease (right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span><span lang="x-none">;</span></div>
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<span style="mso-spacerun: yes;"> </span># chronic kidney disease, stage 3a;</div>
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<span style="mso-spacerun: yes;"> </span># diabetes millitus, type 2, diagnosed in her
79 years of age; and</div>
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<span style="mso-spacerun: yes;"> </span># hypertension.</div>
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附上重要檢查結果、重要用藥</h2>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">接著,還可以進一步精進我們的過去病史。也就是附上重要檢查結果,以及重要用藥。當然,請謹記</span><span lang="x-none" style="font-family: "calibri";">COMR</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的病歷寫作原則,當你附上這種可能會隨時間改變的參數的時候,請記得一定要隨手押上時間!</span></div>
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This
84-year-old woman has a history of:</div>
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<span lang="x-none"><span style="mso-spacerun: yes;"> </span># non-ST-elevation myocardial infarction</span><span lang="en-US"> on 2019/01/30,</span><span lang="x-none"> </span><span lang="en-US">status
post percutaneous coronary intervention with stenting (drug-eluting) to left
anterior descending artery (culprit) and right coronary artery (non-culprit) on
2019/01/31, with concurrently diagnosed coronary artery disease, double-vessel
disease (right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span><span lang="x-none">;</span></div>
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<span style="mso-spacerun: yes;"> </span># chronic kidney disease, stage 3a (eGFR 52 on
2024/01/03);</div>
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<span style="mso-spacerun: yes;"> </span># diabetes millitus, type 2, diagnosed in her
79 years of age (HbA1c 8.3 on 2024/01/03; on metformin, Levemir on 2024/02/05);
and</div>
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<span style="mso-spacerun: yes;"> </span># hypertension, diagnosed in her 60s (on
amlodipine, valsarten on 2024/02/05).</div>
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這樣看起來很繁瑣,但是我認為這是身為內科醫師應該具備的基本功,也是照顧好病人的基本條件。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">很多時候我在打</span><span lang="x-none" style="font-family: "calibri";">Present
Illness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候,可能一半以上的時間都是在整理</span><span lang="x-none" style="font-family: "calibri";">Past History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span></div>
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當然,病人多的時候就無法這樣了(也滿常病人多的)。</div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">從過去病史到入院診斷到</span><span lang="en-US" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">到出院診斷</span></h2>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">接下來要講如何下入院診斷。其實你已經會了,就跟寫</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">一樣罷了。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">不過,我前面在說明怎麼寫</span><span lang="x-none" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候,還有一點沒講到,那就是過去病史。</span></div>
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<span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">列出重要的或相關的過去病史,絕對是必要且重要的。</span></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">從前面</span><span lang="en-US" style="font-family: "calibri";">Lawrence Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">論文中的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">可以發現,他在</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">中列出過去病史的方法,是在過去病史的診斷前面加上「</span><span lang="x-none" style="font-family: "calibri";">Hx (history) of [past history]</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」,並將這個</span><span lang="x-none" style="font-family: "calibri";">problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">列在</span><span lang="x-none" style="font-family: "calibri";">Resolved Problems</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">當中。你可以這樣做,不過我覺得這樣會出現重複的字眼,而且缺乏將過去病史在視覺上集中的效果。因此,我的作法是另列一區</span><span lang="x-none" style="font-family: "calibri";">Problems</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,註明是</span><span lang="x-none" style="font-family: "calibri";">History</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">:</span></div>
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<2024/02/11
Progress Note></div>
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<span lang="x-none" style="font-family: "calibri";">84</span><span lang="en-US" style="font-family: "calibri";"> y</span><span lang="x-none" style="font-family: "calibri";">o woman, to ED and admitted on
2024/02/10, CC:</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">drowsy
consciousness for hours</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"># diabetic ketoacidosis</span>, diagnosed on
2024/02/10, with consciousness change (which subsided)</div>
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<span style="font-weight: bold;">HISTORY:</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none"><span style="mso-spacerun: yes;"> </span># non-ST-elevation myocardial infarction</span><span lang="en-US"> on 2019/01/30,</span><span lang="x-none"> </span><span lang="en-US">status
post percutaneous coronary intervention with stenting (drug-eluting) to left
anterior descending artery (culprit) and right coronary artery (non-culprit) on
2019/01/31, with concurrently diagnosed coronary artery disease, double-vessel
disease (right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span></div>
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<span style="mso-spacerun: yes;"> </span># chronic kidney disease, stage 3a (eGFR 52 on
2024/01/03)</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># diabetes millitus, type 2, diagnosed in her
79 years of age (HbA1c 8.3 on 2024/01/03; on metformin, Levemir on 2024/02/05)</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># hypertension, diagnosed in her 60s (on
amlodipine, valsarten on 2024/02/05)</div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">有沒有發現,</span><span lang="x-none" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面過去病史的部分,只是把</span><span lang="x-none" style="font-family: "calibri";">Admission Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面的過去病史直接貼上去而已!辛苦終於有了代價!</span></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">至於出院診斷,就像我前面說過的,「更簡單,直接複製貼上最後一天的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,再刪除一些多餘的註解就好了」。</span></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這裡要指出一個不好的習慣,就是不管是在寫入院診斷、</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,還是出院診斷的時候,把這次住院的新診斷跟過去病史直接並列。當然,過去病史通常還是被放在後面。但是,你從病歷閱讀者的角度來看,根本不一定看得出來從哪一個診斷開始是過去病史。</span></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">因此,不管是入院診斷、</span><span lang="en-US" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,還是出院診斷,我一定會在過去病史前面加上「</span><span lang="x-none" style="font-family: "calibri";">HISTORY:</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」。</span></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">我也看過有人會寫「</span><span lang="x-none" style="font-family: "calibri";">underlying</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」,或者「</span><span lang="x-none" style="font-family: "calibri";">chronic disease</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」。其實都可以,只是我覺得「</span><span lang="en-US" style="font-family: "calibri";">HISTORY</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」比較概括,例如當你需要在過去病史列出「</span><span lang="x-none" style="font-family: "calibri";">acute appendicitis, status post
laparoscopic appendectomy on 2015/03/09</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」的時候,你就很難說他是個「</span><span lang="en-US" style="font-family: "calibri";">underlying</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」或者「</span><span lang="en-US" style="font-family: "calibri";">chronic disease</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」。</span></div>
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<br /></div>
<h1 style="color: #1e4e79; font-size: 16.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">必須即時更新</span></h1>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">在寫</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的時候,其實就是一個「不斷從『症狀』推理出『診斷』」的過程。</span></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">前面我都用具體的診斷當作</span><span lang="x-none" style="font-family: "calibri";">Problem</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的例子,是為了讓各位熟悉「一個已經有診斷的病人」的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">該如何書寫。</span></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">我前面說過,可能很多人都很熟悉「從症狀到診斷」的</span><span lang="en-US" style="font-family: "microsoft jhenghei";">SOAP</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">病歷書寫法。但其實,可能熟悉的只是那些很簡單可以從症狀歸納到診斷的病歷書寫法。當遇到病人的症狀遲遲得不到好的解釋,或者花了一個禮拜做了好多個檢查才得出診斷的時候,這中間的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">就不太會寫了。</span></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">我們來看</span><span lang="en-US" style="font-family: "calibri";">Lawrence
Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">怎麼描述這個「從症狀到診斷」的過程:</span></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">「</span><span lang="zh-TW" style="font-family: "calibri";">a complete list
of all the patient's problems, including </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">.</span><span lang="en-US" style="font-family: "microsoft jhenghei";">..
</span><span lang="x-none" style="font-family: "calibri";">all</span><span lang="zh-TW" style="font-family: "calibri";"> other unexplained findings that are not
yet clear manifestations of a specific diagnosis, such as abnormal physical
findings or symptoms. When the </span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
data warrant, these
findings can be crystallized into a specific diagnosis. <span style="font-weight: bold;">The “problems list” then is not static in its composition, but is a
dynamic “table of contents” of the patient's chart, which can be updated at any
time. </span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW">Separate
problems all found to be part of the same entity or diagnosis may be combined</span><span lang="x-none">…</span></div>
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<br /></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
For example, if we
know that the patient has a perforated ulcer, it is so stated; if we are not
sure, we honestly </div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
state the problem as
“abdominal pain” and immediately update it on the original list to perforated
ulcer <span style="font-weight: bold;">only when the evidence allows</span>.
Lists of “impressions” and guesses fail to convey the exact level of resolution
of </div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW">a
problem and may result in premature interruption of diagnostic action</span><span lang="x-none">…</span></div>
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<br /></div>
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<span style="font-family: "calibri";">A
diagnosis is a step forward </span><span style="font-family: "calibri"; font-weight: bold;">only when it can be sustained by the evidence at hand</span><span style="font-family: "calibri";">.</span><span style="font-family: "microsoft jhenghei";">」(粗體為作者所加)</span></div>
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<br /></div>
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<span lang="en-US" style="font-family: "calibri";">Lawrence Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">這段文字的關鍵字有兩個,第一是</span><span lang="x-none" style="font-family: "calibri";">dynamic</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,第二是</span><span lang="x-none" style="font-family: "calibri";">evidence</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span></div>
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<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";">Dynamic</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的意思就如同我一再強調的,</span><span lang="x-none" style="font-family: "calibri";">Problem
List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的重點在於要即時更新,才能最準確地反映出你對於病人目前病況的理解。</span></div>
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<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";">Evidence</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的意思則是說,從症狀(或任何異常的發現)到診斷的推進(或者無法推進),都必須基於證據(病史或各種檢查)。</span></div>
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<br /></div>
<h1 style="color: #1e4e79; font-size: 16.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">附上診斷證據</span><span lang="en-US" style="font-family: "calibri";">/</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">重要檢查結果</span><span lang="en-US" style="font-family: "calibri";">/</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">目前治療</span><span lang="en-US" style="font-family: "calibri";">/</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">註解</span><span lang="en-US" style="font-family: "calibri";">/</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">住院重要歷史事件</span></h1>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">因此,當你有信心把一個診斷</span><span lang="x-none" style="font-family: "microsoft jhenghei";">列</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">在</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">當中的時候,就最好附上你這麼做的證據,也就是關鍵的檢查結果。</span></div>
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<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">反之,若你把一個症狀或異常發現列在</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">當中,也最好附上你做了哪些檢查,讓接手的人知道你為什麼不把這個症狀或異常發現歸納為某些診斷,以及接下來還有什麼檢查可以做的。</span></div>
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<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
例如(診斷證據為粗體):</div>
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<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<2019/02/06
Progress Note></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "calibri";">79 y</span><span lang="x-none" style="font-family: "calibri";">o woman, to
ED and admitted on 2019/01/30, CC:</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">胸坎實實三小時</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="en-US">#
Pneumonia</span><span lang="x-none">, right lung, hospital-accquired, diagnosed
on </span><span lang="x-none" style="font-weight: bold;">2019/02/03 by CXR</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span>= Tazocin [2019/02/03- ]</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
#
Consciousness change since 2019/02/01</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"><span style="mso-spacerun: yes;"> </span>- 2019/02/01
Brain CT without contrast: no acute lesion</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"><span style="mso-spacerun: yes;"> </span>- 2019/02/02
EEG: no seizure wave</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
INACTIVE:</div>
<div lang="en-US" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
#
non-ST-elevation myocardial infarction on 2019/01/30,</div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- Killip IV,
TIMI Risk Score for UA/NSTEMI = 5,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- status
post </span><span style="font-family: "calibri"; font-weight: bold;">percutaneous
coronary intervention</span><span style="font-family: "calibri";"> with stenting
(drug-eluting) to left anterior descending artery (culprit) and right coronary
artery (non-culprit) on 2019/01/31,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- with
concurrently diagnosed coronary artery disease, double-vessel disease
(right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="x-none" style="font-family: "calibri";">*</span><span lang="en-US" style="font-family: "calibri";"> </span><span lang="x-none" style="font-family: "calibri";">2019/02/04
became inactive</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none">#</span><span lang="en-US"> diabetes millitus</span><span lang="x-none">, type 2,</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="en-US" style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>-
</span><span lang="x-none" style="font-family: "calibri";">diagnosed on </span><span lang="x-none" style="font-family: "calibri"; font-weight: bold;">2019/01/30 with HbA1c
7.6</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="x-none" style="font-family: "calibri";">*</span><span lang="en-US" style="font-family: "calibri";"> </span><span lang="x-none" style="font-family: "calibri";">2019/02/02
became inactive</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">就如同我在本文一開始所說的,</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡最重要的成分就是</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,</span><span lang="x-none" style="font-family: "calibri";">SOAP</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">甚至可以不寫。這不是我說的,這是被認為是</span><span lang="x-none" style="font-family: "calibri";">SOAP note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">發明人的</span><span lang="en-US" style="font-family: "calibri";">Lawrence Weed</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">說的:</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";">「</span><span style="font-family: "calibri";">Data involving physical findings, vital signs,
laboratory values, medications, intakes and outputs can lead to sound
interpretations and decisions only if they are organized (by means of a “flow
sheet”) to reveal clearly </span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "calibri";">temporal relations.</span><span lang="en-US" style="font-family: "microsoft jhenghei";">..</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "calibri";">Flow sheets can be used to facilitate the comprehension and
interpretation of multiple interrelated and changing variables. </span><span lang="zh-TW" style="font-family: "calibri"; font-weight: bold;">On certain fast moving
problems the flow sheet may be the only progress note.</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」(</span><span lang="en-US" style="font-family: "calibri";">Weed, NEJM 1968</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">要寫好</span><span lang="x-none" style="font-family: "calibri";">Progress
Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,一個很重要的訣竅是,偷學主治醫師寫</span><span lang="en-US" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。主治醫師寫的</span><span lang="en-US" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">常常就是只有</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">而已。你就知道</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">有多重要了。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
另外,在一些特別的問題下面,應該要列出相對應的治療,當然,一定要押上治療開始與結束的時間。例如感染症,一定要列出住院以來所用的所有抗生素。癌症進來打化療的,則要列出這次所打的化療藥物。</div>
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<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
最後,我也會在各個問題下面,寫下住院期間重要的歷史事件,或者其他重要事項,例如:</div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<2019/03/10
Progress Note></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "calibri";">79 y</span><span lang="x-none" style="font-family: "calibri";">o woman, to
ED and admitted on 2019/01/30, CC:</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">胸坎實實三小時</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
# lung
cancer, adenocarcinoma, diagnosed on 2019/02/10 by CT and 2019/02/13 by biopsy,
cT4N3M1c, stage IVB</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"><span style="mso-spacerun: yes;"> </span>* 2019/02/25
family meeting</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"><span style="mso-spacerun: yes;"> </span>* 2019/03/02
DNR signed</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
RESOLVED:</div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="en-US"># </span><span lang="x-none">p</span><span lang="en-US">neumonia</span><span lang="x-none">,
hospital-accquired, diagnosed on 2019/02/03</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"><span style="mso-spacerun: yes;"> </span>= IV Tazocin
[2019/02/03-09]</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span>* 2019/02/09 -> resolved</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
#
diabetic ketoacidosis, diagnosed on 2019/02/08</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span>* 2019/02/11 -> resolved</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
INACTIVE:</div>
<div lang="en-US" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
#
non-ST-elevation myocardial infarction on 2019/01/30,</div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- Killip IV,
TIMI Risk Score for UA/NSTEMI = 5,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- status
post percutaneous coronary intervention with stenting (drug-eluting) to left
anterior descending artery (culprit) and right coronary artery (non-culprit) on
2019/01/31,</span></div>
<div lang="en-US" style="font-size: 11.0pt; margin: 0in;">
<span style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>- with
concurrently diagnosed coronary artery disease, double-vessel disease
(right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="x-none" style="font-family: "calibri";">*</span><span lang="en-US" style="font-family: "calibri";"> </span><span lang="x-none" style="font-family: "calibri";">2019/02/04
-> inactive</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none">#</span><span lang="en-US"> diabetes millitus</span><span lang="x-none">, type 2,</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="en-US" style="font-family: "calibri";"><span style="mso-spacerun: yes;"> </span>-
</span><span lang="x-none" style="font-family: "calibri";">diagnosed on 2019/01/30
with HbA1c 7.6</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="en-US" style="font-family: "microsoft jhenghei";"><span style="mso-spacerun: yes;"> </span></span><span lang="x-none" style="font-family: "calibri";">*</span><span lang="en-US" style="font-family: "calibri";"> </span><span lang="x-none" style="font-family: "calibri";">2019/02/02<span style="mso-spacerun: yes;"> </span>-><span style="mso-spacerun: yes;">
</span>inactive</span></div>
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<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">有了這種病歷,你根本不需要花時間打</span><span lang="x-none" style="font-family: "calibri";">Weekly Summary</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,到了出院那天,你完全可以憑著最後一天的</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,就打出出院病摘!</span></div>
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<br /></div>
<h1 lang="x-none" style="color: #1e4e79; font-family: Calibri; font-size: 16.0pt; margin: 0in;">
Subjective</h1>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">會寫</span><span lang="en-US" style="font-family: "calibri";">Prob</span><span lang="x-none" style="font-family: "calibri";">lem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">之後,接下來要進入</span><span lang="x-none" style="font-family: "calibri";">SOAP</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的部分。</span><span lang="x-none" style="font-family: "calibri";">S</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">我想各位不會有什麼問題。但我還是想引用一下佛羅里達大學教醫學生寫</span><span lang="x-none" style="font-family: "calibri";">SOAP note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的網頁裡,針對</span><span lang="x-none" style="font-family: "calibri";">S</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的部分的提醒:</span></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">「</span><span lang="en-US" style="font-family: "calibri";">Students often
include too much detail and extraneous information in this section.</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」(</span><a href="https://clerkship.medicine.ufl.edu/portfolio/interpersonal-and-communicative-skills/documenting-in-the-medical-record/writing-an-effective-daily-progress-note/?fbclid=IwAR1fuv10VQZrpX5VzwI2YlixTUdnPbQVHl3gVxIWSOTq3eJdXraNt1rlaW4%EF%BC%89"><span lang="en-US" style="font-family: "calibri";">https://clerkship.medicine.ufl.edu/portfolio/interpersonal-and-communicative-skills/documenting-in-the-medical-record/writing-an-effective-daily-progress-note/?fbclid=IwAR1fuv10VQZrpX5VzwI2YlixTUdnPbQVHl3gVxIWSOTq3eJdXraNt1rlaW4</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)</span></a></div>
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<br /></div>
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<span lang="zh-TW" style="font-family: "microsoft jhenghei";">記得了,</span><span lang="x-none" style="font-family: "calibri";">S</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">不要寫太多,我通常也是寫幾個字而已。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">另外我也發現一個非常奇特的現象,就是有些人會把看起來像</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的東西寫在</span><span lang="x-none" style="font-family: "calibri";">S</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的部分,這當然不對。但仔細分析後,會發現之所以會有這樣的現象,並不是因為不會寫</span><span lang="x-none" style="font-family: "calibri";">S</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,反而是因為不會寫</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,所以把</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">寫在</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面,但又想真的想寫</span><span lang="en-US" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,所以就不知道為什麼寫到</span><span lang="x-none" style="font-family: "calibri";">S</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡面去了。</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<h1 lang="en-US" style="color: #1e4e79; font-family: Calibri; font-size: 16.0pt; margin: 0in;">
Objective</h1>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";">O</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的部分,雖然也是沒甚麼訣竅,但我非常在意這部分充斥著無意義的生命徵象、身體檢查組套,以及實驗室數據。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">生命徵象明明就記錄在</span><span lang="x-none" style="font-family: "calibri";">T/P/R</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">sheet</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡,在生命徵象穩定的情況下並沒有必要把它抄到</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡,畢竟你再怎麼抄,也不會比</span><span lang="x-none" style="font-family: "calibri";">T/P/R</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">sheet</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">漂亮。你覺得你不抄就沒有人看得到嗎?並不是,</span><span lang="en-US" style="font-family: "calibri";">T/P/R sheet</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">也是病歷的一部份,並不是只有你寫的</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">才叫病歷。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">杜克大學的</span><span lang="x-none" style="font-family: "calibri";">Daniel
Sexton</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">醫師就寫過一篇教導怎麼寫</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">文章,裡面說:</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">「</span><span lang="en-US" style="font-family: "calibri";">It is not
necessary to put the vital signs in each progress notes; although this can be
useful if they are abnormal (in which case, comments about their significance
are often helpful and/or appropriate)<span style="mso-spacerun: yes;">
</span>e.g. </span></div>
<ul style="direction: ltr; margin-bottom: 0in; margin-left: .375in; margin-top: 0in; unicode-bidi: embed;" type="disc">
<li lang="en-US" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">VS normal </span></li>
<li lang="en-US" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">Resting pulse 125—believe the
reason is hypoxia and CHF</span></li>
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span lang="en-US" style="font-family: "calibri"; font-size: 11.0pt;">Pulse 120—still in
atrial fib</span><span lang="zh-TW" style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">」(</span><a href="https://wiki.duke.edu/download/attachments/16844105/Medicine+Clerkship+-+Student+Guide+to+Progress+Notes.doc%EF%BC%89"><span lang="en-US" style="font-family: "calibri"; font-size: 11.0pt;">https://wiki.duke.edu/download/attachments/16844105/Medicine+Clerkship+-+Student+Guide+to+Progress+Notes.doc</span><span lang="zh-TW" style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">)</span></a></li>
</ul>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
(哇,杜克大學耶,是誰說病歷裡面不可以有縮寫的阿?)</div>
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<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">像</span><span lang="x-none" style="font-family: "calibri";">Daniel Sexton</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">是寫</span><span lang="x-none" style="font-family: "calibri";">vital signs normal</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,我則是寫</span><span lang="x-none" style="font-family: "calibri";">vital signs stable</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。這是習慣問題,倒沒有甚麼對錯。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">說到這裡就不得不提一下,曾經有位大老說,</span><span lang="x-none" style="font-family: "calibri";">vital signs</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">不可以寫</span><span lang="x-none" style="font-family: "calibri";">stable</span><span lang="x-none" style="font-family: "microsoft jhenghei";">,因為</span><span lang="x-none" style="font-family: "calibri";">stable</span><span lang="x-none" style="font-family: "microsoft jhenghei";">就是一條線都是</span><span lang="x-none" style="font-family: "calibri";">0</span><span lang="x-none" style="font-family: "microsoft jhenghei";">,病人死掉了才</span><span lang="x-none" style="font-family: "calibri";">stable</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span></div>
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<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
我是不知道這位大老為什麼會講出這種詭辯的話來。他難道不知道轉入加護病房的其中一個條件就是生命徵象不穩定,相對而言轉出的條件就是生命徵象穩定嗎?轉出加護病房的都是死掉的病人嗎?</div>
<div lang="x-none" style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
再來就是身體檢查的部分,拜託請只寫你有做的身體檢查,不要寫沒做的。</div>
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<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
目前的病歷大概九成九都充斥著每天都一樣的身體檢查組套,內行人都知道你不可能每天都做身體檢查(甚至還是全套的),於是就不會相信你的病歷了。就像是放羊的孩子,等到哪一天你真的做了身體檢查,發現什麼異常的地方寫在病歷裡,其他人(甚至是一個月後的你自己)看了也只會覺得你在這是你腦補的結果。</div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
最後則是實驗室或其他檢查結果。</div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">我還是引用</span><span lang="x-none" style="font-family: "calibri";">Daniel
Sexton</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">醫師的文章:</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">「</span><span lang="en-US" style="font-family: "calibri";">DO NOT
TRANSCRIBE LAB DATA INTO THE PROGRESS NOTES UNLESS YOU INTEND TO COMMENT UPON
IT</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">」(</span><a href="https://wiki.duke.edu/download/attachments/16844105/Medicine+Clerkship+-+Student+Guide+to+Progress+Notes.doc%EF%BC%89"><span lang="en-US" style="font-family: "calibri";">https://wiki.duke.edu/download/attachments/16844105/Medicine+Clerkship+-+Student+Guide+to+Progress+Notes.doc</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">)</span></a></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">我沒什麼好說的了,就照</span><span lang="x-none" style="font-family: "calibri";">Sexton</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">說的做就對了,我就是這樣做的。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">綜上所述,假設今天一個病人是進來打化療的,你問半天他都說沒什麼不舒服,化療前的抽血也沒甚麼異常,你該怎麼寫</span><span lang="x-none" style="font-family: "calibri";">S</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">跟</span><span lang="x-none" style="font-family: "calibri";">O</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">知道了吧:</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
S:</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
No
discomfort</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
O:</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
Conscious</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
Stable
vital signs</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">結束,對,就是這樣,我就是這樣寫的。附帶一提,</span><span lang="x-none" style="font-family: "calibri";">Conscious</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">是形容詞不是名詞,就是</span><span lang="x-none" style="font-family: "calibri";">clear
consciousness</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的意思,不要問說</span><span lang="x-none" style="font-family: "calibri";">Conscious</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">後面怎麼沒有寫</span><span lang="x-none" style="font-family: "calibri";">conscious</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">是怎樣。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<h1 style="color: #1e4e79; font-family: Calibri; font-size: 16.0pt; margin: 0in;">
<span lang="en-US">Assessment</span><span lang="x-none">/Plan</span></h1>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">這部分是除了</span><span lang="en-US" style="font-family: "calibri";">P</span><span lang="zh-TW" style="font-family: "calibri";">roblem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">以外,</span><span lang="zh-TW" style="font-family: "calibri";">Progress Not</span><span lang="en-US" style="font-family: "calibri";">e</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡最重要的部分了。但就如同我一開始所說的,因為老師教的永遠這麼剛好是事實上很少發生的「從症狀到診斷」的那篇</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,而這種</span><span lang="x-none" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的部分正好是診斷,所以大家都以為</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">就是要寫診斷。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">但事實上,除了很少遇到的「從症狀到診斷」的那篇</span><span lang="en-US" style="font-family: "calibri";">Progress Note</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">以外,</span><span lang="x-none" style="font-family: "calibri";">Assessmemt</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">該寫的都不是診斷。你已經</span><span lang="x-none" style="font-family: "calibri";">Assess</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">過的診斷應該寫在</span><span lang="x-none" style="font-family: "calibri";">Problem List</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">裡才對。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">那麼</span><span lang="x-none" style="font-family: "calibri";">A</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">ssessment應該寫什麼呢?</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
概括而言,就是寫你對病人某個問題或整體病況的評估或想法。</div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">如果你是針對一個還沒有診斷的症狀或異常發現寫</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,那還相對簡單,大概可以包括:</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<ol style="direction: ltr; font-family: "Microsoft JhengHei"; font-size: 11.0pt; font-style: normal; font-weight: normal; margin-bottom: 0in; margin-left: .375in; margin-top: 0in; unicode-bidi: embed;" type="1">
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;" value="1"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt; font-style: normal; font-weight: normal;">今天你覺得這個症狀(或異常發現)的原因(或診斷),從最可能到到最不可能分別是什麼?</span></li>
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">還有哪些危險的診斷必須排除。</span></li>
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">你目前做了哪些檢查證實或排除了哪些診斷(之前寫過的就不用再重複寫)</span></li>
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">還有需要做其他檢查查出病因嗎?還是觀察或症狀治療就好?為什麼你做出這樣的選擇?</span></li>
</ol>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">如果你是針對一個診斷或病人的整體病況做</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,則最基本的</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">包含兩個要素。如果你還不會寫更進階的</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,至少也要寫一句包含這兩個要素的</span><span lang="x-none" style="font-family: "calibri";">Assessment</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
這兩個要素就是「疾病嚴重度」以及「疾病發展趨勢」。簡單來說只有六種狀況:</div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<ul style="direction: ltr; margin-bottom: 0in; margin-left: .375in; margin-top: 0in; unicode-bidi: embed;" type="disc">
<li lang="x-none" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">not severe and improved</span></li>
<li lang="x-none" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">not severe and no change</span></li>
<li lang="x-none" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">not severe but progressed</span></li>
<li lang="x-none" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">severe but improved</span></li>
<li lang="x-none" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">severe and no change</span></li>
<li lang="x-none" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">severe and progressed</span></li>
</ul>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
當然這只是最陽春的寫法,你可以用更細緻的寫法來評估。</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">我還是引用</span><span lang="en-US" style="font-family: "calibri";">Daniel
Sexton</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">醫師的例子:「</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<ul style="direction: ltr; margin-bottom: 0in; margin-left: .375in; margin-top: 0in; unicode-bidi: embed;" type="disc">
<li lang="en-US" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">Our working diagnoses remain
bacterial pneumonia and renal failure due to obstructive uropathy</span></li>
<li lang="en-US" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">We have been unable to find a
cause for his lung infiltrates but we believe that they are not due to
pulmonary edema</span></li>
<li lang="en-US" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">We have not been able to make
a conclusive diagnosis that explains his lung infiltrates</span></li>
<li lang="en-US" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">Despite our best efforts he
is still in CHF</span></li>
<li lang="en-US" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">After 5 days in the hospital
we have concluded the following:</span></li>
<ul style="direction: ltr; margin-bottom: 0in; margin-left: .375in; margin-top: 0in; unicode-bidi: embed;" type="circle">
<li lang="en-US" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">His CHF is better</span></li>
<li lang="en-US" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">His renal function is worse</span></li>
<li lang="en-US" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">His confusion and agitation
are multi-factorial</span></li>
<li style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span lang="en-US" style="font-family: "calibri"; font-size: 11.0pt;">He will not be
able to live independently in near future</span><span lang="zh-TW" style="font-family: "microsoft jhenghei"; font-size: 11.0pt;">」</span></li>
</ul>
</ul>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW" style="font-family: "microsoft jhenghei";">最後就是</span><span lang="x-none" style="font-family: "calibri";">Plan</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的部分了。關於</span><span lang="x-none" style="font-family: "calibri";">Plan</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">我也只有一句話要說,就是不要寫那些沒有針對性,誰都知道本來就該做的事情,例如:</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<ul style="direction: ltr; margin-bottom: 0in; margin-left: .375in; margin-top: 0in; unicode-bidi: embed;" type="disc">
<li lang="x-none" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">monitor vital signs</span></li>
<li lang="x-none" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">supportive care</span></li>
<li lang="x-none" style="margin-bottom: 0; margin-top: 0; vertical-align: middle;"><span style="font-family: "calibri"; font-size: 11.0pt;">symptomatic treatment</span></li>
</ul>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<span lang="zh-TW">我還是用我們那位上次心肌梗塞,這次</span><span lang="en-US">DKA</span><span lang="zh-TW">住院的阿嬤來舉例:</span></div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<2024/02/11
Progress Note></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";">84</span><span lang="en-US" style="font-family: "calibri";"> y</span><span lang="x-none" style="font-family: "calibri";">o woman, to ED and admitted on
2024/02/10, CC:</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">drowsy
consciousness for hours</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"># diabetic ketoacidosis</span>, diagnosed on
2024/02/10, with consciousness change (which subsided)</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;"># urinary tract infection</span>, diagnosed on
2024/02/10 by pyuria</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span>= cefmetazole [2024/02/10- ]</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="font-weight: bold;">HISTORY:</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="x-none"><span style="mso-spacerun: yes;"> </span># non-ST-elevation myocardial infarction</span><span lang="en-US"> on 2019/01/30,</span><span lang="x-none"> </span><span lang="en-US">status
post percutaneous coronary intervention with stenting (drug-eluting) to left
anterior descending artery (culprit) and right coronary artery (non-culprit) on
2019/01/31, with concurrently diagnosed coronary artery disease, double-vessel
disease (right<span style="mso-spacerun: yes;"> </span>coronary [70% stenosis])</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># chronic kidney disease, stage 3a (eGFR 52 on
2024/01/03)</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># diabetes millitus, type 2, diagnosed in her
79 years of age (HbA1c 8.3 on 2024/01/03; on metformin, Levemir on 2024/02/05)</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span># hypertension, diagnosed in her 60s (on
amlodipine, valsarten on 2024/02/05)</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
S:</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
Fever
[since 2024/02/10]</div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
食慾差,但可以吃大概平常食量的一半</div>
<div style="font-family: "Microsoft JhengHei"; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
O:</div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";">Conscious</span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="x-none" style="font-family: "calibri";">(improved)</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
Stable
vital signs</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
Lungs:
clear</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
Left
flank knocking pain</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
Limbs no
edema</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
I/O
4080-1600</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
2024/02/11</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span>Na 144 <- 143</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span>K 3.3 <- 4.2</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span style="mso-spacerun: yes;"> </span>Anion gap 9 <- 16</div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<br /></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
A/P:</div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";"># DKA: </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">在給予大量靜脈輸液,及胰島素幫浦後,病人意識恢復正常。因此,病人的意識應該是</span><span lang="x-none" style="font-family: "calibri";">DKA</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">所造成。電解質並沒有因為輸液造成異常。目前食慾差,但食量可以接受。</span><span lang="x-none" style="font-family: "calibri";">Anion gap</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">已經正常。</span><span lang="x-none" style="font-family: "calibri";">DKA</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">整體改善中。</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";">-></span><span lang="en-US" style="font-family: "microsoft jhenghei";"> </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">調降靜脈輸液量</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";">-> </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">胰島素改皮下注射</span></div>
<div style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
<span lang="en-US">->
</span><span lang="x-none">keep I/O balance</span></div>
<div style="font-size: 11.0pt; margin: 0in;">
<span lang="x-none" style="font-family: "calibri";"># UTI: </span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">病人住院前沒有燒,也沒有訴說泌尿道感染症狀,但</span><span lang="x-none" style="font-family: "calibri";">U/A</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">驗出</span><span lang="x-none" style="font-family: "calibri";">pyuria</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">,且昨天開始發燒,因此昨天開始使用抗生素針對</span><span lang="x-none" style="font-family: "calibri";">UTI</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">治療。</span><span lang="x-none" style="font-family: "calibri";">UTI</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">應該是這次誘發</span><span lang="x-none" style="font-family: "calibri";">DKA</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的原因。今天仍在發燒,且左後腰出現敲痛,應為左側</span><span lang="x-none" style="font-family: "calibri";">APN</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">。但抗生素才用第二天,不一定看得出效果,目前生命徵象穩定,沒有</span><span lang="x-none" style="font-family: "calibri";">sepsis</span><span lang="zh-TW" style="font-family: "microsoft jhenghei";">的表現。</span></div>
<div lang="x-none" style="font-family: Calibri; font-size: 11.0pt; margin: 0in;">
->
keep cefmetazole, planned for 5 days if improving</div>
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<br />Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com11tag:blogger.com,1999:blog-7535787533759742354.post-64278191761372872662016-06-09T06:34:00.003-07:002016-06-09T06:34:58.616-07:00醫療去商品化拯救的不只是病人<div class="" data-block="true" data-editor="2agcc" data-offset-key="327bb-0-0" style="background-color: white; color: #1d2129; font-family: helvetica, arial, sans-serif; font-size: 15px; line-height: 18px; white-space: pre-wrap;">
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<span data-offset-key="327bb-0-0">很久沒有公開講醫療去商品化的議題了。但剛剛看到下面這段文字:</span></div>
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<div class="" data-block="true" data-editor="2agcc" data-offset-key="a55gt-0-0" style="background-color: white; color: #1d2129; font-family: helvetica, arial, sans-serif; font-size: 15px; line-height: 18px; white-space: pre-wrap;">
<blockquote class="tr_bq" style="direction: ltr; position: relative;">
<span data-offset-key="a55gt-0-0">「覺得很好啊...以後也別叫醫生了,就當醫療提供者</span><span data-offset-key="cbmup-0-0">以後就可以大聲地問...你每個月交多少錢? 600多...</span><span data-offset-key="frs0q-0-0">每個月交六百多 ? 哩系咧大聲撒小? 600我退你,你給我滾~</span><span data-offset-key="8s27h-0-0">反正你要把醫生搞成醫療服務提供者~那大家就照正常程序來~</span><span data-offset-key="a25ok-0-0">也不需要有醫德~反正就收多少錢辦多少事~不用積極救治了,反</span><span data-offset-key="2nm6i-0-0">正健保又不給付,醫療消費者 ? 這樣寫你算有種。</span><span data-offset-key="1saf6-0-0">敢不敢公布姓名讓各大醫院知道是誰寫的?」</span></blockquote>
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其實只要是經過深思熟慮的人,都應該知道這樣的話只不過是氣話罷了。</div>
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若是真的這樣做,痛苦的絕對不只是病人,醫生的心理也快樂不到哪裡去。</div>
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偏偏在一個醫療越商品化的體系中,越是這樣做的醫生待遇可能會越好。</div>
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無法做到這種程度的醫生,就只能終日怨嘆自己的專業得不到應有的報酬。</div>
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而同時那些做到這種程度的醫生,也只能隱藏心中的良心不安感所帶來的負面情緒,藉由嘲笑做不到這種程度的醫生「自己沒競爭力活該」來療癒認知失調了。</div>
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Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com1tag:blogger.com,1999:blog-7535787533759742354.post-73814924332175320472015-03-15T23:55:00.000-07:002015-03-15T23:55:29.331-07:00《30雜誌》專欄文章--脂肪退散!低GI減肥法讓你吃的好又胖不了黃醫師:正在減重或怕發胖的朋友,你還在每餐計算卡路里嗎?或者一滴油都不敢吃,深怕嘴裡吃進去的油都變成身上的肥油嗎?<br/>
如果還抱持著這些過時、錯誤又不科學的減肥觀念,最後不但無法保持身材,更有可能「減重減重,越減越重。」<br/>
怎樣才是真正新潮有效又科學的減肥方式?<br/>
答案是:低升糖指數(低GI)減肥法......<br/>
<a href="http://30plus.30.com.tw/article-content_345.html">全文連結</a>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-71074578850523538302014-07-23T19:18:00.002-07:002014-07-23T19:18:47.012-07:00YAM專欄《DRG會讓醫生一直趕我出院嗎?》<p><a href="http://n.yam.com/yam/politics/20140717/20140716426140.html">原文連結:http://n.yam.com/yam/politics/20140717/20140716426140.html</a></p>
<p>yam蕃薯藤新聞/黃致翰/專欄-2014年07月17日 上午09:00</p>
<p>七月開始,健保的第二波DRG政策正式實施。所謂DRG,是diagnosis-related groups的縮寫,中文叫「診斷關聯群」。就是依照病人的住院診斷、疾病嚴重度,以及本身的身體狀況,將住院病人分為各個診斷關聯群,給付一筆固定的金額,而不論醫院在個別病人上花了多少成本。</p>
<p>因此,若有些病人產生了一些非預期的併發症,導致醫生必須多做一些檢查,多開一些藥物,甚至讓病人住院比較長的時間,醫院在這次住院上花的成本就可能會超過健保局給付的金額,而在這個個案上虧錢。</p>
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<p>相對而言,若醫院透過採納較有效率的治療流程或技術,就可以花比別人少的成本來完成住院的治療,這樣在DRG固定金額的給付制度下,就可以獲得比較多的給付。</p>
<p>於是,雖然有的個案因為非預期的併發症等因素而讓醫院虧錢,但有的個案比較簡單而讓醫院賺錢,平均而言,若DRG給付的金額是設定在原本的平均花費,則醫院總體而言不賺也不虧,甚至若改善治療效率,還會賺比原本多的錢。</p>
<p>但是,民眾對DRG的最大疑慮就是,醫生會不會為了縮短住院天數以節省成本,就想方設法把病人趕出院?</p>
<p>會的!醫生總是想方設法把病人趕出院──但早在DRG實施以前就是這樣了!</p>
<p>我在醫院實習及當住院醫師的時候,不論是在哪一科的病房,臨床上的老師,也就是主治醫師,幾乎都會再三教導我們,「沒事就趕快讓病人出院」。尤其是感染科或外科的主治醫師,更是強調這點。</p>
<p>為什麼?</p>
<p>第一,醫院是很「髒」的地方。儘管所有醫院都盡心盡力注意清潔與感染控制措施,但醫院本身就是集中住著帶有各種抗藥性病菌病人的地方,住得越久,院內感染的機率越高。</p>
<p>第二,醫院是很無聊的地方。住院的病人最常做的事,就是整天躺在床上看電視,這對於疾病的復原是很糟糕的事情,特別是剛開完刀的病人,大量的研究早已證實,在許可的範圍之內,術後越早下床走動,越早恢復正常生活,身體恢復健康的速度越快。</p>
<p>這就是為什麼病人永遠覺得醫生在「趕」自己出院,其實醫生都是為了病人身體健康著想。</p>
<p>其實,在DRG實施以前,健保給付給醫院的制度是「論量計酬」,也就是病人住越多天,健保給付越多(當然如果超過臨床上合理的住院天數,健保局會「核刪」給付)。因此,在這樣的支付制度之下,醫生為了病人的健康著想,努力把病人「趕」出院,其實是會讓醫院少賺錢的。我認識許多醫學中心的主治醫師,就因為醫術太精湛,病人住院天數都比別人短,所以常常被醫院高層訓誡,說他害醫院虧錢,並以此為藉口減他的薪水。</p>
<p>那麼為什麼,在原本論量計酬的制度下,多數的醫生還是願意違背醫院的利益,想方設法「趕」病人出院?</p>
<p>第一,「論量計酬」只是健保署給付給醫院的機制,若有良心的醫院高層以病人及員工的福祉為優先考量,願意讓下面的醫生盡情發揮醫學專業與醫德,而不將影響醫院盈虧的因素與醫生的薪酬掛勾,醫生也就沒有任何經濟誘因去做對病人不好但對醫院利潤有利的事情。可惜的是,台灣的醫療體系因為法定非營利的財團法人醫院透過「關係人交易」等手段而實質營利,就連公立醫院也受到新自由主義政府的績效主義管理,因此主治醫師的薪水幾乎都是績效制度,與醫院的營虧因素掛勾。</p>
<p>第二,金錢的誘因雖然也是決定醫生與任何人類行為的動機之一,但醫生與任何人類一樣,都不會全然依照金錢誘因做決策。行善的快樂,發揮醫學專業的成就感,都是讓醫生願意違反自身經濟利益而做出對病人有益的事(「趕」病人出院)的原因。</p>
<p>但是,任何人都一樣,當制度扭曲使得金錢誘因的力量大過一切的時候,我們就很難保證醫生或任何其他職業的人不會做出有損職業道德的事情了。</p>
<p>因此,重點根本不在於論量計酬或DRG,而是在於政府有沒有魄力解決台灣醫療體系營利化、績效化的現象,並對那些以DRG為藉口而扣賠錢個案的醫師薪水的醫院,處以重罰。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com1tag:blogger.com,1999:blog-7535787533759742354.post-17855603823728306922014-07-23T19:15:00.002-07:002014-07-23T19:15:57.866-07:00YAM專欄《健保讓醫病關係更好,但好還可以更好》<p><a href="http://n.yam.com/yam/politics/20140710/20140708407416.html">原文連結:http://n.yam.com/yam/politics/20140710/20140708407416.html</a></p>
<p>yam蕃薯藤新聞/黃致翰/專欄-2014年07月10日 上午09:00</p>
<p>台灣腦神經權威魏國珍醫師日前表示:「健保制度讓他面對病人時可以單純看病,不用考慮病患的經濟負擔,降低美國、日本社會中緊張的醫病關係。」</p>
<p>魏醫師這番言論,激起了許多第一線基層醫護人員的不滿情緒,甚至有人直言,「醫界被這種言論害死」。</p>
<p>事實上,魏醫師此番言論所言不假,但卻缺乏對第一線基層醫護人員相對剝削感的同理心;而基層醫護人員的不滿情緒也非無的放矢,但對健保的批評卻也流於片面。</p>
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<p>全世界所有的先進國家除了美國以外,都有全民醫療體系,保障國民的基本醫療權,讓醫療資源的分配以「需求」而非「經濟能力」決定。就連唯一沒有全民醫療體系的美國,都以健保稅提供老人、低收入戶醫療保險,以公共資金維持無法拒收病人的公立醫院,使國家不至於「路有病死骨」。</p>
<p>至於那些沒有全民醫療體系的第三世界國家,或者是沒有全民健保以前的台灣,生重病又付不起醫藥費的病人,就會像「一灘血」故事中的孕婦一樣,病死街頭。在這種環境中,病人可憐,醫護的處境也好不到哪裡。</p>
<p>試想你身為醫者,面對付不起醫藥費的重症病人,良知告訴自己應該以照顧病人的健康生命為優先考量;但你也不像富二代(在此並無貶意)史懷哲一樣有家庭與社會的經濟支持,且家裡還有父母伴侶小孩要養,若免費救治,自己該如何養家活口呢?救與不救,都是煎熬。這種良知與現實的利益衝突,學術上稱為「道德痛苦」(moral distress)。</p>
<p>幸好我們跟世界上所有先進國家一樣,有了全民健保,解決了第一線醫護人員在醫護良知與考慮病患經濟負擔之間抉擇的道德痛苦。</p>
<p>但是,健保也同時製造了第一線醫護人員許多其他的道德痛苦。</p>
<p>首先,政府與醫院管理高層兼醫界大老聯手,放任法定非營利(盈餘禁止分配給董事會)的財團法人醫院透過「五鬼搬運法」等手段將盈餘分配給母企業與相關利益階級,甚至在新自由主義意識形態的政策之下,連公立醫院的管理也追求盈餘與績效。再加上健保給付醫護勞動成本的點值過低與不公。於是,「不該出現的營利動機」與「給付分配不公所產生的扭曲誘因」交互作用之下,逼使醫院管理者不斷削弱照護重症病人的資源,犧牲第一線醫護人員的勞動條件,並擴張門診部門與基層診所「搶生意」,且不得不用「藥價差」來彌補醫護勞動成本給付過低所造成的虧損。</p>
<p>更慘的是,營利動機與扭曲誘因加上醫院管理界風行績效主義,迫使第一線醫護人員面臨績效至上的薪資結構,必須多看病人、多做檢查、多做手術,以求溫飽。在這樣的道德痛苦困境下,還用「醫德」大帽,去責怪醫師沒有做到「初診時通常花上半個小時至一小時與病患溝通病情」,不免給人不食人間煙火之感。</p>
<p>必須強調的是,醫院不該「營利」(盈餘分配給董事會),並不代表醫院不該有「盈餘」,更不代表「虧損」在任何情況下都必須受譴責。台灣政府與人民受新自由主義意識形態影響,習慣用帳面上的「盈虧」、「效率」來檢視公共服務事業。事實上,不管是交通、教育、醫療等公共服務,在經濟學上都已證明為全體國民帶來的利益要遠遠大於支出。</p>
<p>因此我們在思辨醫療等公共服務時,應該跳脫在帳面上「譴責盈餘,咒罵虧損」的新自由主義矛盾思維,投入更多公共資源以提高基層醫護人員的勞動條件及待遇,以扭轉醫療崩壞,確保此等對國家強盛有重要貢獻的公共服務,能夠永續經營。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-14784375724225978602014-07-23T19:10:00.003-07:002014-07-23T19:12:53.938-07:00YAM專欄《公務員不休假獎金是「浪費」?──小心資本家的陰謀》<p><a href="http://n.yam.com/yam/politics/20140703/20140702394749.html?select=http://n.yam.com/tlt/politics/20140711/20140711414325.html">原文連結:http://n.yam.com/yam/politics/20140703/20140702394749.html?select=http://n.yam.com/tlt/politics/20140711/20140711414325.html</a></p>
<p>yam蕃薯藤新聞/黃致翰/專欄-2014年07月03日 上午09:00</p>
<p>根據《中國時報》29日報導,「20萬資深公僕領『不休假獎金』,年燒國庫65億元」。但這樣的事情,真的該拿來批判嗎?還是應該拿出來讚賞呢?而國民黨立委呂學樟也表示:「加班費這麼多是不正常的事!」;民進黨立委吳宜臻則說,公務員應該共體時艱,她將提案全數刪除。若真的刪除了,對台灣民眾來說,真的是好事一件嗎?</p>
<p>其實,很有可能,當你受到這樣的報導影響而激起憤怒之情,便跟隨大眾開始聲討公務員的同時,你已經中了資本階級藉由新自由主義洗腦勞工階級而鞏固自身利益的計謀。</p>
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<p>作為資本階級進行階級鬥爭工具的新自由主義,向來的手段就是以「效率」為唯一追求的意識形態目標,藉由讚揚自由市場、競爭、減稅、大企業、私有化,汙名化公務員、公平稅制,以達成掏空公共資產,掠奪公眾利益的自私目的。</p>
<p>其實,身為新自由主義意識形態誕生地的美國,跟台灣一樣,社會上同樣存在對公務人員的仇視與鄙視,同樣對公務人員的效率質疑。但根據以《為官僚制正名》一書聞名的公共政策教授Charles Goodsell所做的研究顯示,美國公務員的效率不但沒有比私人企業的效率差,甚至可能比私人企業的效率還高。</p>
<p>這樣的研究當然並不一定能外推到台灣來證明台灣的公務員效率也比私人企業高,但卻絕對可以證明「效率實際上比私人企業高的公務員,在民眾眼中的效率也可以是低下的」,說明新自由主義意識形態的力量有多大。</p>
<p>同一時間,消防員張哲偉在生日前夕救火殉職的事件,也暴露出消防人員長期過勞,消防人員裝備品質的問題。新自由主義最厲害的地方就在於,洗腦讓民眾覺得那些在家靠利息與「租金」獲得暴利的資本階級,所得到的每一分錢都是自己「努力工作」而應得的,一毛稅都不該被課;同時又可以洗腦讓民眾覺得那些真正靠勞力付出的公務人員,所賺得的薪水都是「人民的納稅錢」,是社會資源的浪費。</p>
<p>令人慶幸的是,或許是太陽花學運前後一連串社會事件揭露了新自由主義意識形態的神秘面紗,這次這個「不休假獎金」的報導網頁下,幾乎一面倒都是批評這兩位立委的聲音。</p>
<p>同時,也有許多人明智地指出,私人企業的待遇與勞動條件低下,不但不是鬥爭基層公務員、刪減基層公務員福利就可以解決的,甚至若真的刪減基層公務員的福利,惡化基層公務員的勞動條件,只是給私人企業一個更好的藉口可以壓榨底下的員工,而這或許正是《中國時報》這樣一個偏袒資方的媒體做出這樣一份報導的不可告人的目的。</p>
<p>但從新聞底下的回應,我們還是可以看到一些令人擔憂的現象。就是有些人雖然明白鬥爭基層公務人員對私人企業的勞工只有負面影響,但卻不精確地使用「共產主義」這樣的詞彙來形容這些鬥爭基層公務人員的立委。這樣的現象代表台灣人民對新自由主義意識形態的掠奪本質理解尚不夠透徹,對社會現象的批判語彙無法跳脫新自由主義的洗腦。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com1tag:blogger.com,1999:blog-7535787533759742354.post-77778712104007767212014-07-23T19:08:00.000-07:002014-07-23T19:12:39.601-07:00YAM專欄《連勝文漠視階級問題》<p><a href="http://n.yam.com/yam/politics/20140626/20140625378535.html">原文連結:http://n.yam.com/yam/politics/20140626/20140625378535.html</a></p>
<p>yam蕃薯藤新聞/黃致翰/專欄-2014年06月26日 上午09:00</p>
<p>連勝文日前批評柯文哲挑動階級問題,殊不知之所以柯文哲膽敢在新自由主義洗腦教育下的台灣提起階級問題,正是因為連勝文等權貴階級,長期漠視階級問題,甚至主動製造階級問題。</p>
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<p>根據社會學的理論與實證調查,階級問題是一種本體論上主觀存在,而認識論上客觀存在的實質概念,只有程度大小的差異,並非虛構的概念。</p>
連勝文的太太可以每天在帝寶裡鑽研義大利麵烹飪手藝,國道收費員卻只能在吸了一天廢氣後,用受盡職業傷害的雙手提著便當,回家讓小孩及自己填飽肚子,倒頭就睡。失業被無能的政府與勾結的財團背叛之後,還必須承受民眾的辱罵,「早就知道會失業了,為何不好好培養其他專長,提升自己的競爭力呢?」這就是透過「勞動過程」與「勞資衝突」的「階級實踐」經驗,並塑造了主觀階級意識。</p>
<p>根據《崩世代》作者中研院社會學者林宗弘在《失落的年代:臺灣民眾階級認同與意識形態的變遷》論文利用實際的社會調查數據所得出的結論發現,這十幾年來,台灣民眾的相對剝奪感確實越來越強,也就覺得貧富差距越來越大(事實上也越來越大),光靠自己的努力也越來越追不上有錢人。</p>
<p>此外,台灣人對「自由競爭功績主義」的信仰也減弱,同意「吃苦一定會成功」的人的比例在十五年內從91%下降到70%。</p>
之所以台灣的階級認同與意識形態越來越分化,主要的原因就是客觀的貧富差距確實越來越大,社會流動越來越困難,再加上越來越多東西被市場化、商品化、私有化,人民交流的實體與虛擬公共空間不斷被壓縮,勞動力商品化與異化的程度漸增,最終造成《錢買不到的東西》作者桑德爾所說的苦果,亦即「在這個貧富益發不均的時代,把所有的東西都市場化,意味著富裕之人與收入不豐之人漸漸過著隔離開來的生活。」</p>
<p>雖說如此,但新自由主義一方面用「自由市場」、「競爭力」、「效率」、「全球化」、「小政府」、「減稅」、「產業化」、「自由」等意識形態來洗腦民眾,又同時指責「邊緣化」、「公務員」、「公共性」、「階級化」、「社會福利」、「平等」是沒有科學根據的意識形態,使得台灣人的階級意識尚未成熟,扭轉崩世代的力量不夠強大。甚至最可悲的是,連被指責「挑動階級問題」,貌似站在中下階層民眾一方的柯文哲,都主張醫療應該要「產業化」。</p>
<p>上述「階級實踐」經驗所塑造的主觀階級意識,可說只是社會的病徵。真正要能治療這個病態的社會,就必須以微觀層次的階級意識為基礎,在宏觀層次上進行階級鬥爭,並進行政治上的意識形態對抗。</p>
<p>台灣長期受反共教育洗腦與新自由主義洗腦,談「階級鬥爭」一直都是政治上的禁忌。但誠如巴菲特所說:「過去二十年始終存在階級鬥爭,而我的階級贏了。」</p>
<p>權貴階級長期用新自由主義意識形態鞏固自身階級利益,鬥垮中產階級與中下階級,製造出許多終日幻想自己有朝一日能住帝寶吃高級義麵的順民,使得國家機器運轉失靈。這些製造階級問題的權貴階級,卻好意思指責別人「挑動階級問題」?實在是充滿了黑色幽默。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-12489277680866456362014-07-14T03:01:00.001-07:002014-07-15T05:53:35.390-07:00診斷關聯群(DRG)給付制度會讓醫生為了省錢而少開檢查或處置而犧牲病人的權益嗎?<p>這東西其實國外也爭論了好幾十年。</p>
<p>理論上出於個人行善之樂、職業道德,以及滿足發揮醫療專業成就感等動機,不管是甚麼樣的給付制度,醫生都有依照病人的利益去開檢查跟處置的原初心意,該開檢查的就開,不該開的處置的就不開。</p>
<p>另外,檢查跟處置也不是越多就越好,沒有必要就做的話也只是讓病人白白承受副作用而已。</p>
<p>只是原本論量計酬的給付制度下,有可能會讓醫院透過績效薪酬制度或管理階級的壓力,讓某些醫生去開一些不必要的檢查或處置,這在學術上叫「供給誘導需求」(supplier-induced demand)。</p>
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<p>「供給誘導需求」其實也是學術上另一個爭議不斷的議題,有很多研究證實「供給誘導需求」真的存在,但也有幾個研究方法很好的研究得到的結論是「供給誘導需求」不存在。有趣的是有兩個顯示「供給誘導需求」不存在的方法設計良好的研究都是挪威的研究。個人猜想會不會是挪威這個國家貧富差距低,包括醫生在內的人追求金錢報酬而犧牲良知的動機比較低呢?</p>
<p>在大多數的情況下,就算有醫生開一些不必要的檢查或處置,也是讓病人花一些冤枉錢而已(我的意思並不是說這是一件好事),只有極少極少的醫生會開一些不必要又會傷害病人身體健康的檢查或處置。</p>
<p>DRG也是同樣的道理。DRG的目的就是要解決「供給誘導需求」,醫生如果開不必要的檢查跟不必要的處置,虧的就是醫院的錢,所以DRG理論上可以減少這種行為。</p>
<p>至於你說DRG會不會讓醫生去省那些必要的檢查跟必要的處置,也就是學術上所稱的「吝嗇」(skimp),而導致醫療品質變差。美國的研究有的說品質會變差,有的說不會,歐洲的研究幾乎都是說不會變差。</p>
<p>我個人認為這是跟醫療體系的營利性質強度有關。醫療體系的營利程度越強,醫院透過績效薪酬制度或管理階級壓力來逼迫醫生的程度就越強,醫生的薪水嚴重決定於服務量,這時根據醫療經濟學家 McGuire 的理論,醫生在這種底薪低而多做「供給誘導需求」的邊際收益高的情況下,就有比較高的動機去作出有損病人利益又有害醫生自身道德感的「供給誘導需求」或「吝嗇」(skimp)(McGuire 的理論只有用來解釋論量計酬下的「供給誘導需求」,用來解釋論病計酬下的「吝嗇」是我個人對這個理論的衍伸)。</p>
<p>因此,不論是「供給誘導需求」還是「吝嗇」(skimp)所造成的醫療品質下降,都跟論病計酬的DRG或是論量計酬這樣的給付制度沒關係。</p>
<p>畢竟你說假設有個醫生在DRG的時候會為了要賺錢而不去開必要的檢查或必要的處置而傷害到病人,那他在以前論量計酬的時候,也應該會為了賺錢而去作一些傷害病人的不必要的檢查或處置。</p>
<p>所以這是醫德與醫療體系營利程度的問題,而與給付制度沒關係。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com1tag:blogger.com,1999:blog-7535787533759742354.post-14565590474910275402014-07-01T20:29:00.001-07:002014-07-01T20:29:04.035-07:00挺DRG與反DRG,矛盾邏輯與盾矛邏輯的矛盾大對決<p>挺DRG的論述理由是:由於醫療在經濟學上存在資訊不對稱,所以在傳統論量計酬的情況下,醫生會為了賺錢而「創造疾病」,做不必要的檢查,動不必要的手術。所以要改成論病計酬DRG。</p>
<p>但這論述的矛盾點在於,DRG並無法改變資訊不對稱的事實,因此醫生也有可能會為了賺錢而少做必要的檢查,不做必要的手術(人球)。我前陣子發現其實這點在醫療經濟學的教科書裡就有明文提到了。</p>
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<p>而醫界目前反DRG的理由則恰好是在上述挺DRG的矛盾點上大做文章,也就是利用「醫生會為了賺錢而少做必要的檢查,不做必要的手術(人球)」來恐嚇民眾。</p>
<p>為什麼我說這樣的反DRG論述很危險,很可能會傷害醫界?</p>
<p>因為這樣的論述同樣是以「醫生會為了賺錢而做出有損病人利益的事情」為前提。</p>
<p>若遵循同樣的前提推演下去,醫界也必須同意挺DRG方所說的「醫生會為了賺錢而「創造疾病」,做不必要的檢查,動不必要的手術」(醫療經濟學上所謂「供給誘導需求」)。</p>
<p>但有趣的是,反DRG方的部分醫界人士卻又堅決否認「醫生會為了賺錢而「創造疾病」,做不必要的檢查,動不必要的手術」這樣的事情,而力倡醫療應該營利。</p>
<p>其實醫界會有這樣矛盾的的論述,歸根結柢還是出自對「營利」的誤解與錯誤想像,以及將醫療體系複雜的金錢流動過程給簡化為一碗「牛肉麵」的交易過程所導致。</p>
<p>因而使醫界誤將「營利」給簡單等同於自身薪資的提升。殊不知事實上,醫療的營利程度很可能恰好跟基層醫護人員的薪資與勞動條件成負相關。(有趣的是,反對醫療應該「去營利化」的人,又常常會攻擊「去營利化」的公家機關的公務員福利太高。)</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com1tag:blogger.com,1999:blog-7535787533759742354.post-53637595572674559502014-06-18T19:49:00.000-07:002014-06-18T19:49:07.532-07:00YAM專欄《十二年國教的「反教改陰謀」》<p><a href="http://n.yam.com/yam/politics/20140619/20140617361525.html">原文連結:http://n.yam.com/yam/politics/20140619/20140617361525.html</a></p>
<p>am蕃薯藤新聞/黃致翰/專欄-2014年06月19日 上午09:00</p>
<p>十二年國教跌跌撞撞上路,首屆國中會考甫落幕,可說是民怨四起。教改的精神在於破除明星學校迷思,扭轉文憑主義現象,減輕無謂競爭所導致的精神內耗,使我們的青少年有更多的自主學習熱情,讓教育與學習回歸自身的目的,並附帶使國民更能透過終身學習,適應快速變遷的世界。</p>
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<p>其中,高中全面免試入學,是最重要的一項政策。但實際施行,卻擺脫不了菁英教育的意識形態,不但考試不減反增,甚至連才藝體育、服務學習,都成了競技廝殺的場所。弔詭的是,民眾一邊抱怨這種範圍與強度都更大的考試篩選制度,卻沒有訴求政府應落實免試精神,反倒矛盾地懷念起高中聯考,因為至少表面上看起來比較公平。</p>
事實上,即便目前的「菁英主義假教改」實際上因為考試與競爭越來越多,的確是比聯考對社經地位較低的孩子更不利,但這並不能抹煞聯考本身也是對社經地位較低的孩子不利這樣一個有學術證據支持的事實。但是,這樣一個以免試為口號,實質上卻更競爭、更多考試、更菁英主義、更不公平的假教改,卻成功讓人忘記聯考的不公平。這就讓人不得不懷疑,目前的十二年國教政策,背後是否受到欲維持聯考制度的既得利益階級操盤。</p>
<p>若不想讓反教改的既得利益者得逞,我們必須冷靜激動的情緒,實際檢視教育科學證據,以理解並分享「將教育視為公共財」這樣一個平等主義的理念。</p>
根據PISA(學生能力國際評量計劃)在2012年所發表的調查了全球65個國家的研究報告,證實了教改的原始理念是正確的。PISA發現,國家中依照學業表現來篩選學生的菁英學校越多,並不會使學生的整體表現更好,而且還會導致社經地位較低的孩子表現更差。而且,校內能力分班現象越嚴重的國家,學生表現的學業程度就越差(偏相關係數:-0.26)。此外,PISA也發現帶有新自由主義意識型態的學校私有化與市場化競爭策略,並無法達到讓孩子的表現更好的目的,而只能保障權貴子弟的階級,並傷害社經地位較低的學生。更重要的是,PISA還發現,不管用的是聯考還是會考等等五花八門的考試,一個國家依照學生的學業能力來決定可以讀哪間學校(能力分校)的程度越高,學生的學習動機就越低(附圖)。這樣的結果也支持考試與競爭會扼殺學生學習動機,不但讓我們的孩子活在壓力與痛苦之下,還使孩子離開校園後更難具備自主學習與終身學習的能力,更容易受到全球化快速變遷的傷害。
<p>除了以全球數據為基礎的科學研究之外,芬蘭教改的成功經驗也教導我們,應該尊重教師專業,讓老師擁有安穩合理的待遇與教學自主的空間,而不該用各種消費主義式的績效與評鑑指標等外在動機,來扼殺教師的教學熱誠與內在動機。</p>
<p>教育是一生的事,是全民的事。我們誤以為菁英才是帶動國家發展的動力,應該特別篩選出來培育。但競爭篩選與階級培育的後果,卻犧牲了讓更多人培養自我學習與關心社會的公民素養,同時造就了從小與廣大民眾生活隔離而看不見社會底層悲哀的菁英官僚階級。</p>
<p>我們應該抵抗新自由主義侵襲的惡潮,破解教育商品化、私有化、市場化的競爭力迷思,從戒嚴時代反共洗腦教育對平等主義的恐懼中解脫,而不該鴕鳥心態式的只看到聯考那兩天的公平,只看到教師績效與評鑑的枝微末節,只看到學生帳面上、學校內的考試成績,只看到菁英學校由社經地位的撐腰與篩選機制的偏差所美飾的升學指標;卻看不到被競爭扼殺學習動機的學生,喪失了終身自主學習能力,出了社會之後徬徨無助。</p>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOkMh0HM_m7FSKPfKd8QK0WXtVPZIwN0SwhfhxQfUntzZngM47c7fNSZ3nlguKsyWy3zXsnpDcX1DS-qLnd08NtpnZHXftiju-axZDohuQ_xv0i-Az_YkkGtqVJ9_TUpVcH4wavCpR52Nk/s1600/PISA.png" imageanchor="1" ><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOkMh0HM_m7FSKPfKd8QK0WXtVPZIwN0SwhfhxQfUntzZngM47c7fNSZ3nlguKsyWy3zXsnpDcX1DS-qLnd08NtpnZHXftiju-axZDohuQ_xv0i-Az_YkkGtqVJ9_TUpVcH4wavCpR52Nk/s400/PISA.png" /></a>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com1tag:blogger.com,1999:blog-7535787533759742354.post-37275288035326117932014-06-18T19:42:00.000-07:002014-06-18T19:42:36.073-07:00點評《国际专家关于中国医改的六点共识:只靠市场行不通》<p>健保亂世之中,大概只要懂得我老師的老師的(硬是要攀關係)的這些建言,你對於醫療政策的看法大概就可以排名全台灣「兩千名」以內了(這句話好耳熟,ㄏ)。</p>
<p>這篇文章左批台灣無能健保局的荒謬措施,右打台灣那些覺得自己經濟學實力排行前兩千名以內的醫生(千萬不要對號入座阿,ㄏ)。</p>
<p>看完之後,你大概就可以了解為什麼我們醫師勞動條件改革小組、公醫時代、反醫療商品化聯盟等等,跟一般民粹團體走的路線不一樣,而是一邊批衛福部、批健保署,一邊強烈反對醫療商品化、市場化、績效主義。</p>
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<p>我把重點中的重點摘錄如下,並在重點後附上短評:</p>
<p>「第一,在医疗保险和医疗服务领域,市场有严重的失灵。他批评说,有一种观点在中国依然有很大的声音,即政府主要管救济就是了,其他的完全都交给市场。世界各国的经验都证明这是行不通的。」</p>
<p>「政府只管筹资,不举办服务,让市场化的医疗机构充分竞争。萧教授当场问一位作此主张的专家:“这样做的,主要是美国、瑞士两个国家,两个国家的医疗成本,一家世界第一,一家世界第二,美国这样强的监管能力,尚且控制不住医疗成本,你有什么绝招,能让中国做到?”」</p>
<p>「另一位专家更有代表性,英国撒切尔政府的医改顾问Alan Maynard教授,正是“政府购买服务”的发明者。他指出,政府只出钱、不举办服务,就会造成医疗机构恶性竞争,造成过度医疗,提高医疗成本,英国的实践证明,“政府购买服务”的改革是失败的,执行不久就废除了,中国务必吸取教训。」</p>
<p>---發明者懺悔ㄟ,超有說服力!</p>
<p>「第三,预防和基本医疗优先。“预防为主”的方针,如果没有稳定的财政支持,就会流于口号。他举例说,在西部省份做试点,一些干部反对“大小病兼顾”,认为政府只管大病就行。结果就出现小病不治、拖成大病的情况。“多少人因为没有钱,有风湿病、哮喘病,小病拖成了大病,这是最惨的!所以,预防和基本医疗很重要,为了人们的健康,它的成本-收益比要大得多”。」</p>
<p>---趙少康、沈富雄之類的人可以不用再喊保大不保小了。</p>
<p>「第四,要改善价格管理体制。国际专家认为,中国的价格体制有很多问题,医疗服务价格定得那么低,开药可以挣钱,造成卫生总费用迅速上涨。“就好比一个病人胃出血,一边出血一边输血,增加的投入就都流到医院和药厂的口袋里”。」</p>
<p>---台灣健保署同樣需要改進這點!</p>
<p>「第五,激励机制可以左右医生的行医行为。美国为了控制老年医疗保险的成本,把次均诊疗费从10元降低到6元,结果处方量大幅增加。他说,在医疗市场上,价格和量是联系在一起的,医生可以左右数量。所以,对医生要有正确的激励,而不能鼓励医生追求收入。」</p>
<p>---這段話的意思是說要給醫師足夠高且穩定的合理待遇,而不是像現在台灣一樣低底薪、低單價,逼迫醫生衝量。</p>
<p>「据萧教授研究,全世界至少有十几个国家都尝试了商业保险,包括在各方面都刻意模仿美国的菲律宾,到1990年,菲律宾宣布这条路走不通,转而实行全民医疗保险。」</p>
<p>「但还有一些没有引起重视,甚至反其道而行之,向其他国家走过的弯路大踏步迈进。比如,在一个本来是公立医院为主的体系,实行“政府购买服务”,把公共医疗卫生事业变成健康服务产业,重新推向市场」</p>
<p>---他講得很含蓄,我幫忙翻譯一下,就是:馬英九下台!管中閔下台!退回服貿!退回自經區!</p>
<p>「这些,都是国内外实践反复证明走不通的路,很多医改研讨会上,一些信奉市场万能的官员和专家,讲着完全违背医疗体制基本知识的话,连来自西方市场经济国家的专家也听不下去了。」</p>
<p>---這些經濟學專家真是草莓族,如果來台灣見識一下,聽聽那些自認為自己經濟學實力排行前兩千名的人的言論,大概會像對穿腸一樣吐血不停喔!</p>
<br /><a href="http://www.cn-healthcare.com/article/20140610/content-458027.html">原文連結:http://www.cn-healthcare.com/article/20140610/content-458027.html</a>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-11671560140047048992014-06-18T00:53:00.000-07:002014-06-18T00:53:33.896-07:00YAM專欄《趙藤雄教台灣人的一件事──謹記蘇聯與第三世界的教訓》<p><a href="http://n.yam.com/yam/politics/20140612/20140609343809.html" target="_blank">原址連結點我</a></p>
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<p>直到所謂「草莓族世代」之前的台灣民眾與官員,大都長期受填鴨反共教育與美式新自由主義思想洗腦,一味追求私有化、全球化、金融化,相信「對郭台銘、蔡衍明、趙藤雄好的政策,就是對台灣人民好的政策」。聞BOT必鼓掌,見公務員則譙之;減稅就向政府磕頭稱謝,削減公共支出則豎拇讚揚。</p>
<p>直到台北房價所得比直上雲霄而達世界第一,物價直直漲而薪水卻從22K倒退嚕。美麗灣、隘門沙灘事件讓人民驚覺「山也BOT,海也BOT」,更不用說ECT案中遠通所擺出的囂張跋扈與失業收費員的無助感所形成的對照。受市場化的健保體制與血汗「財團」醫院雙重剝削的護師醫師過勞出走。服貿自經區政策更是近一步割地賣國欲圖利財團而無視基層勞工為台灣的血汗貢獻,最終引發太陽花學運,連帶暴露基層警察過勞問題。鄭捷事件更讓人民驚覺輔導老師的人力配置與公共經費根本不足。</p>
<p>直到最近,清寒苦讀出身的台北地檢署檢察官陳玉萍不畏權勢,揭發合宜住宅弊案,使得覺醒的太陽花世代發現,新自由主義的小政府思想,最終只會小到真正為人民獻出血汗的基層公務人員,只會削減掉真正具有公共利益的經費,而完全遏止不了貪汙。甚至因為財團的坐大與人民對表面上的小政府產生鬆懈,而使官商勾結更容易。另外,將具有自然壟斷與公共利益性質的服務BOT、私有化給財團,也只是將反共教育視之如仇的「計畫經濟者」角色,交由私人企業的管理階層來扮演;將可受人民監督的貪污轉化為被「受洗腦者」所讚頌的「激勵獎酬」。進一步使社會上不事生產卻坐收人民血汗錢的「尋租者」更容易與貪官勾結。</p>
<p>美國知名金融與經濟學家Michael Hudson早已指出,近三十年來,「私有化」、「金融化」、「全球化」的三位一體,迫使前社會主義與第三世界國家將具有國家利益的自然資源、基礎建設與地產私有化並賤價出售,使得經濟剩餘由國家資金轉移到「金融」、「保險」、「不動產」等私有部門。更值得借鏡的是,私有化主要是由美國政府的戰略家所推動,意圖在於瓦解蘇聯的工業力量,最終也達成目的,使蘇聯國家見證其公有資源透過政治菁英的內部交易轉手將股份交到西方買主手上。</p>
<p>兩相對照之下,當今台灣政府不斷以「國際競爭力」為理由,「私有化」、「金融化」、「全球化」為修辭,不顧人民反對之浪潮而強推服貿與自經區,不免讓人擔心中國自由派法學家袁紅兵所說的中共「買下台灣」的統戰策略,是否就快要達成?只希望除了太陽花世代之外,趙藤雄的收押,能喚醒其他台灣人民,謹記蘇聯與第三世界的教訓,進而扭轉新自由主義與竊國者侯的崩世代。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-5970998710420602512014-06-18T00:50:00.000-07:002014-06-18T00:50:09.227-07:00簡評《李柏鋒專欄/不革家長的命,教改永遠不會好》<p>原文請見:<a href="http://m.udn.com/xhtml/ViewFreeArticle?type=news&cate=82&page=1&articleid=3849973&sn=1" target="_blank">李柏鋒專欄/不革家長的命,教改永遠不會好</a></p>
<p>評:</p>
<p>1)家長錯在支持廣設大學,而不在拼大學學歷。根據教育社會學與經濟學的研究,大學學歷的確跟未來預期收入正相關(當然有校正其他因素的影響),不論是在台灣還是美國、英國都一樣(台灣私立大學學歷對收入無影響)。</p>
<p>2)這是Thomas Shilling說的多人囚徒困境,解決方法只有改革社會經濟教育制度,把錯推給個人不但沒用,還是會阻礙進步的反動修辭。</p>
<p>3)把社會弄成行行「真的」出狀元才是重點,而不是用特例個案去「騙」弱勢學生行行出狀元。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-21380130634856246072014-05-26T07:22:00.000-07:002014-05-26T07:32:43.557-07:00【蘋果日報】公民之聲:別讓醫師只為富人服務(黃致翰)<p>原文刊載於 <a href="http://www.appledaily.com.tw/appledaily/article/forum/20140526/35852863/%E5%85%AC%E6%B0%91%E4%B9%8B%E8%81%B2%EF%BC%9A%E5%88%A5%E8%AE%93%E9%86%AB%E5%B8%AB%E5%8F%AA%E7%82%BA%E5%AF%8C%E4%BA%BA%E6%9C%8D%E5%8B%99%EF%BC%88%E9%BB%83%E8%87%B4%E7%BF%B0%EF%BC%89" target="_blank">2014年05月26日的蘋果日報</a> ⊕黃致翰</p>
<p>我念建中時就想讀中醫,後來如願念中醫系,雙主修西醫後,對西醫也很有興趣。念醫學院大五時,我進醫院見習,發現醫院為了省成本,醫護人員工時都過長,像醫師一值班就是連續36小時。可是,不管怎麼反映不合理,醫院高層都說,這是學習,他們當年也是這樣苦過來的。</p>
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<p>國內外研究都已證實,護理人員照護病人比例的增加將降低病人死亡率、搶救失敗率及縮短住院時間。美國研究,每年高達2萬個病人死亡,其實是可以避免的。每個護理人員多增加照顧1個病人,病人死亡率增加7%;每多增加照護4個病人,死亡率增加31%。可是官員跟醫院高層,始終不願正視這個事實。2011年,成大實習醫師林彥廷過勞死,可怕的是,大家繼續漠視這問題。</p>
<p>我們20幾歲這一代醫師,看到醫院年輕主治醫師都很慘,薪水要看業績,早已不相信學習跟成長這一套。我們覺得,這全是醫療商業化的結果,所以我們幾個醫學生組成醫療勞動條件改革小組。我們強調,醫療是公共財。看全世界國家,第一類是像非洲一些常被西方認為是「第三世界」的國家,人民生病,沒錢就得不到醫療。第二類是像歐洲、澳洲、加拿大跟日本這些先進國家,有公醫或健保制度,人民生病,不怕沒錢醫。第三是美國,沒健保跟公醫制,醫療徹底商業化,除非病情很嚴重,可以到公立醫院治療,但代價就是要付出先進國家兩倍的醫療支出。</p>
<p><b>盼醫護納《勞基法》</b></p>
<p>台灣想變哪一種?台灣醫療現在像是公共財,今天若非健保,很多沒錢看病的人已經死了,可是健保的設計卻讓醫院營利,現今健保的成果都是透過壓榨醫護人員來的,這不是我們要的,我們希望改革,否則醫療終將崩壞,醫護人員會反抗。我們希望能照顧全民健康,所以要朝改善醫護勞動條件努力。</p>
<p>美國醫療價格昂貴,佔GDP的14%,而台灣醫療花費只佔GDP的6.8%,很多醫師拿到美國醫療帳單會覺得美國真是醫師的天堂,但其實很多利潤都是保險公司跟醫院管理階層拿走。</p>
<p>當政府沒宣導醫療是公共財,讓大家覺得,醫療是服務業,付錢的就是大爺,所以當醫護人員被欺負,民眾不會支持醫護人員。醫療私有化,醫院有錢也不會想改善醫護人員的薪資跟勞動條件。</p>
<p>很多醫師覺得在公醫制下,醫師一定被壓榨,醫療沒效率,事實不是這樣。像英國是公醫制,醫師反而較能依專業判斷,依倫理分配醫療資源,讓需要得到醫療的得到救治,醫護人員也受到保障,他們就全力透過國家力量阻止醫護人員被施暴。</p>
<p>目前我們爭取醫護人員納入《勞基法》,將醫護病比明確列入法規,而且政府要嚴格稽查,不能只是看醫院提供的數據;未來將成立醫師工會。從醫療經濟學角度看,國家要強盛,公共醫療體系一定要建立起來。我希望當個可以發揮專業的醫師,而不是當醫療都私有化,我當醫師只剩三條路,第一,有錢人要我做什麼,我就得做什麼。第二,遇到沒錢的人生病,我要嘛不救他,要嘛第三種,我救他,自己卻過得很慘。記者陳玉梅採訪整理</p>
<p><b>醫師、醫療勞動條件改革小組成員</b></p>
<br />
<p>後記:</p>
<p>有人在蘋果日報下面回應:</p>
<blockquote class="tr_bq">
「所以咧?2014/05/26 14:02<br />又要公醫制, 又要醫生收入高, 錢哪裡來? 不要跟我說又是全民買單<br />199.1*****2.211」</blockquote>
<p>評:這種回應沒必要認真回,只是借題發揮引用一段最近在醫療經濟學家Victor Fuchs的書上看到的精闢文字:</p>
<blockquote class="tr_bq">
「公眾的討論常常會混淆最根本的一點:無論在何種體制下,公眾都必須支付醫療費用。也就是說,那怕支付機制看似把帳單送到了其他地方,費用最終仍將由家庭和個人承擔。<br />除非是蕭條時期,否則沒有甚麼神奇的融資魔棒能使勞動、資本和其他資源轉移到醫療領域而不減少用於食物、住房、教育、娛樂和其他商品、服務的資源。<br />也沒有甚麼公式能把保健費用轉移給『政府』或『企業』,卻不通過增加稅收、抬高價格和降低工資等手段把負擔最終轉嫁給公眾。<br />就算融資體制可以區別對待收入最高和最低的家庭,普通家庭無論在何種體制下都得承擔相同份額的費用。」</blockquote>
<p>其實台灣會有這種留言也不意外,否則大家怎麼會傻傻的覺得讓遠通來搞ETC是好事呢?</p>
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSDSer1WPJr8lvpvHCtLyTidkzt7WxuQAxPuMvZnrPYRY1wemqWonKIDZLr5kTYQWZotNj_wVfRKqUxv9XcQwHfy9AaguBfVYATL2LilwWDQneTVvAkeBg7GBIi-8VcJK0Yi4xm3iRYCN4/s1600/DSC_4871.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSDSer1WPJr8lvpvHCtLyTidkzt7WxuQAxPuMvZnrPYRY1wemqWonKIDZLr5kTYQWZotNj_wVfRKqUxv9XcQwHfy9AaguBfVYATL2LilwWDQneTVvAkeBg7GBIi-8VcJK0Yi4xm3iRYCN4/s400/DSC_4871.JPG" /></a></div>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-70591629373453386282014-05-21T05:44:00.002-07:002014-05-21T05:44:52.673-07:00自經區國際醫療:官員與財團對人民的負面思惟,才會困死台灣<p>本文同時刊載於<a href="http://www.thinkingtaiwan.com/articles/view/2060">「想想論壇」</a>
<p>近日拜讀中華經濟研究院副院長王健全「醫療專區可以救健保嗎?負面思維困死台灣」一文,對於內容有些贊同,有些不贊同。</p>
<p>首先,王副院長稱「就心理學而言,說『不』,代表自己有別於一般民眾,有高人一等的優越意識」,雖然本人從未在心理學教科書中看過這種理論,但最近政府官員與財團老闆對台灣人民與學者「反核四、反國光石化、反博弈、反都更、反自由經濟示範區」的意見,普遍抱持「負面思維」,對人民的意見一概說「不」,這的確可說是政府官員與財團老闆的一種「以為自己有別於一般民眾,有高人一等的優越意識」的心態。</p>
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<p>但王副院長說,「全民健保面臨虧損,必須從國民的所得抽取附加保費來挹注健保赤字,如果無法推廣國際醫療,進行部分的企業化來彌補虧損,全民健保及部分醫院將陷入困境」,就完全是在用不符合醫療經濟學學理的言論來恐嚇民眾。</p>
<p>事實上,根據最新的統計,台灣全民健保從2010開始已經擺脫赤字,連續三年有盈餘,根本沒有虧損。雖然如此,以2010年為例,台灣醫療保健支出佔GDP的6.5%,而政府對醫療保健的公共支出只佔了GDP的3.7%,在包括OECD國家在內的34個先進國家中排名倒數第三。</p>
<p>相對而言,美國的醫療保健支出佔他們GDP的11.7%,幾乎是台灣的兩倍,而美國這個全世界最奉行資本主義的國家的醫療保健公共支出居然佔GDP的8.4%,是台灣的兩倍以上。但最終得到的健康結果,不論是在預期壽命,或是新生兒死亡率上,台灣都優於美國。之所以如此,就因為美國是先進國家中唯一沒有全民健保或公醫制度的國家,私有營利醫院與私人保險相互競爭輕症及有錢的病人,將重病的窮人推給公立醫院及政府保險(Medicare及Medicaid),最終形成經濟學家所稱的「雙重結構」(two-tiered system),而形成全世界效率最差、最浪費的醫療體系。</p>
<p>雖然台灣靠著全民健保而達成了傲視全球的醫療經濟效率,但全民健保或公醫制度等「社會化醫療」也絕對不是毫無缺點的醫療制度,其最大的缺點在於「政治風險」,亦即醫療制度與財務政策因政治因素而無法依照學理上能使全體人民獲得最大利益的方向而行的風險。</p>
<p>台灣的醫事人員、人民與官員生來在極右派思想教育下長大,缺乏勞動權益意識與醫療公共性的概念,因此造成政府的衛生政策與健保制度以社會福利為名,卻又在供給面行商品化、市場化、績效主義之實,鼓勵醫學中心與基層診所相互競爭病人;在需求面不去強調醫療的公共性,使醫療淪為服務業,轉診制度無法落實,偏鄉的中小型醫院頻頻倒閉。最終劣幣逐良幣,使得注重門面行銷、醫療軍備競賽,且又壓榨醫護人員的大型財團醫院甚至公立醫院獨大。真正照顧鄉親健康或對員工友善的醫院診所反而因為沒有所謂「競爭力」而被淘汰。</p>
<p>再加上理論上屬非營利機構與社會公共財的醫療財團法人,藉由各種法律漏洞而行營利之實,使得既得利益的醫院管理高層與政府官員互相勾結而形成政策一言堂,讓真正在第一線服務的醫護人員及民眾的聲音無法影響政策,而且任何表面上對基層醫護人員的報酬補助都會被醫院管理階層利益分配掉,像是投入無底黑洞。</p>
<p>前面說過台灣醫療保健公共支出排名倒數第三,這絕對不是甚麼值得驕傲的事情。首先,台灣能利用不到美國一半的醫療支出來達到病人照護結果更好的醫療體系,靠的除了是經濟學學理上先天就優於自由競爭的全民健保制度以外,還利用包著社會福利外皮而行商品化績效主義之實的方式,來榨取基層醫事人員,造成了「五大皆空」、護理師荒、血汗藥師等現象,更面臨「假日飛刀手」的人才外流現象。再者,根據公衛學家史塔克勒與巴蘇兩人所著《失控的撙節》書中的研究,說明了政府在公共衛生的公部門支出越多,國家因經濟蕭條而死亡的人數越少,甚至從經濟蕭條中復甦的速度也越快,因為人民的健康有保障,因病而貧的可能降低,人民才有本錢拚經濟。</p>
<p>總而言之,台灣醫療崩壞之病因正在於醫療公共性的喪失,商品化的橫行。如今政府卻妄想透過將醫療徹底當作一門服務業的自經區國際醫療來改善血汗健保與醫療崩壞之困境,無疑「請鬼帖藥單」,然後鬼叫你飲酖止渴。</p>
<p>根據哈佛大學政治經濟學教授羅德里克的研究,民主可以帶來長期的經濟增長,且能讓國家在處理經濟危機時表現更好。這是因為一旦政策制定者不受民主制衡而權力過大,就會一心鞏固自身利益而做出有損全民福祉的決策。而當今政府卻一意孤行,不肯聽取基層醫護人員與民眾的聲音。依照羅德里克教授的研究,官員與財團對人民的負面思惟,才會困死台灣!</p>
<p>因此,若政府真心想要拚經濟,就應該遵照社會科學的實證研究,落實國家與勞資談判的民主制度,明確醫療的公共性,修法確立基層醫事人員的勞動權益,並健全健保與賦稅財源,增加醫療的公共支出。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-81601742738047864472014-05-21T05:41:00.001-07:002014-05-21T05:41:20.613-07:00醫學就是社會學,醫生當學社會學<p>本文同時刊載於 <b><a href="http://www.thenewslens.com/">關鍵評論</a></b> <a href="http://www.thenewslens.com/post/39847/">《血汗健保成為醫療崩壞的病根,就是因為某些醫生不懂社會學》</a></p>
<p>德國細胞病理學之父微爾嘯說過:「醫學是門社會科學,而政治學不過是一門較大規模的醫學」。若微爾嘯在天之靈,聽到蘇清泉醫師立委居然說「念社會系、社會所到底是在研究什麼?」,不知會做何感想。</p>
<p>涉獵社會學、經濟學、社會心理學等知識,讓我明白,許多讓第一線醫師感到無奈的現象,看似醫學問題,其實都是社會問題。</p>
<p>例如,從小到大,學校教育或社會媒體都教育我們,身體不舒服,或者出現奇怪的症狀,就要趕快看醫生,以免小病拖成大病。另外,最好不要自己去藥局隨便買成藥吃,應該去看醫生讓專業的醫生來評估。</p>
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<p>可是長大成為醫生之後,卻每天都聽到有人抱怨民眾小感冒也來擠醫學中心的門診,又每天都聽到有人說健保不應該浪費錢給付感冒的門診費用,或者說小病來看急診應該加收個幾千塊。然後,這些人就開始罵政府,說政府沒有負起教育民眾的責任,應該要教育民眾小病自己去藥局買藥吃,不要來看醫生浪費健保資源。</p>
<p>我記得以前上感染科醫師王任賢的課的時候,他說過一段很經典的話。病人如果來看他的門診,說醫生我感冒了,馬上就會被他唸,不可以說自己感冒,要說自己有什麼症狀。為什麼?因為感冒是一個醫學診斷,是他身為一個感染科醫師該去鑑別診斷的。</p>
<p>王醫師說得沒錯,根據我門診的經驗,來說自己感冒的病人,從緊張型頭痛發作的年輕女子、過敏性鼻炎的國中生,到氣喘急性發作讓我馬上轉到急診的老先生都有。</p>
一句健保不給付小病很簡單,但民眾如何知道自己是小病?如果民眾真的知道的話,醫生的專業價值何在?</p>
<p>其實,那些一面抱怨民眾自己買成藥吃而小病拖成大病,一面又抱怨民眾小病愛來看門診急診的人,很少是真正在基層診所服務,或者是在一個績效主義氾濫的醫院工作的主治醫師。<b>因為,在這些地方服務的醫師根本就很希望(但也很掙扎)小病的民眾多多來看自己的門診好嗎。</b></p>
<p>因為,基層診所或者績效主義氾濫的醫院的受雇醫師,其收入正好決定於門診量。當然,我們絕對不該像少數仇醫的民眾一樣,說這些醫生就是死愛錢,畢竟誰不愛錢,否則支持服貿的人為何支持服貿?反服貿的人為何反服貿?養家活口錯了嗎?</p>
<p>話雖如此,但錢絕對不是人類做決策的唯一考量,不論是醫生還是其他任何職業,都時時刻刻在想要滿足良知、賺錢,以及發揮專業等等心理驅動力之下,做出掙扎的取捨。而要讓我們的社會越來越美好,就要盡量減少這種掙扎、糾結,與矛盾。</p>
<p>而研究這種掙扎、糾結,與矛盾的學問,就是蘇清泉立委不知道在研究甚麼的社會學。</p>
<p>用蘇清泉委員認為一無事處的社會學來分析這樣的矛盾,問題就出在醫療商品化、市場化。我國雖然有政府引以為豪的全民健保,但這樣的血汗健保,卻像是披著羊皮的狼,聯合財團醫院,以社會福利之名,行醫療商品化、市場化、績效化管理之實。在這種誘因環境之下,醫師要不成為無法發揮醫療專業的醫療商品推銷員,要不就只能當個養不活家人的現代史懷哲。</p>
<p>有些醫界人士習慣咒罵健保,開口閉口就說健保是「共產主義」、是搞均貧。殊不知,全世界包括日本、南韓、澳洲、加拿大,以及幾乎所有歐洲國家等58個先進國家,都是實施全民健保或公醫制度,而醫師在這些國家中的薪資收入,也大多排行國內所有職業的前三名。難道這58個先進國家都是共產國家?當然,若從蘇醫師委員最鄙視的社會學的角度來分析,少數不斷用共產主義來抹黑健保醫界人士其實也情有可原,畢竟大部分醫學院的人文教育欠缺社會科學思考方法的養成,只會用偶像崇拜式的「醫德」當作工具來壓榨基層醫事勞動者。而缺乏社會科學思維又被壓榨得不成人形的醫師,當然只能把怨氣發洩在健保上。</p>
<p>但是,如此缺乏社會科學思維的思考模式,卻無法抓住醫療崩壞的商品化病根,而罵錯對象,正中勾結的高官與財團醫院高層之下懷。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-85681841115596371752014-05-21T05:37:00.000-07:002014-05-21T05:37:22.490-07:00Victor Fuchs《誰將生存》(Who Shall Live)讀書筆記<p>「政策制定者在對指定用途和以現金為形式的資源轉移方案進行取捨時,也應該考慮到他們的經濟效應。舉例來說,老年保健醫療制度(Medicare)和醫療補助制度(Medicaid)的一個結果就是增加了醫生的收入--這顯然不是『大社會計劃』的目標。這兩項制度還抬高了一般公眾面臨的醫療價格,其中包括很多不夠條件加入醫療補助制度的低收入者。」--醫療經濟學家Victor Fuchs</p>
<p>短短一段話,實在有太多的點可以著墨的了。</p>
<p>1) 根據Fuchs的說法,美國政府搞的老人跟低收入戶的健保讓醫生的收入跟醫療的價格上升了(不過沒列出參考文獻),台灣的醫生看到這段話大概會吐血。</p>
<p>2) 第二,這段話還隱含著一件事實,那就是醫療經濟學的書籍裡面有很大的篇幅都在談(美國的)醫生薪水太高了,應該怎麼樣讓醫生的薪水降低,應該怎麼樣讓醫療價格變便宜。相對而言,台灣有一些一直靠杯健保,一直股吹醫療應該商品化、自由市場化的醫生,卻一直在說「醫療制度規劃不需要社會學家,需要經濟學家」。
實 在 是 太 好 笑 了 。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-87333594348470086602014-05-01T23:35:00.000-07:002014-05-02T00:52:04.284-07:00太陽花學運後談累進稅率的迷思<p>我不敢說這次立法院財委會通過的「財政健全方案」直接跟太陽花學運有關,但這次輿論居然沒有像以前一樣一面倒的咒罵聲,肯定跟太陽花學運扭轉新自由主義修辭有關。</p>
<p>當然,特別是「無效論」之類的反動修辭一如預期還是很多,如何破解以提升自己的思考我這裡就不多加著墨,請參見《反動的修辭》一書。</p>
<p>雖然我看的許多經濟學的書都一再強調累進稅率對社會好處並提出科學實證,甚至去年的諾貝爾經濟學獎得主席勒還主張累進稅率應該與社會上實際的貧富差距連動,也就是把「稅」轉化為一種「貧富差距社會保險」的概念,但我畢竟不適這方面的專家,因此這方面也暫且不多加著墨。</p>
<p>我想特別針對的是目前可以說是最常見到的一種反對累進稅率的理由,也就是認為要讓努力的人獲得大量的財富才能激勵人努力,而累進稅率會削弱努力的動機,大家就會變懶而減少工作。</p>
<a name='more'></a><br />
<p>首先必須澄清的是,所有的累進稅率不論怎麼設計,在大多數的情況下理論上都不可能會讓稅前收入高於某乙的某甲,在繳稅之後的收入變得比某乙低。也就是說,如果把所有的台灣人依照所得作排名,稅前跟稅後的排名理論上會是一模一樣的。再者,累進稅率不管再怎麼累進,也絕對不會是讓所有人的錢都完全一樣多的共產主義。以上是幾乎所有人在論述累進稅率對社會的好處的時候都會先特別澄清的部分,雖然我覺得這樣的澄清非常無聊,但這都是因為反對累進稅率的人就真的常常會提出這麼無聊的質疑。</p>
<p>在無聊的澄清之後,我們再回到累進稅率會削弱努力動機的論述上。因為這樣的論述既沒有談到科學實證,也根本不被認為是真正嚴謹的經濟理論,所以我也就不怕自己不是這方面的專家,而可以純粹就邏輯、道理,與部分科學實證來反駁這樣的論述。</p>
<p>我們用職業棒球來比喻這個社會好了。反對累進稅率的人會說,我們應該盡量提高冠軍的獎金,或是說盡量提高表現優異的棒球選手的薪水,這樣才會激勵棒球選手努力打球,我們才有優質好看的棒球比賽。其實Michael Sandel已經在《錢買不到的東西》裡用《魔球》的例子來反對過這樣的論述了,但我在這邊還要延伸補充。</p>
<p>首先,根據經濟學的第一原則,資源是有限的。所以提高排名前面的獎金或薪水,就一定是犧牲後面的獎金或薪水,而拉大貧富差距。(當然反累進稅率的人會說如果沒有累進稅率的話,就會更激勵大家工作,總收入就會更多,餅就更大,但這些人也幾乎都同意貧富差距會更大這樣的事實,只是他們認為窮的人的絕對收入會變多。)</p>
<p>犧牲了拉大的貧富差距而創造了鉅額的報酬誘因,收先面對的便是經濟學所謂邊際效應遞減的問題,難道你真的覺得王建民的年薪從一億元變成兩億元,會讓他的表現突飛猛進?</p>
<p>甚至,實際的情況還不只是邊際效應遞減,甚至邊際效應還會變成負的!早在一百多年前,心理學家葉爾基斯(Robert Yerkes)以及道森(John Dodson)就利用老鼠實驗,證明了隨著激勵強度的提升,績效開始會提高,但在達到一個高峰值之後,績效便會隨著激勵強度的提升而下降。而後續無數針對人類的心理學研究,更是不斷證實了這一點。也就是說,王建民的年薪從一億元變成兩億元,可能會讓他的表現更差!因為過高的獎酬造成得失心太重導致過大的壓力而影響表現。</p>
<p>再者,王建民的年薪從一億元變成兩億元,除了如心理學所說的可能會因為壓力而造成表現更差以外,還可能因為經濟學上的所得效應而變得更懶,亦即因為錢已經夠多了所以也不太想努力工作(A-rod?)。</p>
<p>另外如前所述,累進稅率並不會影響稅前收入的排名,也就是說,如果人介意的並不是絕對收入,而是相對收入,則累進稅率根本不會影響人努力的動機,而這點已經被許多心理學研究證實(Sara J. Solnicka and David Hemenway(1998) Is more always better?: A survey on positional concerns. Journal of Economic Behavior & Organization 37, 373-383)</p>
<p>而且,過高的獎酬也會吸引過多可能更適合其他行業的人材投入職業棒球,而造成社會資源分配的無效率。這點可參見經濟學家Robert Frank的《贏家通吃的社會》。<br />
再來,因為資源有限,所以前面過高的獎酬所造成的資源排擠效應,也造成表現沒那麼好的棒球選手所領到的薪水可能難以餬口,不但可能必須兼職而無法專心訓練,甚至可能迫使一些有潛力的選手提早放棄棒球身涯,造成資源浪費(例如許多美國職棒小聯盟的選手)。(同樣參見《贏家通吃的社會》)</p>
<p>當然,以上的討論還是在假設努力程度可以高度決定薪酬的前提之下所做的保守推測,而許多社會學的研究早已打破了這樣的迷思,也就是說決定薪酬高低的重要因素可能是運氣(包括家世、基因...等等),這也就更進一步削弱鉅額獎酬的誘因功能。</p>
<p>最後,過高獎酬所造成的薪酬貧富差距過大,甚至可能直接對注重團隊合作的棒球運動的球隊表現造成負面影響。這點不但有美國大聯盟的實證資料支持(參見Ichiro Kawachi跟Bruce P. Kennedy所合著的《The Health Of Nations: Why Inequality Is Harmful To Your Health》),台灣職棒的研究也支持這樣的結論(Gee Sana & Wen-Jhan Janea. Wage dispersion and team performance: evidence from the small size professional baseball league in Taiwan)(但我懷疑台灣的研究結果受到血汗兄弟象的影響很大XD)。</p>
<p>若就整個社會的層次來說,科學證據也的確支持過大的貧富差距會降低社會上的信任感,進而提高政治成本,減損社會資本。</p>
<p>你覺得,我們的社會像不像是在打棒球呢?</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-85964805106769951582014-05-01T06:11:00.001-07:002014-05-01T06:11:25.319-07:00自經區醫療專區肥了誰?<p>一個三歲小孩也懂的道理,健保是中華民國政府管的,自經區也是中華民國政府管的,哪來的競爭?那些每天都在罵政府為了選票只會討好民眾透過健保壓榨醫護人員的人,到底是哪來的自信有了自經區之後政府就會佛心來了寧願放棄選票而改善健保不壓榨醫護人員?</p>
<p>現在政府處理五大皆空的招術就是PGY跟縮限非五大科名額!而且政府現在都敢說要限制醫師出國賺錢了,之後你以為那些能進自經區賺錢的是誰?真的是技術高超的醫生?還是連勝文?</p>
<p>不要以為我在開玩笑,自經區條例對外國醫事人員的資格認定根本是空白授權!你覺得是技藝高超又有醫德的草民醫生能進自經區賺錢,還是background超硬的波波能進去?</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-70707620473183334462014-04-29T06:22:00.000-07:002014-04-29T06:22:41.140-07:00台灣醫療崩壞之三個病因與對應處方<p>面對政府欲將醫療服務納入服貿與自經區,使素來被視為具有公共性的醫療商品化,社會上掀起了一股爭辯醫療究竟是公共財還是商品的風潮。</p>
<p>其實,就算沒有服貿與自經區的威脅,台灣的醫療也早就沉痾難起,瀕臨崩壞。</p>
<p>沉痾有三,第一,披著非營利醫療財團法人外皮,行營利公司之實的「醫療『財團』化」問題;第二,醫護過勞等「醫護人員勞動權益」問題;第三,「醫療資源與醫護薪酬分配不公」問題。</p>
<p>造成這三個問題的病因,乃政府之衛生福利政策,以社會福利為名,行商品化、市場化、績效主義之實;以公共財為口號,行逼迫醫療成為以追求利潤為首要任務之商業、服務業之實;再加上衛福政策被利益集團把持,基層醫藥衛生從業人員無法發聲,使得健保給付與財團化醫院共謀壓低醫護人員待遇,造成基層醫療從業人員被迫拚績效、衝服務量,犧牲人民健康福祉。</p>
<p>站在政府自身利益的立場,其實這樣做的好處有三。第一可以推卸政府照顧人民健康的責任;再者可以討好以五鬼搬運法營利之財團化醫院;第三點更高招,利用不公平、不合理的健保給付與核刪機制,繁複虛假的評鑑與不盡責的勞動稽查等手段,壓榨第一線醫護人員,同時利用殘破的轉診制度與總額給付制度,讓醫藥社福政策披著公共財的外衣以討好民眾,暗地卻將台灣的醫療與社福漸漸商品化、市場化,最終達成讓醫療從業人員與民眾誤將健保等社福理念當敵人,將醫療崩壞的解藥寄託在「飲自由市場之鳩以止渴」之上,最終達成政府背棄人民,圖利財團之目的。</p>
<p>在此,我提出三帖醫療崩壞之解藥。第一,修定醫療法以解決「醫療財團化」問題。第二,醫師納入勞基法並修訂法條鼓勵成立工會以解決「醫護人員勞動權益」問題。第三,將基層醫護代表納入衛生福利與健保政策(核刪、給付、藥價等)決策過程以解決「醫療資源與醫護薪酬分配不公」問題。</p>
<p>最後,我鄭重呼籲政府負起捍衛人民健康的責任,解決「醫療財團化」、「醫護人員勞動權益」、「醫療資源與醫護薪酬分配不公」等問題,並將社福醫療排除在服貿、自經區之外,因為若引進中國等國外資本,將形成更難撼動的利益團體,使醫療崩壞之沉痾更難解決,最終將病入膏肓,使被政府背棄的全體人民與崩壞之醫療陪葬。</p>
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjizALx6hn9taAolj7fmAy5hxTlpPDjyOiHxZ1CEFY7BDTZHQIQebw22QHkqPfxxbs_CnIYfPwSS05le-i8kTKIdlqXmWQxIpZjXukl8ddaHe6s0milthLZH5Gs4VoqvoGyhxDhKkstg9Qq/s1600/1267533_627127587381244_6801407154022760262_o.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjizALx6hn9taAolj7fmAy5hxTlpPDjyOiHxZ1CEFY7BDTZHQIQebw22QHkqPfxxbs_CnIYfPwSS05le-i8kTKIdlqXmWQxIpZjXukl8ddaHe6s0milthLZH5Gs4VoqvoGyhxDhKkstg9Qq/s400/1267533_627127587381244_6801407154022760262_o.png" /></a></div>
<p>新聞連結:
<a href="http://n.yam.com/healthnews/healthy/20140429/20140429261221.html">http://n.yam.com/healthnews/healthy/20140429/20140429261221.html</a><br />
<a href="http://news.rti.org.tw/news/detail/?recordId=104059">http://news.rti.org.tw/news/detail/?recordId=104059</a></p>
<iframe width="420" height="315" src="//www.youtube.com/embed/_R4GcEO8H_c" frameborder="0" allowfullscreen></iframe>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-41339424288148830672014-04-29T05:57:00.001-07:002014-04-29T05:57:40.421-07:00醫界悖論之醫療不是服務業?<p>我真的不懂,為什麼少數那些反對醫療去商品化的人,又很喜歡在那邊說醫療不是服務業。</p>
<p>有人說醫療去商品化的概念很難懂,所以他不贊成,但難道一個「商品化的非服務業醫療」概念就更好懂嗎?</p>
<p>我真的不懂,為什麼少數那些反對醫療去商品化的人,可以一邊抨擊醫療比台灣還去商品化的歐洲國家看病要等很久,一邊又在那邊不爽某些台灣的病人總是希望醫生趕快先給自己看診。</p>
<p>我真的不懂,為什麼少數支持自由經濟區國際醫療的人,可以一邊詛咒健保趕快倒,一邊咒罵衛福部補助給護理師、住院醫師的錢都被財團醫院A走,又可以一邊在那邊期待自經區賺到的錢補助健保之後會讓自己的待遇變好。</p>
我真的不懂。</p>
<p>PS: 推文請不要推「啊現在台灣的醫療就已經是服務業了啊!」。是啊,台灣現在的醫療已經是服務業了,所以呢?跳出來跟我們一起反抗啊!</p>
<p>其實我們反對醫療商品化的理由真的很簡單,如果你想要當一個願意犧牲專業性與臨床自主性而以病人滿意度與業績為優先以得到優渥報酬的醫生,或者是想當一個能夠盡情發揮醫療專業卻領取微薄薪資的醫生,那麼我真的歡迎你支持醫療商品化(儘管你不一定可以選到你想當的上述兩種醫生之一)。但如果你想發揮專業又合理報酬,那只有醫療去商品化一途。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-18836662065173749702014-04-29T05:54:00.001-07:002014-04-29T05:55:28.864-07:00商品化是解決醫護被壓榨的良方還是毒藥?<span style="color: #37404e; font-family: lucida grande, tahoma, verdana, arial, sans-serif;"><span style="font-size: 14px; line-height: 18px;">太陽花學運,讓年輕世代覺醒,破滅了新自由主義追求「個人競爭力」以促進人民幸福的神話。</span></span><br />
<span style="color: #37404e; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 14px; line-height: 18px;">希望接下來的努力,也能讓更多人覺醒,讓「醫療不商品化的結果就是現在醫療人員被壓榨」的神話破滅。</span><br />
<span style="color: #37404e; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 14px; line-height: 18px;">如果說「醫療不商品化的結果就是現在醫療人員被壓榨」,那麼現在</span><span style="color: #37404e; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 14px; line-height: 18px;">消防隊基層也被壓榨,所以解決之道是消防商品化嗎?</span><br />
<span style="color: #37404e; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 14px; line-height: 18px;">警察基層也被壓榨,所以解決之道是警察商品化嗎?</span><br />
<span style="color: #37404e; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 14px; line-height: 18px;">國道收費員也被壓榨,所以解決之道是國道商品化嗎?</span><br />
<span style="color: #37404e; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 14px; line-height: 18px;">鴻海員工也被壓榨,所以解決之道是iPhone商品化嗎?(咦?)</span><br />
<span style="color: #37404e; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 14px; line-height: 18px;">高科技產業基層員工也被壓榨,所以解決之道是電腦晶圓商品化嗎?(咦?)</span><br />
<span style="color: #37404e; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 14px; line-height: 18px;">拜託,這麼明顯的矛盾,真的需要我來點破嗎?</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLE9_wqdQ3B52z5zhRyLGxUXgs-efgih-_ugoyYAY75spsbv2y6yatBGRAb3hLtdxsZ5PZ7JGoRU2o9oIk2Ej_w_t-47LcZtI3cMjlp33bsLf3WBamOY79pGTejPU7nvP0FprQnIwP30NC/s1600/%E5%9C%96%E7%89%872.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLE9_wqdQ3B52z5zhRyLGxUXgs-efgih-_ugoyYAY75spsbv2y6yatBGRAb3hLtdxsZ5PZ7JGoRU2o9oIk2Ej_w_t-47LcZtI3cMjlp33bsLf3WBamOY79pGTejPU7nvP0FprQnIwP30NC/s1600/%E5%9C%96%E7%89%872.jpg" /></a></div>
<span style="color: #37404e; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 14px; line-height: 18px;"><br /></span>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0tag:blogger.com,1999:blog-7535787533759742354.post-60622319843956825252014-04-18T09:45:00.001-07:002014-04-18T11:06:00.273-07:00從疫苗分配探討醫療商品化之概念<p>昨天的公衛倫理與法律課堂,討論了四種分配缺稀致命急性傳染病疫苗的原則。其中三種主要依據的是<a href="http://zh.wikipedia.org/wiki/%E6%95%88%E7%9B%8A%E4%B8%BB%E7%BE%A9" target="_blank">功利主義(utilitarianism)</a>,或輔以羅爾斯的差異原則來建立優先順序,以分配疫苗。簡單來說,就是以能讓最多人活下來的分配方式為主,但也會有某種程度與比例強調社會上弱勢族群的優先分配性。</p>
<p>第四種分配疫苗的方式,是<a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8519.2008.00636.x/abstract" target="_blank">哲學家Martin Peterson以平等主義為中心思想所提出</a>,認為應該用抽籤的方式來分配疫苗,使每個人因為這次疫情的活命機率盡量達到相同。但Peterson並不特別強調平等主義,而是為了說服功利主義者,用「活命機率」帶給人的效用的邊際遞減原理來說明活命機率相同的抽籤方式才能讓總效用最大化。(但Peterson卻又批評功利主義者認為每個人的效用可以相加的假設是不合理的,這就自相矛盾了。)</p>
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<p>我個人雖然是偏好Peterson的抽籤分配疫苗方式(只要看過<a href="http://www.books.com.tw/products/0010590630" target="_blank">《反脆弱》</a>就會愛上用抽籤來分配很多事情!)但其實這四種分配方式我都可以接受。</p>
<p>令我意外與慶幸的是,用自由市場來分配疫苗的方式,完全就不在這次考慮的選項之內。雖然說這四種方式是老師挑選來讓我們辯論的,但不只課堂上完全沒有人提到用自由市場來分配,就我的生活經驗中,也幾乎沒有聽到有人主張疫苗分配用自由市場來決定的。</p>
<p>還好,至少在台灣人的心中,還是認為有某些價值是無法用金錢來衡量、用市場來分配、當商品來販賣的。</p>
<p>最近許多醫界公衛界的朋友及我,共同發起了<a href="https://www.facebook.com/medicine.not.for.sale" target="_blank">反醫療商品化聯盟</a>,也引起了醫界公衛界內部對於「商品化」,甚至是「市場化」的定義的爭辯與討論。</p>
<p>其實,根據「<a href="http://zh.wikipedia.org/wiki/%E8%AA%8D%E7%9F%A5%E8%AA%9E%E8%A8%80%E5%AD%B8" target="_blank">認知語言學</a>」的研究結果與理論顯示,所有人類的概念的誕生與演化所依據的都「<a href="http://zh.wikipedia.org/wiki/%E5%8E%9F%E5%9E%8B%E6%95%88%E6%87%89" target="_blank">原型理論</a>」,而且常常具有「<a href="http://terms.naer.edu.tw/detail/1308191/" target="_blank">家族相似性</a>」。</p>
也就是說,要真正理解一個概念,並讓這個概念真正在腦中的對這個世界所建構的「認知地圖」佔有一席之地,最好的方式是用這個概念的典型例子,以及概念的發生演化過程,來建構這個概念的模型。而非像我們習以為常的那樣,喜歡用「定義」來理解一個概念。(除非這個概念的家族相似性很弱。)</p>
<p>用維根斯坦的例子來說明,<a href="https://www.angle.com.tw/File/Try/5D104GA-02.pdf" target="_blank">我們幾乎不可能用「定義」的方式,來理解「遊戲」這個具有強烈家族相似性的概念</a>,而最好是用舉出各種遊戲的典型例子來理解,並且隨著認知的典型遊戲例子越來越多,我們腦中對遊戲這個概念的模型也越來越完善。</p>
<p>特別是像「商品化」這種社會學的概念,常常具有很強的家族相似性,因此最好是用典型例子來理解,再逐一探討各種現象是否屬於商品化,屬於商品化的程度又有多深,才能建立腦中對於商品化的認知模型。</p>
<p>回到疫苗分配的討論,就現況來說,全世界致命急性傳染病缺稀疫苗(請注意我所限制的這些條件,因此像是自費的子宮頸癌預防疫苗並不在討論中)的國內分配,幾乎都是以功利主義的原則建立優先順序來分配的。這時,如果一個國家決定改用打破這個分配原則,將疫苗標上(販售給人民的)價格(無論這個價格是否依據自由市場決定),販賣給需要的人。這個過程,就是典型的商品化。而若此商品化的疫苗價格是由自由市場來決定價格與分配,就叫做市場化(注意,這並不代表疫苗的研發與製造不用成本,也不代表政府採購疫苗不用錢,只是就疫苗對民眾的分配上,從非商品化轉換為一種商品化的過程)。商品化常常與市場化並行,因此,同樣根據認知語言學的「隱喻」機制,「商品化」與「市場化」常常被混用或交互指稱。只要在不引起混淆的狀況下,這其實沒有甚麼問題。</p>
<p>要特別注意的是,「去商品化」或「去市場化」這個名詞之所以會引起醫界某些人這麼大的反感,是因為把「商品化」或「市場化」的概念給簡單化而誤以為等同於「賺錢」;把「去商品化」或「去市場化」的概念給簡單化而誤以為等同於「免費」、「低價」,或「壓榨」。</p>
<p>會產生這樣的誤解,主要是只用「消費者」與「生產者」的簡單模型來理解現實中的複雜社會現象。事實上,社會的經濟政治結構中,至少有政府、資本家、受雇者、消費者。</p>
<p>例如上述疫苗的例子,若疫苗是由政府跟國外廠商採購的,則這樣的過程是可以在某種程度上商品化、市場化的。就算政府在分配疫苗的時候採取去商品化、去市場化的原則,也絕對不代表負責施打疫苗的醫護人員就不能獲得合理的待遇。例如,英國的鐵路、消防等在消費者端「去商品化」或「去市場化」的司機與消防隊員等勞工,就靠著強大的工會而得到合理的待遇。</p>
<p>其實,台灣的醫療從業人員之所以會產生「去市場化一定等於低薪」的誤解,主要有兩個原因。</p>
<p>第一,政府將醫療政策披上「去商品化」、「去市場化」的社會福利外衣(雖然暗地裡充滿了商品化、市場化,鼓勵競爭的內涵),又同時聯合(或者沒有聯合而分頭進行)財團醫院壓低醫護人員待遇,造成醫療從業人員對自身不合理待遇錯誤歸因於「去商品化」、「去市場化」。</p>
<p>第二,對於薪資的決定因素,台灣人普遍相信沒有證據支持的新古典工資理論,認為工資完全透過自由市場的供給與需求而受勞工的邊際生產力所決定。因此台灣人相信,只要政府不插手干預,市場越自由,勞工就能得到越合理的待遇。</p>
<p>但事實上,根據<a href="http://www.books.com.tw/products/CN11020566" target="_blank">哥倫比亞大學經濟學教授Moshe Adler的綜合經濟史與實證證據後的說法</a>,勞工薪資的決定因素是由勞方與資方的「相對議價能力」所決定的(當然,勞動力的供給與需求也會部分影響到勞方的相對議價能力),也就是古典工資理論。</p>
<p>因此,台灣的醫療從業人員之所以待遇越來越不合理,除了健保機制給付不公的問題以外,醫師身為勞工而相對於政府或受政府縱容的財團醫院,議價能力相對低下,才是根本原因。</p>
<p>結論是,在討論「醫療商品化」或「醫療市場化」的議題時,不能將醫療分配正義問題與勞動權益正義問題相混淆,而讓我們攻擊錯了敵人,小了政府,大了高官權貴。</p>Ellery Huanghttp://www.blogger.com/profile/05906695028631210320noreply@blogger.com0