第 3 章 重新思考醫(yī)學(xué)專(zhuān)業(yè)知識(shí)

專(zhuān)業(yè)能力：醫(yī)療實(shí)踐中不可或缺的部分

盡管公眾對(duì)醫(yī)學(xué)專(zhuān)業(yè)能力的價(jià)值存在疑慮，但毋庸置疑的是，專(zhuān)業(yè)能力在患者護(hù)理中仍發(fā)揮著至關(guān)重要的作用。當(dāng)然，這種專(zhuān)業(yè)能力需要通過(guò)多年的醫(yī)學(xué)教育與臨床實(shí)踐經(jīng)驗(yàn)來(lái)培養(yǎng)和積累。然而，即便接受了相同的教育、擁有相似的經(jīng)驗(yàn)，并非每位臨床醫(yī)生都能達(dá)到同等的專(zhuān)業(yè)水平 —— 這需要一種關(guān)鍵技能：在 1 型思維與 2 型思維之間找到巧妙平衡。

不過(guò)，這些前提條件并非確診的必要條件。事實(shí)上，最優(yōu)秀的臨床醫(yī)生會(huì)將 1 型思維與 2 型思維融入自己的認(rèn)知 “工具箱”，并根據(jù)需要在兩者間靈活切換。以 “區(qū)分非 ST 段抬高型心肌梗死（NSTEMI）與其他心臟綜合征” 的診斷過(guò)程為例：前者是一種心肌梗死，其特征是患者心電圖（EKG）顯示特定異常 —— 即 ST 段無(wú)抬高。通常情況下，當(dāng)為心肌供血的冠狀動(dòng)脈完全阻塞時(shí)，心肌梗死患者的心電圖會(huì)出現(xiàn) ST 段抬高；而 ST 段無(wú)抬高的心肌梗死，則可能提示冠狀動(dòng)脈部分阻塞。

阿拉巴馬大學(xué)內(nèi)科住院醫(yī)師項(xiàng)目的威廉?施萊弗（J. William Schleifer）醫(yī)學(xué)博士在詳細(xì)分析該病例時(shí)解釋道，他會(huì)基于對(duì)所有收集到的數(shù)據(jù)（包括一項(xiàng)與 “非 ST 段抬高型心肌梗死” 初步懷疑不符的體格檢查結(jié)果）進(jìn)行系統(tǒng)性評(píng)估，逐步轉(zhuǎn)向 2 型思維。這一 “不符點(diǎn)” 便是瓊斯先生的左腿放射痛。真正專(zhuān)業(yè)的診斷專(zhuān)家有兩個(gè)顯著特征：一是擁有更完善的 “疾病腳本”，二是能識(shí)別出與 “疾病腳本” 不符的異常信號(hào)。左腿疼痛正是這樣一個(gè)線索，提示醫(yī)生可能需要轉(zhuǎn)向其他診斷方向。

施萊弗還為診斷推理過(guò)程增加了第三個(gè)維度：在 1 型與 2 型思維之外，加入 “預(yù)死亡分析”（mental premortem examination）—— 即鼓勵(lì)醫(yī)生設(shè)想 “做出某一診斷并采取相應(yīng)治療后，可能出現(xiàn)的結(jié)果（包括有利與不利后果）”。以瓊斯先生為例，若按典型心肌梗死的治療方案為他使用抗凝藥，但他實(shí)際患有的是其他疾?。ㄈ缰鲃?dòng)脈夾層），后果可能是災(zāi)難性的。正是 “預(yù)死亡分析”，再加上患者存在左腿放射痛這一異常信號(hào)，醫(yī)生決定暫緩 “心肌梗死” 的治療，直至收集到更多數(shù)據(jù)。當(dāng)患者被收入內(nèi)科病房后，其出現(xiàn)的收縮期雜音與胸痛癥狀強(qiáng)烈提示 “主動(dòng)脈夾層”（主動(dòng)脈這一主要血管出現(xiàn)撕裂）；最終，計(jì)算機(jī)斷層掃描血管造影（CTA）證實(shí)了這一診斷。影像學(xué)檢查還顯示，瓊斯先生的主動(dòng)脈夾層已延伸至胸降主動(dòng)脈全程 —— 這也解釋了其神秘左腿疼痛的原因。

這些實(shí)驗(yàn)并非表明 “常見(jiàn)認(rèn)知偏差對(duì)診斷無(wú)負(fù)面影響”—— 已有充分證據(jù)顯示，過(guò)早定論、確認(rèn)性偏差與可得性偏差確實(shí)會(huì)降低診斷準(zhǔn)確率。但事實(shí)上，部分認(rèn)知偏差可能同時(shí)與 1 型思維和 2 型思維相關(guān)。正如諾曼（Norman）及其同事所解釋的：“'糾正錯(cuò)誤’并非簡(jiǎn)單地'投入更多分析精力’；若缺乏足夠知識(shí)儲(chǔ)備，額外的分析過(guò)程對(duì)糾正錯(cuò)誤可能毫無(wú)幫助?！?這里的關(guān)鍵詞是 “足夠知識(shí)儲(chǔ)備”。

拓展專(zhuān)業(yè)能力的定義

EXPANDING THE DEFINITION OF EXPERTISE The list of innovators who have profoundly changed the practice of medicine — but who were ignored by the experts of their day — is long. Mary Putnam Jacobi comes to mind. She was not considered an expert at a time when experimentation and statistics were viewed as unimportant. Dr. Jacobi might best be described as the mother of modern scientific medicine — or at the very least, one of its founding parents. In 1868, she was the first woman to enroll in the University of Paris School of Medicine. After graduating in 1871, this unconventional thinker arrived in the United States, where she advocated for the inclusion of laboratory science, experimentation and statistics as the foundation cornerstone of modern medical practice. Equally important, Jacobi “became a powerful advocate for the equal contribution of women to medicine.” 8 Pushing clinicians to buy into the notion that experimentation and statistics were needed for good-quality patient care may seem unimpressive today, but it was almost heresy in an age when the received wisdom from one’s medical school professor was all that was necessary to “demonstrate” that a treatment protocol was effective. Jacobi’s unconventional thinking can be observed in several other historical settings, as has the resistance of experts of the day. Newborn incubators in the Neonatal Intensive Care Unit are now considered standard of practice but were rejected in the United States for many years. Similarly, percutaneous transluminal coronary angioplasty was introduced in 1976 by German cardiologist Andreas Roland Grüntzig; at the time, one catheterization specialist proclaimed: “It’ll never work.” 9 Medical experts initially rejected the role of viruses in cancer, Helicobacter pylori in gastric ulcers, prions in mad cow disease, the germ theory of disease, Gregor Mendel’s laws of inheritance and the occurrence of traumatic brain injuries among professional football players. 10 Some experts have not only failed to recognize major advances in medical science, they’ve embraced medical procedures that should have been abandoned or given medical advice that was not supported by scientific evidence. In the 1960s, for instance, Fredrick Stare, a prominent Harvard University professor and founder of the Department of Nutrition at Harvard School of Public Health, downplayed the role of refined sugar as a contributing cause of disease in the professional and popular press: “Drinking colas and other soft drinks is an acceptable substitute for drinking equal amounts of water if the extra calories are not a problem for you,” he stated in one consumer book. 11 And despite evidence that strongly suggested sugar contributes to a variety of degenerative diseases, Stare and another Harvard expert published two reviews in the New England Journal of Medicine stating that sucrose did not play a role in coronary heart disease. Several years later, investigators discovered that both men were secretly paid the equivalent of $48,000 in 2016 dollars by the sugar industry for writing the reviews. 12 Similarly, an analysis of medical practice published in Mayo Clinic Proceedings found numerous medical practices that required rethinking. Among 363 articles that looked at standard-of-care practices, 146 (40.2%) had to be reversed. 13 Prasad and colleagues explain: Stenting for stable coronary artery disease was a multibillion dollar a year industry when it was found to be no better than medical management for most patients with stable coronary artery disease. Hormone therapy for postmenopausal women intended to improve cardiovascular outcomes was found to be worse than no intervention, and the routine use of the pulmonary artery catheter in patients in shock was found to be inferior to less invasive management strategies.” Reversals like this have several causes. One is the inherent nature of the scientific method, which requires changes in policy and procedures as the collection of larger datasets are developed and as new discoveries come to light. But sometimes there are less noble issues involved as well. We need to recognize that medical training is not only a form of enlightenment, but also a form of indoctrination into a club, in which new members too often worship their mentors and are rarely encouraged to think differently. The same point is made by Jerome Groopman, M.D., chair of Medicine at Harvard Medical School. 14 He points out that the culture of conformity and orthodoxy begins in medical school. At one medical school, for instance, “the faculty of one distinguished university hospital taught his class that thinning the blood with anticoagulants like heparin or Coumadin was the treatment of choice for a threatened pulmonary embolism and that using any other therapy constituted unprofessional conduct. At another equally distinguished hospital, the students were told that the only correct treatment was surgically tying off the inflamed veins. One could use such an exposure to controversy as training in uncertainty. In neither setting…was the divergent view made a teaching exercise. Nor were we encouraged to keep an open mind. In both, we were educated for dogmatic certainty…” 14 The lesson learned here is that uncertainty is a normal part of the life of any expert, but that they are rarely trained to admit to this uncertainty. Nonetheless, patients need to know! Richard Feynman, the Nobel prize-winning physicist, expressed a similar sentiment: “In order to progress, we must recognize our ignorance and leave room for doubt…” His uncompromising search for truth “insisted on scrupulous honesty in presenting all data from experiments, on bending over backwards to show we may have been wrong…” 15 Thomas Huxley, the 19th-century British biologist, took that observation a step further, pointing out that new truths in science “often begin as heresy, advance to orthodoxy, and end as superstition.” 16 Unfortunately, many medical experts continue to label brilliant insights and inventions as medical heresies, delaying their implementation in patient care by decades. This inertia is often reflected in the decisions of institutions that award research grants to promising physician scientists and clinicians because their projects support the orthodox thinking currently in fashion. Of course, in the real world of clinical medicine, decisions often have to be made rapidly, even when the scientific evidence does not provide a certain path to take. In situations like this, patients need to be aware of the uncertainty and involved in a shared decision-making process. EMBRACING UNCONVENTIONAL EXPERTS If health care is to move beyond its limited view to expertise, it will have to embrace others who have traditionally been shunned in the medical community, including, patients, citizen scientists and independent scholars who are not affiliated with learned societies, major universities or medical centers. Although learned societies, universities and academic medical centers are an indispensable source of clinicians and medical scientists with true expertise, they can be a limiting force that crowds out unconventional thinkers who can “color outside the lines” and generate innovations that move medicine into the future. Because academicians also serve as gatekeepers and peer reviewers for the most influential medical journals, their role needs to be carefully evaluated. Kyle Siler, in the Department of Strategic Management, University of Toronto, and associates published an analysis of over 1,000 manuscripts that were submitted to three elite medical journals. They found that among the 808 articles that were eventually published, many impactful and frequently cited manuscripts had been rejected by peer reviewers and/or editors and published in other journals, including the 14 most popular ones. Siler and colleagues concluded: “This finding raises concerns regarding whether peer review is ill-suited to recognize and gestate the most impactful ideas and research.” 17 Analyses like this only serve to highlight the shortcomings of the current peer review process in biomedicine, and the need to find a better way of judging expertise and fitness for publication. Shortcomings like this may also have been one reason why BMJ Health and Care Informatics recently launched a program that brings patients, the general public and caregivers into the loop, enabling them to serve as both authors and peer reviewers. 18 The new program will give those outside traditional academic circles influence that has long been denied them. As Lewis and colleagues state: “There are many benefits to having patient reviewers, such as providing clarity to the authors by asking more detailed questions about design, methods and analyses. Patient reviewers can provide insight into the language of a manuscript that can be unintentionally written in a jargon-filled way that may not be understandable to patients or other researchers.” Similarly, the opportunity to write for the professional medical press will enable readers to be exposed to “perspectives that are not currently found in existing medical literature…[and] improve the understanding of the lived experience of the disease or condition, including interactions and communication with the healthcare system.” 18 Another important reason to bring patients into the mix is the fact that many have become expert in their own disease, a result of spending years searching for solutions, collecting lab reports and analyzing the medical literature. Louis Phillippe Boulet, at the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, Canada, summed up this need for such expert patients in managing respiratory diseases: The concept of “expert patient” has been developed in the last two decades to define a patient who has a significant knowledge of his/her disease and treatment in addition to self-management skills. However, this concept has evolved over the last years, and these patients are now considered, not only to be more efficient in the management of their own condition and communicating effectively with health professionals, but to also act as educators for other patients and as resources for the last, provide feedback on care delivery, and be involved in the production and implementation of practice guidelines, as well as in the development and conduct of research initiatives. 19 Such collaborations are long overdue. As National Magazine Award-winning journalist S.E. Smith points out: “The healthcare system will improve only when we rethink who counts as an expert.” 20 The pool of experts who currently steer the healthcare ecosystem is primarily composed of healthcare executives in hospitals, clinics and insurance companies, as well as physician leaders and other high- level policy makers, but Smith believes: “Underrepresented in these conversations are those who know the system at its worst, like ambulance crews…nurses in underfunded community health clinics, and uninsured patients… [T]hose who are considered lowest in status often have the best observations about the systems they are trapped in…Repairing America’s health care system requires the humility to recognize expertise no matter where it comes from, and the ability to integrate stakeholders into the process as early as possible.” Also underrepresented in the pool of potential experts are “citizen scientists,” unemployed PhDs in the health sciences, and perhaps even your local car mechanic or fashion designer, if they possess an uncommon vision or insight. It’s presumptuous to believe that higher education is the only pathway to innovation or genius. Unfortunately, it’s virtually unheard of for a top healthcare journal to accept a commentary or review from an “unlettered” author. Nonetheless, such submissions should be judged on the strength of the arguments they contain and the depth of the author’s grasp of the relevant issues, not on how many degrees accompany their name or their professional affiliation. The practice of medicine is just that — an ongoing collection of experience and continuous learning that shapes decision-making. We must avoid an echo chamber of the same experts reinforcing the same ideas with the next generation of experts. While we need to be prudent and filter the signal from the noise in crowdsourcing, we must embrace a multi-stakeholder approach if we’re going to capture the thinking of all with experience. References | 1 |Baron R, Berinsky A. Mistrust in Science — A Threat to the Patient–Physician Relationship. N Engl J Med. 2019;381:182-185. | 2 |Cerrato, P, Halamka J. Reinventing Clinical Decision Support: Data analytics, Artificial Intelligence, and Diagnostic Thinking. Taylor and Francis; 2020. | 3 |Sun M, et al. Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record. Health Affairs. Published online Jan 19, 2022. https://www./doi/10.1377/hlthaff.2021.01423. Accessed Dec. 16, 2022. | 4 |Croskerry P. A Universal Model of Diagnostic Reasoning. Academic Med. 2009;84:1022-1028. | 5 |Brieger D, et al. Acute Coronary Syndromes without Chest Pain, an Underdiagnosed and Undertreated High-Risk Group: Insights from the Global Registry of Acute Coronary Events. Chest. 2004;126:461-469. | 6 |Schleifer JW, et al. NSTEMI or Not: A 59-Year-Old Man with Chest Pain and Troponin Elevation. J Gen Internal Med. 2013;28:583-590. | 7 |Norman GR, et al. The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking. Academic Med. 2017;92:23-30. | 8 |Horton R. Offline: The Paris Commune and the birth of American medicine. Lancet. 2021;397:181. | 9 |Forrester J. The Heart Healers: The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives. St. Martin’s Griffin; 2016. | 10 |Miller G. Medical breakthroughs that were initially ridiculed or rejected. Medscape. Nov 19, 2015. https:// www./features/slideshow/medical-breakthroughs#page=1. Accessed Jan. 6, 2022. | 11 |Stare F, Olson R, Whelan E. Balanced Nutrition: Beyond the Cholesterol Scare. Bob Adams, Inc; 1989. | 12 |Bailey M. Sugar industry secretly paid for favorable Harvard research. STAT NEWS. SEPT 12, 2016. https:// www./2016/09/12/sugar-industry-harvard-research/. Accessed Dec. 16, 2022. | 13 |Prasad V, A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices. Mayo Clin Proc. 2013;88:790-798. | 14 |Groopman J. How Doctors Think. Houghton Mifflin; 2007. | 15 |Skrabanek P. A subversive mind. Lancet. 1989;339:94-95. | 16 |Bartusiak M. How to Encourage new heresies. NY Times. Jan 28, 1990. | 17 |Siler K, Lee K, Bero L. Measuring the effectiveness of scientific gatekeeping. Proc Natl Acad Sci U S A. 2015;112:360-365. | 18 |Lewis D, Scott P. BMJ HCI launches partnership programme for patients and carers as authors and peer reviewers. BMC Health Care Inform. 2021;28:e100471. | 19 |Boulet L-P. The expert patient and chronic respiratory diseases. Can Respir J. 2016;2016:9454506. | 20 |Smith SE. How we get better. Time. Jun. 21/Jun. 28, 2021. CHAPTER 4 Finding a role for spirituality and the humanities

拓展專(zhuān)業(yè)能力的定義

雅各比這種打破常規(guī)的思維，在多個(gè)歷史場(chǎng)景中均有體現(xiàn)，而同時(shí)代專(zhuān)家對(duì)新事物的抗拒也同樣屢見(jiàn)不鮮。如今，新生兒重癥監(jiān)護(hù)室（NICU）中的新生兒培養(yǎng)箱已成為標(biāo)準(zhǔn)醫(yī)療設(shè)備，但在美國(guó)，這一設(shè)備曾多年遭到拒絕采用。無(wú)獨(dú)有偶，1976 年德國(guó)心臟病學(xué)家安德烈亞斯?羅蘭?格倫茨希（Andreas Roland Grüntzig）提出了經(jīng)皮腔內(nèi)冠狀動(dòng)脈成形術(shù)，當(dāng)時(shí)一位心臟導(dǎo)管專(zhuān)家直言：“這絕不會(huì)成功?！盵9]

部分專(zhuān)家不僅未能認(rèn)可醫(yī)學(xué)領(lǐng)域的重大進(jìn)展，還堅(jiān)持采用本應(yīng)被摒棄的醫(yī)療手段，或給出缺乏科學(xué)依據(jù)的醫(yī)療建議。例如，20 世紀(jì) 60 年代，哈佛大學(xué)著名教授、哈佛公共衛(wèi)生學(xué)院營(yíng)養(yǎng)學(xué)系創(chuàng)始人弗雷德里克?斯塔爾（Fredrick Stare）在專(zhuān)業(yè)期刊與大眾媒體中，極力淡化精制糖作為疾病誘因的作用。他在一本面向消費(fèi)者的書(shū)中寫(xiě)道：“只要額外攝入的熱量對(duì)你而言不成問(wèn)題，飲用可樂(lè)及其他軟飲料完全可以替代等量飲水?！盵11] 盡管已有充分證據(jù)表明糖與多種退行性疾病相關(guān)，但斯塔爾與另一位哈佛專(zhuān)家仍在《新英格蘭醫(yī)學(xué)雜志》上發(fā)表兩篇綜述，聲稱(chēng)蔗糖與冠心病無(wú)關(guān)。數(shù)年后，研究人員發(fā)現(xiàn)，這兩位學(xué)者撰寫(xiě)這些綜述時(shí)，曾秘密接受糖業(yè)協(xié)會(huì)的資助 —— 換算成 2016 年的貨幣價(jià)值，資助金額約合 4.8 萬(wàn)美元 [12]。

同樣，發(fā)表在《梅奧診所論文集》（Mayo Clinic Proceedings）上的一項(xiàng)關(guān)于醫(yī)療實(shí)踐的分析發(fā)現(xiàn)，許多常規(guī)醫(yī)療手段亟需重新審視。在 363 篇探討 “標(biāo)準(zhǔn)護(hù)理實(shí)踐” 的文章中，有 146 篇（40.2%）所提及的實(shí)踐方法被證明需要推翻 [13]。普拉薩德（Prasad）及其同事解釋道：“穩(wěn)定型冠狀動(dòng)脈疾病支架植入術(shù)曾是一個(gè)年產(chǎn)值數(shù)十億美元的產(chǎn)業(yè)，但研究發(fā)現(xiàn)，對(duì)于大多數(shù)穩(wěn)定型冠狀動(dòng)脈疾病患者而言，這種手術(shù)并不優(yōu)于藥物治療。旨在改善絕經(jīng)后女性心血管預(yù)后的激素替代療法，被證實(shí)效果不如不干預(yù)；而對(duì)于休克患者，常規(guī)使用肺動(dòng)脈導(dǎo)管的治療方式，效果也不如創(chuàng)傷更小的治療方案?！?/p>

此類(lèi) “醫(yī)療實(shí)踐被推翻” 的情況由多種原因造成。其一，科學(xué)方法的本質(zhì)決定了隨著更大規(guī)模數(shù)據(jù)集的積累與新發(fā)現(xiàn)的出現(xiàn)，相關(guān)政策與流程必須隨之調(diào)整。但有時(shí)，這背后也存在一些不夠高尚的因素。我們必須認(rèn)識(shí)到，醫(yī)學(xué)培訓(xùn)不僅是一種知識(shí)啟蒙，在某種程度上也是一種 “圈子文化” 的灌輸 —— 新成員往往過(guò)度崇拜導(dǎo)師，且很少被鼓勵(lì)跳出固有思維。哈佛大學(xué)醫(yī)學(xué)院內(nèi)科學(xué)系主任杰羅姆?格魯普曼（Jerome Groopman）醫(yī)學(xué)博士也提出了類(lèi)似觀點(diǎn) [14]。他指出，這種 “循規(guī)蹈矩、墨守成規(guī)” 的文化在醫(yī)學(xué)院時(shí)期便已形成。例如，在某所頂尖大學(xué)的附屬醫(yī)院中，“教師向?qū)W生傳授，對(duì)于疑似肺栓塞患者，使用肝素或華法林等抗凝藥稀釋血液是首選治療方案，采用其他任何療法都屬于不專(zhuān)業(yè)行為。而在另一所同樣頂尖的醫(yī)院，學(xué)生卻被告知，唯一正確的治療方法是通過(guò)手術(shù)結(jié)扎發(fā)炎的靜脈。原本，這種觀點(diǎn)分歧可以作為'醫(yī)學(xué)不確定性’的教學(xué)案例，但在這兩所醫(yī)院中…… 分歧觀點(diǎn)均未被納入教學(xué)內(nèi)容，學(xué)生也未被鼓勵(lì)保持開(kāi)放心態(tài)。相反，兩所醫(yī)院都在培養(yǎng)學(xué)生'教條式的確定性’……”[14] 這一案例帶給我們的啟示是：“不確定性” 本是所有專(zhuān)家工作中正常的一部分，但他們卻很少接受過(guò) “承認(rèn)不確定性” 的培訓(xùn)。然而，患者有權(quán)知曉這一點(diǎn)！

諾貝爾獎(jiǎng)得主、物理學(xué)家理查德?費(fèi)曼（Richard Feynman）也表達(dá)過(guò)類(lèi)似觀點(diǎn)：“要取得進(jìn)步，我們必須承認(rèn)自己的無(wú)知，并為懷疑留有余地……” 他對(duì)真理的不懈追求 “堅(jiān)持以極其誠(chéng)實(shí)的態(tài)度呈現(xiàn)實(shí)驗(yàn)中的所有數(shù)據(jù)，并竭力證明我們可能存在的錯(cuò)誤……”[15] 19 世紀(jì)英國(guó)生物學(xué)家托馬斯?赫胥黎（Thomas Huxley）則進(jìn)一步指出，科學(xué)領(lǐng)域的新真理 “往往始于異端邪說(shuō)，繼而成為正統(tǒng)理論，最終淪為迷信”[16]。遺憾的是，許多醫(yī)學(xué)專(zhuān)家仍將卓越的見(jiàn)解與發(fā)明貼上 “醫(yī)學(xué)異端” 的標(biāo)簽，導(dǎo)致這些成果在數(shù)十年后才得以應(yīng)用于患者護(hù)理。這種保守傾向在科研資助決策中也有所體現(xiàn) —— 部分機(jī)構(gòu)更愿意將資助授予有潛力的醫(yī)生科學(xué)家與臨床醫(yī)生，僅僅因?yàn)樗麄兊捻?xiàng)目符合當(dāng)前主流的正統(tǒng)觀點(diǎn)。

當(dāng)然，在真實(shí)的臨床實(shí)踐中，即便缺乏明確的科學(xué)證據(jù)指引，醫(yī)生往往也需要迅速做出決策。在這種情況下，患者需要知曉 “不確定性” 的存在，并參與到 “共同決策” 過(guò)程中。

接納非傳統(tǒng)專(zhuān)家

盡管學(xué)術(shù)團(tuán)體、大學(xué)與學(xué)術(shù)醫(yī)療中心是培養(yǎng)具備真正專(zhuān)業(yè)能力的臨床醫(yī)生與醫(yī)學(xué)科學(xué)家的重要力量，但它們也可能成為一種限制性力量 —— 排擠那些 “跳出條條框框”、能為醫(yī)學(xué)未來(lái)發(fā)展帶來(lái)創(chuàng)新的非常規(guī)思考者。由于學(xué)術(shù)界人士同時(shí)還擔(dān)任著最具影響力醫(yī)學(xué)期刊的 “守門(mén)人” 與同行評(píng)審員，其角色需要得到審慎評(píng)估。

多倫多大學(xué)戰(zhàn)略管理系的凱爾?西勒（Kyle Siler）及其同事，對(duì)向三本頂尖醫(yī)學(xué)期刊投稿的 1000 多篇手稿進(jìn)行了分析。他們發(fā)現(xiàn)，在最終發(fā)表的 808 篇文章中，許多具有重大影響力且被頻繁引用的手稿，最初曾被同行評(píng)審員和 / 或編輯拒絕，隨后發(fā)表在包括 14 本最具影響力期刊在內(nèi)的其他刊物上。西勒及其同事得出結(jié)論：“這一發(fā)現(xiàn)引發(fā)了人們的擔(dān)憂 —— 同行評(píng)審制度是否不適合識(shí)別和培育最具影響力的思想與研究?！盵17]

此類(lèi)分析進(jìn)一步凸顯了當(dāng)前生物醫(yī)學(xué)領(lǐng)域同行評(píng)審制度的缺陷，也表明我們亟需找到一種更優(yōu)的方式來(lái)評(píng)判 “專(zhuān)業(yè)能力” 與 “發(fā)表適宜性”。這類(lèi)缺陷或許也是《英國(guó)醫(yī)學(xué)雜志?健康與護(hù)理信息學(xué)》（BMJ Health and Care Informatics）近期推出一項(xiàng)新項(xiàng)目的原因之一 —— 該項(xiàng)目將患者、公眾與護(hù)理人員納入流程，允許他們同時(shí)擔(dān)任作者與同行評(píng)審員 [18]。這個(gè)新項(xiàng)目將讓傳統(tǒng)學(xué)術(shù)圈之外的群體獲得長(zhǎng)期被剝奪的影響力。正如劉易斯（Lewis）及其同事所言：“讓患者擔(dān)任評(píng)審員有諸多益處，例如通過(guò)就研究設(shè)計(jì)、方法與分析提出更詳細(xì)的問(wèn)題，幫助作者厘清思路。患者評(píng)審員還能對(duì)稿件語(yǔ)言提出見(jiàn)解 —— 有些稿件可能會(huì)無(wú)意間使用過(guò)多專(zhuān)業(yè)術(shù)語(yǔ)，導(dǎo)致患者或其他研究者難以理解?！?同樣，“讓患者有機(jī)會(huì)為專(zhuān)業(yè)醫(yī)學(xué)刊物撰稿”，也能讓讀者接觸到 “現(xiàn)有醫(yī)學(xué)文獻(xiàn)中尚未涵蓋的視角……[進(jìn)而] 更好地理解疾病或健康問(wèn)題的真實(shí)體驗(yàn)，包括與醫(yī)療體系的互動(dòng)和溝通情況”[18]。

這種合作早就應(yīng)該實(shí)現(xiàn)了。正如獲得國(guó)家雜志獎(jiǎng)的記者 S.E. 史密斯（S.E. Smith）所指出的：“只有重新思考'誰(shuí)能被視為專(zhuān)家’，醫(yī)療體系才能得到改善?！盵20] 當(dāng)前主導(dǎo)醫(yī)療體系的 “專(zhuān)家群體” 主要由醫(yī)院、診所與保險(xiǎn)公司的醫(yī)療管理者，以及醫(yī)生領(lǐng)袖和其他高層決策者構(gòu)成，但史密斯認(rèn)為：“在這些討論中，那些最了解醫(yī)療體系缺陷的群體卻代表性不足，例如急救人員…… 資金不足的社區(qū)衛(wèi)生診所的護(hù)士，以及沒(méi)有醫(yī)療保險(xiǎn)的患者……[事實(shí)上]，那些在體系中地位最低的人，往往對(duì)自己所身處的體系有著最深刻的觀察…… 要改善美國(guó)的醫(yī)療體系，我們必須秉持謙遜態(tài)度，認(rèn)可無(wú)論來(lái)自何處的專(zhuān)業(yè)能力，并盡早讓相關(guān)利益方參與到改革進(jìn)程中?！?/p>

在潛在專(zhuān)家群體中，代表性同樣不足的還有 “民間科學(xué)家”、健康科學(xué)領(lǐng)域待業(yè)的博士，甚至可能包括你身邊的汽車(chē)修理工或時(shí)裝設(shè)計(jì)師 —— 只要他們擁有獨(dú)特的視角與見(jiàn)解。認(rèn)為 “高等教育是創(chuàng)新或成為天才的唯一途徑” 的想法過(guò)于武斷。遺憾的是，頂尖醫(yī)學(xué)期刊幾乎從未接受過(guò) “非專(zhuān)業(yè)背景作者” 撰寫(xiě)的評(píng)論或綜述。然而，評(píng)判這類(lèi)稿件時(shí)，應(yīng)基于其論證的力度與作者對(duì)相關(guān)問(wèn)題理解的深度，而非作者的學(xué)位數(shù)量或所屬機(jī)構(gòu)。

參考文獻(xiàn)

第 4 章 探尋靈性與人文科學(xué)在醫(yī)療中的角色