Leon Piterman，黃文靜，楊 輝

·世界全科醫(yī)學(xué)工作瞭望·

《The Medical Republic》案例分享
——在預(yù)測嚴(yán)重疾病時，“第六感”能發(fā)揮作用嗎？

Leon Piterman1，黃文靜2，楊 輝1

全科醫(yī)生；危重??；感覺

PITERMAN L，黃文靜，楊輝.在預(yù)測嚴(yán)重疾病時，“第六感”能發(fā)揮作用嗎？[J].中國全科醫(yī)學(xué)，2017，20(13)：1531-1533.[www.chinagp.net]

PITERMAN L，HUANG W J，YANG H.Can ′sixth sense′ play a role in serious illness prediction?[J].Chinese General Practice，2017，20(13)：1531-1533.

日常生活中，我們經(jīng)常會使用“第六感”這個詞，一般情況下其指的是感知。很多人(可能不是所有的人)有時會產(chǎn)生一些特殊的想法或額外的感知，認(rèn)為將會發(fā)生一些不好的事。

有些事情可能是讓人不愉快的，而“第六感”使我們有能力去避免這些事情的發(fā)生。人體擁有5種以上的感覺，如嗅覺、味覺、視覺、聽覺及觸覺，這使我們能夠感覺到疼痛、位置、溫度及平衡，也有人認(rèn)為人體有一種電磁感覺，可以預(yù)測天氣的變化?！禩he Sixth Sense》是一部關(guān)于幽靈的電影，由海利·奧斯蒙、布魯斯·威利斯及澳洲的托妮 ·科萊特主演。

在臨床服務(wù)中，也常常會使用“第六感”這個詞，是指醫(yī)生懷疑可能會發(fā)生在患者身上的糟糕的事，即使這種懷疑很難取證于病史和實驗室檢查。醫(yī)生會感覺到可能忽略了患者的某些情況，或者給予了患者不足甚至不當(dāng)?shù)闹委?，亟須采取修正措施。這使醫(yī)生很困惑，但卻無法合理地描述出擔(dān)心的原因。

接下來要講述的患者故事，就是在描繪這種進(jìn)退兩難的情形，以及在應(yīng)對困境時，醫(yī)生的“第六感”所起的作用。

湯姆的故事

湯姆是一名72歲的退休鍋爐制造工人，和68歲的妻子同住。他很積極地享受退休后的生活，平時會打高爾夫、釣魚、參加長途徒步旅行。既往有高血壓史，在口服血管緊張素轉(zhuǎn)換酶抑制劑的情況下血壓控制良好，無其他病史。既往吸煙，但在40歲出頭時已經(jīng)戒煙。

某個周五下午很晚的時候，在妻子的堅持下，他來到全科醫(yī)學(xué)診所就診。就診前他告訴妻子，在前一天的長途徒步旅行中感覺到了胸部緊縮和疼痛，約持續(xù)20 min，這迫使他停下腳步，待疼痛緩解后又繼續(xù)行走。之后一直感到疲憊，但并未出現(xiàn)胸痛或其他癥狀。

查體過程中，患者一般情況較好，血壓在參考范圍內(nèi)，心率68次/min，但心電圖提示前胸導(dǎo)聯(lián)缺血。為其安排了心肌酶和肌鈣蛋白檢查，幾小時后，檢驗室電話通知檢查結(jié)果正常。于是，為他開了阿司匹林，并囑周一至診所復(fù)診，如再次出現(xiàn)疼痛癥狀，可打電話叫救護(hù)車。

按照排班，我周六上午在診所當(dāng)班。早晨醒來時，突然有種不安的感覺，心想自己對湯姆病情的處理是否過于草率？也許下周一太遲了，是否應(yīng)該盡早采取一些干預(yù)措施？

我決定打電話給湯姆，并在上班的路上去他家進(jìn)行家庭訪視。湯姆感到很意外，但我的訪視給他的妻子帶來了安慰。湯姆表示，他在夜間再次發(fā)生了類似胸痛，約持續(xù)5 min，認(rèn)為是阿司匹林導(dǎo)致的消化不良。

在接下來的查體過程中，湯姆出現(xiàn)了心臟停搏。他的妻子立刻打電話叫救護(hù)車，與此同時我開始為他行心肺復(fù)蘇。心肺復(fù)蘇成功了，湯姆被送到了當(dāng)?shù)氐慕虒W(xué)醫(yī)院，病情穩(wěn)定，之后在阻塞的冠狀動脈處植入了3個支架。

我常常反思我對湯姆的處理過程，是不是應(yīng)該在周五晚上就把他送到醫(yī)院？但當(dāng)時并沒有任何心肌梗死的證據(jù)。根據(jù)周五采集的病史，醫(yī)院會收他入院嗎？他是否需要行緊急血管造影檢查？

或許這些問題的答案是肯定的。很顯然，我一直受到這些想法的困擾，而這些困擾也毫無疑問地影響了我，最終使我決定去做一個意想不到的家庭訪視。是“第六感”讓我感覺到有些地方可能做錯了？還是簡單的臨床直覺讓我對患者進(jìn)行了更早的隨診？當(dāng)湯姆出現(xiàn)心臟停搏時，我正好在他身邊，這是幸運嗎？還是“命中注定”和“第六感”，決定了這個還算不錯的結(jié)果？

目前，尚沒有科學(xué)證據(jù)支持全科醫(yī)學(xué)中“第六感”的概念。但HJERTHOLM等[1]在《British Journal of General Practice》發(fā)表了一項研究，該研究調(diào)查了404例丹麥全科醫(yī)生和4 518例患者，發(fā)現(xiàn)在全科醫(yī)生懷疑患者患有腫瘤或其他嚴(yán)重疾病的情況下，為該患者安排的實驗室檢查是其他患者的兩倍，全科醫(yī)生希望通過大量的實驗室檢查來證實其所擔(dān)心的問題。該研究的作者建議，在存在懷疑指征的情況下，全科醫(yī)生應(yīng)盡早為患者提供專科化的實驗室檢查。

那么，臨床懷疑是“第六感”的同義詞嗎？也許是，也許不是。然而無論如何，自從經(jīng)歷過湯姆的病案后，我對心源性胸痛患者的管理方法已經(jīng)永遠(yuǎn)地改變了。

志謝：特別感謝原文出版者《The Medical Republic》同意將此文編譯后刊登于《中國全科醫(yī)學(xué)》。

[1]HJERTHOLM P,MOTH G,INGEMAN M L,et al.Predictive values of GPs′ suspicion of serious disease:a population based follow-up study[J].Br J Gen Pract,2014,64(623):e346-353.DOI:10.3399/bjgp14X680125.

The term “sixth sense” is widely used in our daily lexicon and usually refers to the perception that, from time to time, many, if not all of us, have some special notion or extrasensory perception that something untoward is about to happen.

That something might possibly be unpleasant,and the sixth sense gives us the capacity to avoid that occurrence.Of course,we possess more than the five senses of smell,taste,sight,hearing and touch.We sense pain,position,temperature,balance,and some believe that we have an electromagnetic sense which can predict changes in the weather.TheSixthSensehas also been the subject of a movie about ghosts,starring Hayley Joel Osment,Bruce Willis and our own Toni Collett.

The sixth sense is also a term used in clinical practice where it refers to the notion that the doctor is suspicious there is something seriously wrong with the patient,even though it is difficult to define based on history and examination.There is a sense that something may have been missed,or that the management may be inadequate or even inappropriate,and steps need to be taken urgently to correct this.

The doctor remains troubled,but is not able to rationally pinpoint the cause for concern.

The patient that I describe below serves to illustrate the dilemma and the role of the sixth sense in dealing with it.

Tom′s story

Tom was a 72-year-old retired boilermaker who lived with his 68-year-old wife.He was active in retirement,playing golf,fishing and going on long walks.Apart from a history of hypertension,well controlled on an ACE inhibitor,he had no other medical problems.He had been a smoker,but had stopped in his early 40s.

He came to see me late on a Friday afternoon at his wife′s insistence.He had told her that on his long walk the previous day he had tight chest pain which lasted around 20 minutes,and caused him to stop walking.It eventually eased and he continued.He had since felt tired,but had had no further chest pain or other symptoms.

On examination he looked well,was normotensive with a regular heart rate of 68 b/m.However,an ECG showed evidence of ischaemia in the anterior chest leads.I arranged cardiac enzymes and troponin levels,which were phoned through to me several hours later and were normal.I prescribed aspirin and told him to see me again on Monday or call an ambulance if pain recurred.

I was scheduled to work at the clinic on Saturday morning.I woke with an uneasy feeling.Perhaps I was being too cavalier about Tom′s management.Maybe Monday was too far away and I needed to intervene earlier?

I decided to call in and do a home visit on Tom on my way to work.He was surprised to see me,although his wife expressed some relief at my visit.He had had another bout of chest pain during the night which lasted five minutes.Tom thought it was indigestion caused by the aspirin.

As I examined him he had a cardiac arrest.I began CPR while his wife called for an ambulance.He was resuscitated and taken to the local teaching hospital where he was stabilised,and subsequently had three stents inserted into blocked coronary arteries.I have often reflected on my management of Tom.Should I have sent him to hospital on the Friday night? There was no evidence of an infarct.Would he have been admitted with his history? Would he have had an urgent angiogram?

Perhaps the answers to these questions are "yes".It is clear that I remained troubled by these thoughts and no doubt they influenced me to undertake an unexpected home visit.Was it my sixth sense that something might be wrong,or was it simply common clinical sense to follow up earlier? Was it fortunate that I happened to be there when he had a cardiac arrest or did destiny,combined with a sixth sense,determine this favourable outcome?

There is little scientific evidence to support the notion of a sixth sense in general practice,but a study published by Hjertholm et al in theBritishJournalofGeneralPractice,involving 404 Danish GPs and 4 518 patients,showed that where the GPs were suspicious of cancer or other serious disease,investigations were twice as likely to reveal a serious cause for their concern than if they were not suspicious.

The authors recommend that GPs have urgent access to specialised investigation where there is an index of suspicion[1].

So is clinical suspicion synonymous with a sixth sense? Maybe,or maybe not.But,regardless,my management of patients with chest pain of cardiac origin has changed for evermore.

Reference

[1]HJERTHOLM P,MOTH G,INGEMAN M L,et al.Predictive values of GPs′ suspicion of serious disease:a population based follow-up study[J].Br J Gen Pract,2014,64(623):e346-353.DOI:10.3399/bjgp14X680125.

(本文編輯：王鳳微)

Can ′Sixth Sense′ Play A Role in Serious Illness Prediction?

General practitioners;Critical illness;Sensation

R 197 R 395

A

10.3969/j.issn.1007-9572.2017.13.001

2017-03-31)

【編者按】 澳大利亞的全科醫(yī)生具有行業(yè)自律性，體現(xiàn)在其自行制定行業(yè)標(biāo)準(zhǔn)、自主進(jìn)行資質(zhì)考核及自主執(zhí)業(yè)等方面，也體現(xiàn)在《The Medical Republic》這一共享平臺上。Leon Piterman是Monash University的副校長、全科醫(yī)學(xué)教授，從事全科醫(yī)學(xué)臨床服務(wù)近40年，其建議我國的全科醫(yī)生應(yīng)培養(yǎng)“共和”思想，以為全科醫(yī)學(xué)領(lǐng)域提供更多的平等交流機(jī)會。目前Piterman教授定期為《The Medical Republic》撰寫文章，本刊深受“醫(yī)學(xué)共和”思想的啟發(fā)，特邀本刊編委Monash University楊輝教授對Piterman教授的文章進(jìn)行編譯，并將進(jìn)行連載刊登，希望對我國的全科醫(yī)生有所幫助和啟發(fā)！本文中，Piterman教授講述了自己對一例心源性胸痛患者的臨床管理經(jīng)過，并認(rèn)為是“第六感”幫助其做出了正確的管理和修正措施，從而建議全科醫(yī)生在臨床工作中如果產(chǎn)生了患者可能患有更嚴(yán)重疾病的“第六感”，應(yīng)盡早為其提供?？苹膶嶒炇覚z查，以避免嚴(yán)重事件的發(fā)生，敬請關(guān)注！

1.3168 Monash University,Melbourne,Australia

2.518003 廣東省深圳市，羅湖醫(yī)院集團(tuán)黃貝嶺社區(qū)健康服務(wù)中心

注：本文首次刊登于《The Medical Republic》