，邱珊嬌(譯)，黃文靜(譯)，楊 輝(譯)

·世界全科醫(yī)學(xué)工作瞭望·

《The Medical Republic》案例分享
——為什么全科醫(yī)生需要時刻保持警惕？WhyGPsNeedtobeEverVigilant?

LeonPiterman1，邱珊嬌(譯)2，黃文靜(譯)2，楊 輝(譯)1

全科醫(yī)生；精神分裂癥，偏執(zhí)型

General practitioners;Schizophrenia,paranoid

PITERMAN L.為什么全科醫(yī)生需要時刻保持警惕？[J]. 邱珊嬌，黃文靜，楊輝，譯.中國全科醫(yī)學(xué)，2017，20(25)：3072-3074.[www.chinagp.net]

PITERMAN L.Why GPs need to be ever vigilant?[J]. QIU S J,HUANG W J,YANG H,translators.Chinese General Practice，2017，20(25)：3072-3074.

全科醫(yī)生需要為患者診治各種各樣的疾病，我們從不挑選疾病和患者。

在全科醫(yī)學(xué)的定義中包含了綜合性服務(wù)(comprehensive care)的概念。即使部分全科醫(yī)生仍有自己的?？婆d趣，我們?nèi)云谕覀兯?wù)的人群是未經(jīng)過挑選的，是不分性別、器官系統(tǒng)或病種的。因此，在我們的服務(wù)人群中，也包括了慢性心理疾病的患者，如精神分裂癥、雙相情感障礙、邊緣性人格障礙等。

我所在的診所安排了周末值班，每位醫(yī)生每5周都會輪到一次周六、日全天值班。這就是所謂的“24 h全科診所”的雛形，包括個別用大鋼琴裝飾的診所。我第一次見到珍妮，就是在我當班的某個周末。珍妮45歲左右，比當時的我年長約10歲，是一位優(yōu)雅、打扮精心、穿戴奢華的女士。珍妮已經(jīng)離婚了，當時和她年邁的父親居住在一起，她的兩個孩子已經(jīng)成年，在外獨立生活。她的住址信息顯示，她住在城市的富人區(qū)。

珍妮的疾病看起來似乎很簡單，當時正值“流感季節(jié)”，她的癥狀和體征符合流行性感冒。我給她做出了診斷，而且無論是否管用，給她開了一些抗生素。她想了解我是不是新來的醫(yī)生，還有是不是打算繼續(xù)做下去。珍妮走之前的最后一句話讓我感到很奇怪，直到我有機會看到了她的病歷，才真正理解了那句話的含義。她說：“我希望你不會和比爾醫(yī)生做同樣的事”。

我找出珍妮的病歷放在手邊，午休的時候開始仔細查看。病歷封面上很顯眼地寫著一行字：“永遠不找比爾看病”。比爾是一位與我共事的、經(jīng)驗豐富的全科醫(yī)生，看上去誠實、博學(xué)、敬業(yè)、關(guān)心他人，簡單地說，比爾應(yīng)該是患者理想的全科醫(yī)生。為什么要拒絕比爾的服務(wù)呢？當我閱讀完珍妮的病歷，就一切都明白了。珍妮有長期的精神分裂癥病史，典型臨床表現(xiàn)是被害妄想(encapsulated delusion)。珍妮認為比爾曾經(jīng)強奸過她，而且認為比爾還會一次又一次地試圖潛入她壁壘森嚴的豪宅去強奸她。我迫不及待地和比爾討論了珍妮的病情，進一步了解到的情節(jié)讓人感到悲傷和煩擾。大約是在我給珍妮看病的10年前，比爾給珍妮做了一次巴氏涂片檢查。幸運的是，鑒于珍妮有心理健康問題，做檢查時請了診所的護士在場。隨后，珍妮向醫(yī)學(xué)委員會舉報比爾強奸她。比爾只好在委員會為自己做辯護，這絕不是愜意的經(jīng)歷。珍妮的舉報很快就理所應(yīng)當?shù)乇获g回了，但比爾感覺自己遭到了重創(chuàng)、身心俱疲。之后珍妮仍然處于被害妄想之中，她沒有接受自己精神分裂癥的診斷，拒絕治療，也不想按照醫(yī)學(xué)委員會的任何決定做出改變。

大約1年以后，我被要求去珍妮家做家庭訪視，當我知道我要訪視的患者是珍妮的父親、85歲的布魯斯時，我松了一口氣。布魯斯一直在接受慢性心力衰竭的治療。在通過珍妮家前門保安系統(tǒng)的時候，珍妮喝住了流著口水狂吠的德國牧羊犬，我被帶進前門，然后上樓梯進入布魯斯的臥室。走上樓梯的時候，我看到了一把刻意放置在樓梯口的獵槍。在這個人口稠密的近郊，獵殺狐貍和兔子似乎是不可能的。我隨口問珍妮，是不是懷疑可能會有入侵者。珍妮說：“就是比爾醫(yī)生”。她的話讓我脊柱僵直、胃腸痙攣。

布魯斯的臥室非常悶熱，我注意到墻上的通風(fēng)口被報紙蓋住了。布魯斯小聲地嘀咕到：“這是為了擋住比爾醫(yī)生，珍妮真的需要幫助，你了解的”。布魯斯病得不輕，存在呼吸困難等多種臨床癥狀，表明他的癥狀加重了，需要住院治療。我給布魯斯做了解釋，也下樓給等在那里的珍妮做了解釋。我聯(lián)系好當?shù)氐囊患宜搅⑨t(yī)院，叫了急救車，然后建議珍妮在急救人員到來之前把獵槍收起來。

給布魯斯做完訪視離開珍妮家的時候，我感到既憂心又擔(dān)心。很顯然，珍妮是存在心理健康問題的，是需要幫助的，之前為她做的各種治療都失敗了。同時，我也很擔(dān)心比爾醫(yī)生。在一些公眾案例中，曾經(jīng)有偏執(zhí)型(妄想型)精神障礙患者射殺或刺傷醫(yī)生的情況。精神分裂癥也有很高的自殺危險，雖然珍妮沒有表現(xiàn)出抑郁癥狀，但她幻聽到的聲音很可能會指導(dǎo)她結(jié)束自己的生命。

我和比爾以及診所的其他同事討論了我的思考困境，是保護珍妮隱私，還是因為面對迫在眉睫的傷他危險而報告警方。最終，我認為應(yīng)該向警方報告珍妮的情況，希望警醫(yī)可以介入，將珍妮強制性地收入當?shù)鼐癫≡哼M行治療。警方迅速地采取了行動，收繳了未經(jīng)注冊的非法槍支，然后警醫(yī)給珍妮安排住院進行精神病學(xué)評估。珍妮在精神病院住院治療4個星期，然后帶著抗精神病藥物按計劃出院。我接到的精神病院報告上寫到：雖然珍妮平靜了很多，但她絲毫沒有改變自己的執(zhí)念，堅信比爾醫(yī)生有邪惡行為。深藏的妄想是很難改變的。

值得注意的是，大多數(shù)精神分裂癥患者是非暴力的，是不會置醫(yī)生或其他醫(yī)療行業(yè)人員于危險境地的。然而，目前關(guān)于醫(yī)療行業(yè)人員被襲擊的案件數(shù)量呈不斷上升趨勢，尤其是針對急診科和急診過程中的醫(yī)護人員。在我寫這篇文章的時候，墨爾本博山醫(yī)院的一名醫(yī)生因為在急診科外遭到襲擊而正處于昏迷狀態(tài)。在此類襲擊中，毒品發(fā)揮了驅(qū)動作用，特別是甲基苯丙胺(冰毒)。因此，我們必須提高警惕，不要使自己暴露于不必要的危險之中。

譯者注：被害妄想——妄想是精神疾病患者的一項重要癥狀，表現(xiàn)為多疑、多慮、胡亂推理和判斷、思維障礙，可能伴有幻覺。被害妄想是妄想的常見類型，患者毫無根據(jù)地堅信某人(或團體)對自己(或親人、家庭)進行監(jiān)視、攻擊、迫害(非議、誣陷、暗算、搶劫、強奸等)?；颊咛幱诳謶譅顟B(tài)，因此處處防備、生活極度謹慎，對外界極度不信任。因擔(dān)心被害，患者的生活和社交受到嚴重影響。被害妄想者可能存在自殺和謀殺企圖，這可能受到幻聽的指引，因此及時的診斷和治療非常必要。

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)》。

GPs care for patients with a range of maladies.We do not pick and choose.

Comprehensive care is embodied in the definition of our discipline,and while some of us have special interests,the expectation is that we will care for an unselected population of patients not defined by gender,organ system or disease.Included in that population are patients with chronic mental illnesses,such as schizophrenia,bipolar disorder or borderline personality disorder.

Our practice ran a weekend roster where one in five weekends someone worked all day Saturday and Sunday.This was before the advent of the so-called "24 hour clinics",including those occasional ones adorned with grand pianos.

It was during one of these weekends that I first met Jenny.She was an attractive,well-groomed,expensively dressed woman in her mid-40s,which was 10 years older than me at that time.She was divorced and lived with her elderly father.Her two adult children lived independently.Her address indicated her abode was in the expensive end of town.

The consultation seemed very straightforward.It was the "flu season" and she had a full house of flu-like symptoms and signs.I offered a diagnosis and,for better or worse,prescribed some antibiotics.She wanted to know if I was new to the clinic and whether or not I intended to stay.Jenny then ended with a remark that I thought strange at the time,but only understood the significance of later when I had time to read through her file.She said:"I hope you don′t go the same way as Dr Bill."

I set her file aside and during the lunch break began to delve into it.Boldly inscribed on the front of the file was a message:"Never to see Dr Bill".Bill was my senior colleague.He seemed honest,knowledgeable,dedicated and caring.In short,he seemed a patient′s ideal GP.

Why would someone be deprived of his services? All was revealed as I read through the notes.Jenny had a long history of schizophrenia.A particular feature of her illness was an encapsulated delusion that Bill had raped her and that he was trying to do this again and again by gaining entry into her well-protected mansion.I could hardly wait until Monday to discuss this case with Bill.

What followed was a sad and disturbing tale.Some 10 years earlier Bill had done a Pap smear on Jenny,fortunately in the presence of the clinic nurse,given the nature of Jenny′s mental-health problems.She subsequently reported him to the Medical Board for raping her.Bill had to defend himself before the board.Never an enjoyable experience.

Naturally,the case was summarily dismissed.But Bill felt traumatised and scarred.And Jenny′s delusions continued.She had never accepted the diagnosis of schizophrenia,had refused treatment and was not going to be influenced by any decisions of a Medical Board to change.

About 12 months later I was asked to do a home visit at Jenny′s place.I was relieved to hear that the patient was Bruce,her 85-year-old father,who had been treated for chronic heart failure.Having worked my way through the security system at the front gate while Jenny restrained a barking,salivating German shepherd dog,I was ushered past the front door and upstairs to Bruce′s bedroom.

I left Jenny′s home deeply worried and concerned.She was clearly mentally unwell and needed help.

As I reached the top of the stairs I noticed a strategically placed shotgun.Shooting foxes and rabbits seemed an unlikely past time in this heavily populated suburb.I flippantly asked Jenny if she was expecting any intruders.She responded,"Only Dr Bill".This sent a shiver down my spine and sparked my irritable bowel into action.

Bruce′s bedroom seemed very stuffy.I noticed the air vents in the walls had been covered over with newspaper.Bruce whispered to me:"It′s to keep Dr Bill out.She really needs help,you know."

Bruce was unwell.He was short of breath and clinical signs were compatible with exacerbation of heart failure.He needed hospital admission.I explained this to him and to Jenny who was waiting downstairs.I arranged this at the local private hospital,called an ambulance and suggested to Jenny that she might remove the shotgun when the ambulance was in attendance.

I left Jenny′s home deeply worried and concerned.She was clearly mentally unwell and needed help.Efforts to convince her of this in the past had failed.

I was just as concerned for the wellbeing of my colleague Dr Bill.There is a history of paranoid patients shooting or stabbing their doctors with some well-publicised cases.Schizophrenia also carries a high risk of suicide,and although Jenny did not appear depressed,voices might have instructed her that she should take her own life.

I discussed my dilemmas with colleagues at the clinic and with Dr Bill,and felt that I needed to report this to the police in the hope that the police surgeon might become involved and Jenny would be compelled to be admitted to the local psychiatric facility.

The police acted quickly,removing the shotgun,which was unlicensed.The police surgeon in attendance arranged for admission for psychiatric assessment.Jenny then spent the next four weeks in hospital and was discharged on antipsychotic medication.The report I received indicated that although she was much calmer,her belief in Dr Bill′s nefarious activities had not changed.Encapsulated delusions are hard to shift.

It is important to remember that most schizophrenic patients are not violent and do not pose a risk to doctors or other health professionals.

We are,however,experiencing record numbers of assaults directed at health professionals,particularly in emergency departments and towards paramedics on the road.

As I write this piece,a surgeon in Melbourne is in a coma,having been assaulted outside the emergency department at Box Hill hospital in Melbourne.

Many of these attacks are fuelled by drugs.In particular,methamphetamine.To be effective,we must remain vigilant and not expose ourselves to unnecessary risk.

(本文編輯：王鳳微)

R 749.3

A

10.3969/j.issn.1007-9572.2017.25.002

2017-06-05)

【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)標準、自主進行資質(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是醫(yī)學(xué)學(xué)士，醫(yī)學(xué)博士，教育學(xué)碩士，英國醫(yī)生學(xué)會會員，澳大利亞全科醫(yī)生學(xué)會會員，Monash University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；研究興趣為慢性病管理、心理健康、醫(yī)學(xué)教育；曾獲澳大利亞勛章，醫(yī)學(xué)部醫(yī)學(xué)教育獎，澳大利亞全科醫(yī)生學(xué)會研究獎，香港全科醫(yī)生學(xué)會研究獎等；獲多項澳大利亞衛(wèi)生和醫(yī)學(xué)研究理事會等大型研究項目，發(fā)表科學(xué)文章和著作章節(jié)120余篇，是《全科醫(yī)學(xué)中的精神病學(xué)》合作著者。Piterman教授建議我國的全科醫(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教授的文章進行編譯，并進行連載刊登！本期Piterman教授為我們講述了一例精神分裂癥患者的臨床處理經(jīng)過，該例患者有著較為嚴重的被害妄想，經(jīng)全科醫(yī)生充分考慮后，最終借助警察和警醫(yī)的力量幫助其接受了強制治療，避免了自殺和他殺事件的發(fā)生。Piterman教授提醒全科醫(yī)生，在臨床上為存在精神障礙的患者提供服務(wù)時，應(yīng)提高警惕，如有需要應(yīng)及時采取強制措施為患者提供治療，敬請關(guān)注！

1.3168MonashUniversity,Melbourne,Australia

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

注：本文首次刊登于《TheMedicalRepublic》