当病患选择补充替代医学（CAM）而非循证医学（EBM）

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1、1 Mr.Crowley visited his primary care physician after experiencing several months of fever,night sweats,nonspecific back pain,and“lumps in his shoulders and chest.”1.克劳利先生在过去几个月中饱受发热、盗汗、非特异性背痛的折磨，他还感觉到肩膀和胸部有肿块，他去看了他的初级保健医生。When Patients Choose CAM over EBMHow to Negotiate TreatmentAfter a meticulous

2、 workup,including a biopsy that revealed Reed-Sternberg cells,he was promptly referred to Dr.Randolph,an experienced and reputable oncologist.经过细致检查，活检发现有里-斯细胞。医生立即引荐他去找伦道夫医生，他是一位经验丰富、口碑很好的肿瘤学专家。When Patients Choose CAM over EBMHow to Negotiate TreatmentAfter Mr.Crowley was seated in his office,Dr.R

3、andolph pulled up his own chair,leaned forward,and explained that Mr.Crowley had classic stage I Hodgkin lymphoma.等克劳利先生在办公室坐定之后，伦道夫医生把椅子挪近，身体前倾，并解释说克劳利先生的病情已经进入典型的霍奇金淋巴瘤第一阶段。When Patients Choose CAM over EBMHow to Negotiate TreatmentHe added that the survival rate was generally 90 percent or better

4、 with chemotherapy,which made the prognosis a good onemost patients who entered remission lived normal,healthy lives.他还补充说，通过化疗存活率一般为90%或以上，预后良好，大部分患者在得到有效缓解之后都过着一种正常而且健康的生活。When Patients Choose CAM over EBMHow to Negotiate Treatment2 Dr.Randolph could see that Mr.Crowley,an active and previously he

5、althy man in his 50s,was upset.He said he would go home to consider his options before proceeding,so Dr.Randolph scheduled an appointment for one week later to finalize the treatment course.2.伦道夫医生看得出来，50多岁的克劳利先生生活态度积极，以前身体非常健康，但是现在他很沮丧。他说他想回家先考虑考虑再决定选择何种治疗方式，于是伦道夫医生就和他约定一个星期之后过来最终决定治疗方案。When Patien

6、ts Choose CAM over EBMHow to Negotiate TreatmentAt his return visit,it was clear Mr.Crowley had come to a decision.After taking a deep breath,he began,“Doctor,I know that you think chemotherapy is best for me,but I think I want to try a macrobiotic diet instead.一周后，克劳利先生回来了，很明显他已有了决定。深吸一口气之后，他说道：“医生

7、，我知道您认为化疗对我来说是最好的，但是我想尝试用生机饮食排毒来替代化疗。When Patients Choose CAM over EBMHow to Negotiate TreatmentChemo will only introduce its own harmful chemicals,and that really seems like the last thing I need right now.At the very least,I want to attempt a few months of macrobiotic cleanses before I even think

8、about chemotherapy.”化疗只会给我带来有害的化学物质，我觉得这似乎是我目前最不想做的。最起码，我想尝试一下几个月的生机饮食排毒法后再考虑是否接受化疗。”When Patients Choose CAM over EBMHow to Negotiate Treatment3 At this point Dr.Randolph began to speak more firmly:“I understand where youre coming fromchemo is a frightening and unpleasant prospect.But without it,th

9、e risk of death rises to 95 percent.3.这时，伦道夫医生更坚定地说道：“我理解你为什么会这么想，化疗是很恐怖、很折磨人，但不接受化疗，死亡风险会升至95%。When Patients Choose CAM over EBMHow to Negotiate TreatmentEven delaying treatment could be detrimental,resulting in rapid tumor growth,which may happen if you follow the regimen you suggest.”甚至连延缓治疗也会是有害

10、的，它会导致肿瘤快速生长。如果按照你的排毒法治疗，结果很有可能就是这样。When Patients Choose CAM over EBMHow to Negotiate TreatmentMr.Crowley shook his head.“Im sorry,but I need a second opinion,from someone who ismore open-minded about alternative therapies.”克劳利先生摇了摇头，说道：“很抱歉，但我需要听听其他人的想法，需要一个对替代疗法持更加开放态度的人的意见。”When Patients Choose C

11、AM over EBMHow to Negotiate Treatment4 Dr.Randolph considered the situation.He had heard anecdotes about the benefits of macrobiotic diets but knew there was no scientific evidence that they could treat cancer successfully.4.伦道夫医生仔细考虑了这种情况。他以前确实听说过一些通过生机饮食排毒法而使病情好转的传闻，但他也知道并没有科学证据表明生机饮食排毒法可以成功治疗癌症。W

12、hen Patients Choose CAM over EBMHow to Negotiate TreatmentHe cared about patient autonomyand Mr.Crowley was clearly a competent adultbut was he really informed enough scientifically to make a proper decision?Perhaps negotiating a treatment plan that included a macrobiotic cleanse was necessary,but w

13、as it ethical?他尊重病人的自主权，而且克劳利先生显然是有想法的成年人，但真有足够的科学知识信息帮他做出明智的选择吗？或许医患之间有必要协商一个包括生机饮食排毒法在内的治疗方案，但这符合伦理道德吗？When Patients Choose CAM over EBMHow to Negotiate Treatment 5 A key question to explore is what underlies the choice of the macrobiotic approach.Is it the idea of“doing everything possible”or a d

14、esire to prioritize“natural”approaches?Perhaps Mr.Crowley is driven by fear from a past experience or maybe by a family members beliefs or experience.5.需要探讨的一个关键问题是究竟什么原因促使克劳利先生选择生机饮食排毒法。是基于“做一切可以做的事情”的理念，抑或是一种优先使用自然疗法的渴望？也许克劳利先生选择健康饮食生机饮食排毒法可能是被过去的经历给吓到了，又或者是被某个家庭成员的信仰或经历所影响。When Patients Choose CA

15、M over EBMHow to Negotiate TreatmentOverall,thorough and respectful assessment of Mr.Crowleys beliefs and understanding will help assess if he is open to discussion about his medical decision and,if so,how best to approach the conversation.总而言之，对他的观念和认知进行全面客观的评估有助于推测他是否会敞开心扉谈谈自己的医疗决策，如果他愿意，如何最有效地进行沟

16、通。When Patients Choose CAM over EBMHow to Negotiate Treatment 6 The belief of many patients that CAM therapies offer nontoxic and effective options is frequently based on nonscientific data.For patients without a medical background,it can be very difficult to distinguish between therapies supported

17、by clinical research and those endorsed by anecdotal evidence or tradition.6.很多患者认为补充替代疗法不会产生毒副作用而且富有成效，但这种想法通常没有科学依据。对于那些没有医学背景的患者来说，弄清那些有临床研究作支撑的疗法以及那些基于传统和传闻的疗法是非常困难的。When Patients Choose CAM over EBMHow to Negotiate TreatmentNot all patients know that most therapies advertised as cancer cures ha

18、ve not undergone human clinical trials,whereas there is clearly data to recommend,for example,chemotherapy for stage I Hodgkin lymphoma.并非所有的患者都知道，大多数标榜能够治愈癌症的疗法其实都没有经过人体临床试验证明，但是很明显，用化疗手段治疗I期霍奇金淋巴瘤是有临床数据支撑的。When Patients Choose CAM over EBMHow to Negotiate TreatmentSome patients find the pharmaceut

19、ical industry suspect and believe it to be overwhelmingly profit-motivated;they may not realize that other information may come from sources with similar or more direct conflicts of interest.一些病人不信任制药业，认为它完全受利益驱使。他们可能没有意识到，其它信息可能也受类似利益驱使或者有更直接的利益冲突。When Patients Choose CAM over EBMHow to Negotiate T

20、reatmentDiscussing the specific source of the information patients are using will help evaluate its worth and create a better environment for informed decision making.探讨病人引用的这些信息的具体来源将有利于评估信息价值，为明智决策创造更良好的环境。When Patients Choose CAM over EBMHow to Negotiate Treatment7 This discussion also requires t

21、he physician to be,to some degree,knowledgeable about the topics involved.Dr.Randolph would do well to admit,if it were true,that he is not completely familiar with the details about macrobiotic cleanses.7.这种讨论还要求医师必须对所涉及的话题有一定了解。如果果真如此，伦道夫医生会做的很好，承认他并不完全熟悉生机饮食排毒法的具体细节问题。When Patients Choose CAM ove

22、r EBMHow to Negotiate Treatment An empathic approach goes a long way,and the patient will be able to sense the physicians sincere compassion.Dr.Randolph could thus honestly express his worries about the implications of delaying chemotherapy without downplaying his concern for the patient and the pat

23、ients explicit goal of achieving cure with the fewest possible side effects.协商治疗之路很难走，病人要感觉到医生发自内心的同情心。如此，伦道夫医生既可以真诚地表达自己对推迟化疗可能产生后果的担忧，又可以表达他对患者的关心，重视患者希望把治疗副作用降到最低的明确目标。When Patients Choose CAM over EBMHow to Negotiate TreatmentIf needed,he could use a“time out”and set up an early follow-up visit

24、to give himself some time to think through these issues carefully and,if necessary,learn more about macrobiotic diets.如果需要，他可以利用自己工作以外的时间，建立早期随访，抽出时间认真思考这些事情。如有必要，他还可以去更多地了解生机饮食排毒法。When Patients Choose CAM over EBMHow to Negotiate Treatment8 Dr.Randolph might acknowledge,at some point,that he is not

25、 on the same page as Mr.Crowley and propose some way forward using negotiation skills.8.伦道夫医生可能会承认他和克劳利先生在某些点上无法达成共识，也许他可以采用协商技巧，提出一些进一步的治疗方案。When Patients Choose CAM over EBMHow to Negotiate TreatmentDismissal of Mr.Crowleys views could easily result in a broken relationship,leaving Mr.Crowley too

26、uncomfortable to return for further care.一味否定克劳利先生的观点很容易导致医患关系破裂，让患者感觉特别不舒服，以致患者再也不回来接受进一步治疗。When Patients Choose CAM over EBMHow to Negotiate TreatmentInstead,respectful acknowledgement of Mr.Crowleys views and a willingness to work with him,at least to monitor his health,will leave Mr.Crowley the

27、option to return for further discussion and care.相反，尊重并且认可克劳利先生的意见，同时愿意与他一起努力，至少在治疗过程中监测他的健康状况，这样克劳利先生就会愿意选择回来进行进一步的讨论和治疗。When Patients Choose CAM over EBMHow to Negotiate TreatmentDepending on his level of commitment to the macrobiotic diet,a time-limited trial of 4-8 weeks would be reasonable,as l

28、ong as Mr.Crowley was fully informed that this approach could allow the disease to progress and perhaps lower the chances of curing it.只要充分告知克劳利先生，生机饮食排毒法可能会使他病情恶化，降低治愈机率，那么根据他对生机饮食排毒法的认知程度，4-8周的试验期会是合理的。When Patients Choose CAM over EBMHow to Negotiate TreatmentIf,after a trial period,there were cl

29、ear signs of disease progression,Mr.Crowley could then feel comfortable reconsidering Dr.Randolphs recommendation of chemotherapy.试验期过后，如果有明显的病情恶化迹象，克劳利先生便可以放心地重新考虑伦道夫医生的化疗建议。When Patients Choose CAM over EBMHow to Negotiate TreatmentRegardless of the patients eventual choice,Dr.Randolph could empha

30、size his desire to stay closely connected to Mr.Crowley and help him in any possible way,thereby maintaining a therapeutic alliance.不管病人的最终选择是什么，伦道夫医生要强调，他希望能够与克劳利先生保持密切联系，并愿意用任何可能的方式来帮助他，从而维护治疗同盟。When Patients Choose CAM over EBMHow to Negotiate Treatment9 A macrobiotic diet entails recommendations

31、 for certain foods and cooking methods.Unfortunately,no clinical trials have been performed to identify the risks and benefits associated with this approach.9.生机饮食排毒法推荐使用特定食材和烹饪方法。遗憾的是，目前还没有临床试验研究来确认此法的风险和好处。When Patients Choose CAM over EBMHow to Negotiate TreatmentThe current medical understanding

32、 of this diet is that the likelihood of any favorable impact on the course of Hodgkin lymphoma is extremely low.目前医学的理解是，它治疗霍奇金淋巴瘤期有效的可能性极低。When Patients Choose CAM over EBMHow to Negotiate TreatmentReferring Mr.Crowley to a colleague with additional knowledge about CAM could help satisfy the patien

33、ts desire to explore all avenues with expert care.If such a consultant is not available,referral to a licensed dietician might be helpful.把克劳利先生推荐给另一个更懂补充替代医学、能提供专业治疗的同事，将有助于满足他了解所有治疗选择的渴望。如果找不到这样的一位顾问，把他推荐给执业营养师也可能有所帮助。When Patients Choose CAM over EBMHow to Negotiate Treatment10 Physicians are com

34、monly confronted with dilemmas like the one described in this vignette.10.医生会经常面临以上所描述的两难困境。When Patients Choose CAM over EBMHow to Negotiate TreatmentIn this case,it is not clear whether Mr.Crowley reacted badly because of the news he had received or because of the way Dr.Randolph handled the encou

35、nter itself.The basis for the patients treatment decision appears to have been multifactorial.本案例中，我们不知道克劳利先生的反应是否是因为他听过有关化疗的负面消息，还是因为伦道夫医生处理问题的方式本身不对。患者的治疗决定似乎一直受多重因素影响。When Patients Choose CAM over EBMHow to Negotiate Treatment11 Conflict between patients and physicians most often involves disagre

36、ement about the goals of care or the familys role in decision-making.11.医患矛盾大多离不开以下两个方面：双方未就治疗目标达成共识和患者家庭对决策过程产生的影响。When Patients Choose CAM over EBMHow to Negotiate TreatmentThere is very little high-quality evidence about how to approach the subject of CAM with patients,but there is a wealth of in

37、formation and expert opinion from the literature in oncology about general principles of effective patient-physician.现在还没有有力的证据表明如何与患者探讨补充替代疗法的话题，但在与肿瘤相关的文献中有大量的信息和专家意见提到有效的医患沟通的准则。When Patients Choose CAM over EBMHow to Negotiate TreatmentRespecting patient autonomy sometimes entails adult patients

38、 making what we,in allopathic medicine,view as poor decisionseven at the risk.Despite this,we continue to play an active role in caring for these patients.从对抗疗法的角度看，尊重患者的自主决定权，有时就使得一些成年患者做出我们认为是不明智的，甚至是危及生命的决定。尽管如此，我们还是会积极地照顾这些病人。When Patients Choose CAM over EBMHow to Negotiate Treatment Physicians

39、 like Dr.Randolph would be well served to continue advocating for their patients health and unequivocally supporting competent adult patients,such as Mr.Crowley,in their right to accept or decline chemotherapy for a highly curable disease such as stage I Hodgkin lymphoma.像伦道夫医生一样，还要继续为促进患者的健康而努力，明确地支持像克劳利先生这样有自己想法的成年患者。即使像用化疗治疗非常有效的期霍奇金淋巴瘤的患者，不论他们接受还是拒绝化疗，也要尊重他们的选择。When Patients Choose CAM over EBMHow to Negotiate Treatment