Leon Piterman，黃振武(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
——艾德娜女爵士，南瓜餅和一顆沉重的心

Leon Piterman1，黃振武(譯)2，黃文靜(譯)2，楊 輝(譯)1

全科醫(yī)生；心理問題軀體化表現(xiàn)；軀體形式障礙

PITERMAN L.艾德娜女爵士，南瓜餅和一顆沉重的心[J]. 黃振武，黃文靜，楊輝，譯.中國全科醫(yī)學(xué)，2017，20(19)：2303-2305.[www.chinagp.net]

PITERMAN L.Dame edna,pumpkin scones and a sinking heart[J]. HUANG Z W,HUANG W J,YANG H,translators.Chinese General Practice，2017，20(19)：2303-2305.

他們可能會讓我們心情沉重。但是如果懂得審視自我的話，那么治療軀體化患者會讓我們振奮起來。

1 伊迪斯的故事

在我第一次見到伊迪斯的時候，她已經(jīng)快70歲了。我診所的老同事正考慮退休，他認為自己有道德上的義務(wù)，將他的所有“麻煩患者”移交給我這個社區(qū)里的全科新人。

那時，伊迪斯是單身，且從未結(jié)過婚。她住在離診所八千米遠的地方，這就意味著她每個日常就診都是一次火車旅行。幾年后我發(fā)現(xiàn)，她來診所就診有一個鮮為人知的秘密，她的朋友米爾德就住在診所附近的拐角處。米爾德也是我的患者，而伊迪斯和米爾德是多年的戀人。不過，如果讓大家知道他們的關(guān)系，可能會被理解為不合時宜的、令人不自在的、沒有必要的。但最重要的是，他們互相在意和關(guān)照，我想這對于他們才是勝過一切的東西。

我一直覺得伊迪斯在模仿Barry Humphries創(chuàng)作的喜劇人物艾德娜女爵士(Dame Edna Everidge)的言行舉止。事實上，根據(jù)日歷上的粗略計算，反過來說可能更接近事實，艾德娜女爵士很有可能抄襲了伊迪斯的舉止和服飾。伊迪斯又高又瘦，常常戴著紫色或綠松石顏色的帽子或貝雷帽，配同樣顏色的手套。戴著像鷹一樣的眼鏡，挎同樣風(fēng)格的手提包。穿高跟鞋，偶爾穿皮草時裝。我覺得她打扮得像是晚上去劇場看演出，而不是周五下午出門去全科醫(yī)生處就診。她的鼻子總會撲厚厚的粉，兩頰隱藏在胭脂下。她說話的聲音高亢而刺耳，如果她有上過朗誦課，那她一定會在低級班就被淘汰。

伊迪斯的腸胃問題由來已久。她做過很多實驗室檢查，也去過很多次專家門診，但都無法得到像教科書中一樣的經(jīng)典診斷。腸易激綜合征是她的疾病標(biāo)簽，但各種干預(yù)措施都無法緩解她因此而帶來的痛苦。伊迪斯總是把她的就診時間定在周五的16：30，并且拒絕我每一次要把時間提早一點的建議。作為一名年輕的醫(yī)生，我相對缺乏以患者為中心的服務(wù)經(jīng)驗，但我會認真傾聽伊迪斯那種如詩如歌般的描述。食物如何從她的口腔一點點輾轉(zhuǎn)到肛門，每一個腸道的蠕動和扭曲都是獨特的挑戰(zhàn)。我嘗試從生理和心理上去解釋她的癥狀，但結(jié)果卻往往讓她訴說出新的更多的不適，而且這種不適不能用已知的綜合征去解釋。通常情況下，30 min的看診結(jié)束后，我會收到伊迪斯準(zhǔn)備的一紙袋新鮮南瓜餅。但花費了這么長時間在她的胃腸系統(tǒng)旅行后，南瓜餅對我來說已經(jīng)不那么具有誘惑力了。

于我而言，周五下午充滿了恐懼。伊迪斯會在我的預(yù)約患者名單中嗎？像她這樣的患者是會頻繁來就診的，而且她非常有可能會鎖定我16:30以后的門診時間，然后再去和米爾德約會。我需要一個掙脫的辦法，將她的就診時間限制在15 min以內(nèi)，以減輕我自身的腸道不適而不是她的，從而把我那顆擱淺的心給打撈出來。我想到了一個辦法，那就是讓接診員在她就診15 min后打電話，通知我去處理治療室的緊急情況。這個招數(shù)貌似很奏效，不過經(jīng)過4～5次這種精心策劃的計劃后，伊迪斯很有禮貌地問我：“醫(yī)生，為什么你總是在周五下午的4點45分有急救？”。

在她面前我很失敗和受挫，治療方面也沒有很好的辦法。我仿佛被捆綁住，動彈不得，我的情緒也一點一點陷下去。后來我發(fā)現(xiàn)，這是我自己的問題。我需要從更深的層面去了解自己，以及我對伊迪斯的反應(yīng)。之后，我鉆研了Michael Balint博士的著作，學(xué)習(xí)心理問題軀體化表現(xiàn)(somatisation)和軀體形式障礙(somatoform disorder)的相關(guān)知識，這幫助我能夠更好地處理像伊迪斯這樣的患者。很遺憾我沒有在初級醫(yī)生時就學(xué)到Michael Balint博士的文章，否則我就會使用再歸因的方法幫助患者理解病情，并讓自己能夠應(yīng)對像伊迪斯這樣的患者。

2 后記

“讓人心沉的患者”(heart sink patient)，是已故的Michael Balint博士總結(jié)出的術(shù)語。Michael Balint博士是一名在上世紀50年代與全科醫(yī)生一起探討看診過程中的情感維度，以及面對困難患者時全科醫(yī)生感受的精神病學(xué)專家。著有開創(chuàng)性的著作《The Doctor,his Patient and the Illness》，是遍布全球的巴林特小組(Balint Group)創(chuàng)始人。巴林特小組指定期探討臨床醫(yī)生遇到的問題。

每位全科醫(yī)生都會遇到許多“讓人心沉的患者”，他們無處不在，癥狀難以診斷且痛苦更難以治療。我們給這些患者貼上心理問題軀體化表現(xiàn)和軀體形式障礙的標(biāo)簽。然而，標(biāo)簽本身既不能讓我們更容易地與他們建立起聯(lián)系，也不能幫助他們明白自身痛苦可能是有心理因素的。

這些患者總會徘徊在醫(yī)生周圍，不會離開。他們反復(fù)地接受大量檢查，但結(jié)果都是陰性；他們多次轉(zhuǎn)診至?？漆t(yī)生處，但依然堅信自身的一些“毛病”并未被診斷出來。他們和醫(yī)生間無法達成協(xié)議。每次，當(dāng)我和其他全科醫(yī)生在預(yù)約名單上看到這些患者名字的時候，就會陷入絕望和沮喪的境地。就像有只蝴蝶在胃里翻騰一樣，心里難受，心情低落。

譯者注：艾德娜女爵士(Dame Edna Everidge)是澳大利亞喜劇男諧星Barry Humphries創(chuàng)造的家喻戶曉的喜劇形象，男扮女裝表演艾德娜夫人，是澳大利亞最成功、最知名、最受澳大利亞和英美各國喜愛的喜劇人物。他的形象是珠光寶氣、搔首弄姿、華麗登場的貴婦，有時薔薇紫、有時粉紅、有時酒紅的蓬松卷發(fā)，眼彩、紅唇，艷麗奪目。標(biāo)志性的還有鑲滿彩色寶石的飛檐鸞鳳眼鏡，身穿宮廷華服。嗓門極大，笑聲極為夸張。Barry Humphries的成功讓他獲得了澳大利亞騎士勛章、英國表演界最高榮譽勛章CBE，墨爾本市中心的一條街道也因此更名為艾德娜路。

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)》。

They may make our hearts sink,but treating somatising patients can be uplifting if we learn to look within ourselves.

Edith was in her late 60s when I first met her.My senior partner in the practice was contemplating retirement and saw it as his moral duty to hand over all of his "troublesome patients" to me,the new boy on the block.

Edith was single and had never married.She lived about eight kilometers from the clinic,which meant a train journey to attend her regular visits.

It was only years later that I discovered that the ulterior motive for her visits to our patch was that her friend Mildred lived around the corner from the clinic.Mildred was also one of my patients.Edith and Mildred had been lovers for many years.It was unfashionable,uncomfortable,and perhaps unnecessary,for them to come out.Importantly,they cared for each other,and that is all that mattered.

I always felt that Edith had modelled her demeanor on that of Barry Humphries′ comic creation Dame Edna Everidge.In fact,based on rough calendar calculations,the converse may have been closer to the truth.Dame Edna may well have plagiarised Edith′s manner and haute couture.

She was tall and lean.Always wore a purple or turquoise hat or beret,matching gloves,eagle-like glasses,a matching handbag,high heels,and occasionally a fur.I felt she was dressed for a night at the theatre rather than a Friday afternoon outing to a suburban general practice.Her nose was always heavily powdered and her cheeks drowned in rouge.She spoke with a high-pitched,piercing voice.If she′d had elocution lessons then she must have missed the lower-register classes.

Edith had a long history of bowel problems.Numerous tests and specialist visits had failed to reach a classic text-book diagnosis.Irritable bowel was the label attached to her malady,and as is often the case,multiple interventions failed to alleviate her suffering.

Edith always scheduled her appointments for 4：30 on a Friday afternoon,thwarting any of my attempts for an early exit.As a young doctor relatively inexperienced in patient-centred care,I would listen to Edith describe,in almost poetic terms,the passage of food from her oral cavity to the anus.Each turn and twist of the gut provided its unique challenges.I tried to explain her symptoms in physiological and psychological terms only to be met with a further battery of ailments that defied any known syndrome.

At the end of these 30-minute consultations,I was usually presented with a paper bag of her freshly prepared pumpkin scones.Having spent a consultation travelling through the interstices of Edith′s bowels,the pumpkin scones were hardly an enticing delicacy.

Friday afternoons were filled with trepidation.Was Edith on my appointment list? Patients such as her were frequent attenders so the likelihood was always high that she would fill my 4:30 time slot,en route to Mildred.

I needed an escape strategy.Something that would enable me to terminate the consultation after 15 minutes,diminish the tension in my gut if not in hers and save my heart from sinking.I thought of a solution.I instructed my reception staff to call me after 15 minutes to attend an emergency in the treatment room.This seemed to work,however,after four or five such carefully planned emergencies,Edith politely asked:"Doctor,why is it that you always have an emergency at 4:45 on a Friday?"

I was lost and defeated.Therapeutically destitute,I was now trapped and emotionally bereft.

I discovered then and there that I was the problem.I needed to understand myself and my reaction to Edith at a deeper level.The discovery of Balint′s work,learning about the nature of somatisation and somatoform disorders,later helped me to manage Edith and many others like her.It is a pity I was not exposed to this literature as a junior doctor and to the role of reattribution in helping patients understand the disorder and in helping me cope with patients such as Edith.

Post script

The term "heart-sink" patient was coined by the late Dr Michael Balint,a psychiatrist who worked with GPs in the 1950s to explore the emotional dimensions of consultations and the feelings of GPs when confronted with difficult patients.

He subsequently wrote the seminal text,TheDoctor,hisPatientandtheIllness,and was the founding father of Balint groups now scattered all over the globe which meet regularly to explore the problems facing clinicians.

Every GP has a number of heart-sink patients.They are ubiquitous.Their symptoms are difficult to diagnose and even more difficult to treat.We use the terms somatisation and somatoform disorder to attach a label to these patients.The label itself does not make it easier to connect with them nor help them understand that there may be a psychological basis to their suffering.

These patients do not go away.After repeated multitudes of negative tests and specialist referrals they are still convinced that something has been missed.There is absence of agreement between physician and patient.

Each time I and other GPs see these patients on an appointment list we are thrown into a state of despair and frustration.The butterflies rise in the stomach.The heart sinks.

(本文編輯：王鳳微)

Dame Edna,Pumpkin Scones and a Sinking Heart

General practitioners;Somatisation;Somatoform disorder

注：本文首次刊登于《The Medical Republic》

R 197 R 395.9

A

10.3969/j.issn.1007-9572.2017.19.002

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(biāo)準(zhǔn)、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，《全科醫(yī)學(xué)中的精神病學(xué)》合作著者。Leon 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Leon Piterman教授為我們講述了一例“讓人心沉的患者”(heart sink patient)，該名詞由Michael Balint博士總結(jié)得出。全科醫(yī)生在接診該類患者時往往感覺無奈和無力，像有塊石頭壓在心頭，影響了接診情緒。臨床中，這類患者往往會被貼上心理問題軀體化表現(xiàn)(somatisation)和軀體形式障礙(somatoform disorder)的標(biāo)簽，但單純地貼上這種標(biāo)簽并無益于與患者的溝通和診治。因此，Leon Piterman教授建議全科醫(yī)生，應(yīng)積極學(xué)習(xí)相關(guān)知識，以切實了解患者病情，提高自身接診該類患者的能力，敬請關(guān)注！

1.3168 Monash University,Melbourne,Australia

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