，周海鈴(譯)，黃文靜(譯)，楊 輝(譯)

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

·世界全科醫(yī)學(xué)工作瞭望·

《The Medical Republic》案例分享
——當(dāng)臨床服務(wù)還有其他意思的時(shí)候，會讓人感到困惑

LeonPiterman1，周海鈴(譯)2，黃文靜(譯)2，楊 輝(譯)1

1.3168MonashUniversity,Melbourne,Australia2.518003 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《TheMedicalRepublic》

全科醫(yī)生；職業(yè)關(guān)系；職業(yè)邊界

PITERMAN L.當(dāng)臨床服務(wù)還有其他意思的時(shí)候，會讓人感到困惑[J]. 周海鈴，黃文靜，楊輝，譯.中國全科醫(yī)學(xué)，2017，20(28)：3468-3470.[www.chinagp.net]

PITERMAN L.When clinical caring becomes confused for something more[J].ZHOU H L,HUANG W J,YANG H,translators.Chinese General Practice，2017，20(28)：3468-3470.

一般而言，醫(yī)生，特別是全科醫(yī)生，會與患者及其家屬形成密切的職業(yè)關(guān)系。我們分享他們的喜悅，也受到他們悲傷情緒的影響。然而，我們需要時(shí)刻保持這種關(guān)系的職業(yè)性，有實(shí)際案例表明，如果不適當(dāng)?shù)乜缭搅寺殬I(yè)邊界，醫(yī)生將會面臨暫停執(zhí)業(yè)、注銷注冊的危險(xiǎn)，在某些情況下甚至有可能會面臨刑事指控。培訓(xùn)是為了讓我們明確這些職業(yè)邊界，采取符合職業(yè)倫理的行為，從而避免把臨床服務(wù)誤解為眷愛或個(gè)人關(guān)照。在處于危險(xiǎn)狀態(tài)的時(shí)候，患者及其照護(hù)者會表現(xiàn)得較為脆弱，并且有可能會把全科醫(yī)生在此時(shí)提供的幫助誤解為別的意思。

簡的故事

簡，30歲，與母親露易絲同住，并由母親照顧她。露易絲，65歲，患有晚期乳腺癌。簡的丈夫克里斯，35歲，是一名采礦工程師，經(jīng)常在州際或海外旅行。簡和克里斯有一名3歲的女兒斯蒂芬妮，在當(dāng)?shù)厣贤袃核?。簡的父母很多年前就離婚了，父親已經(jīng)再婚，居住在新西蘭。簡沒有兄弟姐妹，是家里唯一的照護(hù)者，她認(rèn)為自己是“三明治一代”，既要照顧病重的媽媽，也要照顧年幼的孩子。

露易絲在我所在的診所就診了20余年，8年前被診斷為晚期乳腺癌。雖然看起來她的癌癥似乎已經(jīng)得到了控制，但后來還是出現(xiàn)了骨轉(zhuǎn)移和肺轉(zhuǎn)移，轉(zhuǎn)移癌治療無效，目前她正在接受姑息治療。我是姑息治療團(tuán)隊(duì)的一員，每個(gè)星期都要去探望露易絲1次，給她開藥，傾聽她和簡訴說遇到的難題，并且給她們提供支持和建議。家訪很簡單，露易絲和簡居住的地方離診所只有幾百米遠(yuǎn)，而且她們通常會給我沖一杯咖啡。我為露易絲提供服務(wù)的時(shí)間久了，覺得可以把我的家庭電話號碼告訴她，以備發(fā)生緊急情況的時(shí)候聯(lián)系我。當(dāng)時(shí)，我確信她們不會無緣無故打電話給我。

我的車經(jīng)常停在離診所最近的“醫(yī)生專用”車位上。后來我發(fā)現(xiàn)，很多時(shí)候，事實(shí)上幾乎每隔一天，我汽車前擋風(fēng)玻璃的刮水器下都會插著一朵花。起初我并沒有在意，但后來因?yàn)樵谲嚿喜寤ㄟ@件事太有規(guī)律了，所以我察覺到我一定是有了一個(gè)秘密的崇拜者。我向診所的同事們提及此事，他們對此一笑了之。

接著電話來了，剛開始是打到診所的，通常在中午。一名女性告訴接診員：“請您通知里昂，我們在老地方見面吃午飯……他知道在哪兒。”打電話的人沒有留下任何身份線索。接診員帶著狡黠和猜疑的笑容，告訴我那個(gè)有規(guī)律的午餐約會，我很難讓她相信我并不知情。后來，午餐約會變成了晚餐約會。然后，我開始在家里接到電話，電話里傳來沉重的呼吸聲。如果我的妻子接電話，沉重的呼吸聲就不見了。電話打得實(shí)在太頻繁了，最后我不得不請電信公司在適當(dāng)?shù)牡胤皆O(shè)置分機(jī)。

照顧了露易絲這么久，我覺得給她我的家庭電話號碼以備不時(shí)之需是合理的。

我通知了當(dāng)?shù)鼐?，警察表示，因?yàn)闆]有犯罪證據(jù)，所以不能為我提供幫助。然后我通知了醫(yī)療保護(hù)組織，他們答應(yīng)會為我提供支持，并給我做了登記。在此期間，我繼續(xù)為露易絲提供家訪。當(dāng)我發(fā)現(xiàn)，簡會特意因?yàn)槲业膩碓L而花很長時(shí)間精心打扮、穿著時(shí)尚衣服時(shí)，我開始懷疑了，但只是懷疑。直到診所里的一名接診員親眼看到她把花放在我汽車的擋風(fēng)玻璃上，謎團(tuán)才終于揭開。

我感覺受到了侮辱、遭受了冒犯，并感到困惑，我需要心理咨詢和指導(dǎo)。另外，我覺得我不能再為露易絲提供服務(wù)了，醫(yī)療保護(hù)組織也建議我把照顧露易絲的工作轉(zhuǎn)交給診所里的其他醫(yī)生。我為露易絲擔(dān)心，很顯然她并沒有意識到簡的行為，還可能會認(rèn)為是我嫌棄她。但是，我別無選擇，只能放棄對露易絲的照顧。我很快安排了一個(gè)假期，以此為理由請別的同事來接替我去照顧露易絲。與簡當(dāng)面談這個(gè)問題是件很困難的事，我選擇通過電話來跟簡說清楚。一周后，我收到了簡發(fā)來的一封長長的道歉信，信中概述了她對我的那種難以說清楚的感覺，她在婚姻中遇到的困難，她不知道如何面對即將去世的媽媽。我很理解她，她感到很失落。但是，我不可能是她的救星。

有時(shí)候，我們的職業(yè)標(biāo)準(zhǔn)和未來所遭遇的危險(xiǎn)，超過了照顧患者的需要。上述的故事就是其中的一種情況。4周后露易絲去世了，簡離開了她的丈夫，搬到了新西蘭。后來，我收到簡寄來的圣誕卡，告訴我她找到了新愛，并感謝我對她母親的照顧。

譯者注：職業(yè)關(guān)系(professional relationships)——因?yàn)槟硨ｉT工作而形成的人與人之間的關(guān)系，如醫(yī)患關(guān)系、師生關(guān)系、警民關(guān)系、干群關(guān)系、上下級關(guān)系等。職業(yè)關(guān)系是人際關(guān)系中的一種特定關(guān)系，并因職業(yè)的性質(zhì)、特征、應(yīng)遵從的職業(yè)守則和倫理，被賦予特定職業(yè)關(guān)系的特定范圍、邊界及行為規(guī)范。職業(yè)邊界(professional boundaries)——醫(yī)患(護(hù)患)關(guān)系的重要內(nèi)容，是肉眼看不到的結(jié)構(gòu)，是關(guān)系雙方對各自行為的合理性控制。職業(yè)邊界是法律、倫理、職業(yè)標(biāo)準(zhǔn)所決定的，并尊重醫(yī)生/護(hù)士和患者/家屬雙方權(quán)益，以建立起安全的、僅以治療目的為聯(lián)系的醫(yī)患關(guān)系，任何一方“越界”都是對尊重和信任的背叛。

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)》。

Doctors in general,and GPs in particular,form close professional relationships with patients and their families.We share in their joys and we are affected by their sorrows.

However,at all times those relationships need to remain professional,and in instances where boundaries are inappropriately crossed doctors run the risk of suspension from practice,deregistration and,in some cases,may face criminal charges.

Our training prepares us to define those boundaries and to act ethically to avoid circumstances where clinical care is misconstrued for loving,personal care.

Patients and their carers may find themselves vulnerable during times of crisis and may misconstrue the attention that we,as GPs,give in difficult circumstances.

The case of Jane,below,illustrates the difficulties that arise when patients themselves cross boundaries.

Jane′sstory

Jane was aged 30 and was living with,and caring,for her 65-year-old mother,Louise,who had terminal breast cancer.She was married to Chris,a 35-year-old mining engineer who was often travelling interstate or overseas.They had a three-year-old daughter,Stephanie,who attended a local crèche.

Jane′s parents divorced many years ago and her father had remarried and was living with his family in New Zealand.Jane had no siblings,so was the sole carer,and found herself part of the "sandwich generation" looking after a critically ill mother and a young child.

Louise had been a patient of our clinic for 20 years.The breast cancer was diagnosed eight years earlier and,although apparently eradicated,returned with bone and lung metastases which had not responded to treatment,and she was now in palliative care.

As part of the palliative care team I visited Louise on a weekly basis,prescribed her medications,listened to the difficulties she and Jane were encountering,and offered support and advice.Home visits were made simple as Louise and Jane lived only a few hundred metres from the clinic and were often accompanied by a welcome cup of coffee.Having cared for Louise for such a long time I felt it reasonable to supply my home number in case of emergencies.I was sure this would not be abused.

My car was often parked in an allocated "Doctors Only" space close to the clinic.On a number of occasions,in fact almost every second day,I noted a flower placed under the windscreen wiper of my car.

At first I didn′t think much of this,but given its regularity,I felt I must have a secret admirer.I mentioned this to my colleagues who laughed it off.

Then the phone calls came.At first they were directed to the clinic and would generally happen around midday.The female voice told the receptionist:"Please let Leon know that we will meet for lunch at the usual place … he will know where it is." No identification was offered.

With a wry and suspicious smile,the receptionist informed me about my regular lunch-time date.I found it hard to convince her of my ignorance,or my innocence.These lunch-time dates turned into dinner dates.And then I began to receive calls at home,accompanied by heavy breathing.

When my wife answered the phone the heavy breathing was absent.The calls were so frequent that eventually I had to arrange for Telstra to put diversion mechanisms in place.

Having cared for Louise for such a long time I felt it reasonable to supply my home number in case of emergencies.

I notified the local police who informed me that no crime had been committed so there was little they could do.I notified my Medical Defence Organisation,which offered support and recorded my story.During this time I continued to visit Louise.I became suspicious when I noticed Jane went to some lengths with make-up and stylish clothing for my visits,but it was not until one of our receptionists caught her red-handed placing a flower on my windscreen that the mystery was solved.

I felt insulted,violated and confused and needed advice and counselling.

I also felt that I could no longer care for Louise and was advised my Medical Defence to hand her care over to another doctor in the clinic.

I was concerned for Louise.She was clearly unaware of Jane′s activities and would be concerned that I had abandoned her.However,I had little choice.

A timely holiday break gave me an excuse to hand over her care.Confronting Jane was difficult and I chose to do this by phone.A week later I received a long letter of apology which outlined her confused feelings for me,as well as the difficulties she was experiencing in her marriage in addition to dealing with the imminent death of her mother.Understandably,she felt lost.However,I was not in a position to be her saviour.

There are times when the risks to our professional standing and our future outweigh the need for patient care.This was one of those occasions.

Louise died four weeks later.

Jane subsequently left her husband and moved to New Zealand.I later received a Christmas card from Jane informing me of her new-found love and thanking me for caring for her mother.

WhenClinicalCaringBecomesConfusedforSomethingMore

General practitioners;Professional relationships;Professional boundaries

R 197

A

10.3969/j.issn.1007-9572.2017.28.004

2017-09-10)

(本文編輯：王鳳微)

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(xiàng)澳大利亞衛(wèi)生和醫(yī)學(xué)研究理事會等大型研究項(xiàng)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(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，并進(jìn)行連載刊登！本期Piterman教授為我們講述了一例跨越了職業(yè)邊界患者的案例，職業(yè)邊界是醫(yī)患(護(hù)患)關(guān)系的重要內(nèi)容，患者在脆弱狀態(tài)下會對全科醫(yī)生無微不至的照顧產(chǎn)生誤解，而全科醫(yī)生應(yīng)具備一定的職業(yè)素養(yǎng)，應(yīng)懂得采用符合職業(yè)倫理的行為與患者溝通并保護(hù)自己，敬請關(guān)注！