目前日期文章:201104 (6)

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不少民眾筋骨痠痛、扭傷時,習慣上中醫院所治療,繳掛號費和部分負擔合計一百元,便可順道推拿、按摩;但健保局規定,五月一日起,凡設有民俗調理區的中醫院所,不准申請傷科給付。換言之,民眾日後到中醫院所將不再有推拿人員幫你推拿按摩,否則就得自掏腰包。

這是繼去年健保局要求中醫師需親自為病人推拿,才得請領健保給付後,再祭出整頓中醫推拿過於浮濫的鐵腕措施。健保局表示,下月起,無論是中醫醫療院所、西醫醫院附設中醫部門,都要撤除民俗調理區,才能申報傷科治療及脫臼整復。院所聘用有照物理治療師推拿則除外,健保仍有給付。

衛生署中醫藥委員會主委黃林煌說,全國約有三千一百家中醫院所,其中九百多家設有民俗調理區,聘用推拿人員超過一千八百人,每家平均有兩人。這些附設民俗調理區的中醫院所,最多只能緩衝到明年四月。

中醫師公會全聯會理事長孫茂峰指出,唯為避免正統醫療與民俗調理的混淆,該會願意配合政府政策辦理讓中醫傷科診療回歸專業,至於推拿等非治療性的按摩,就改到其他地方消費。

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貴重物品管理系統+單車烙碼   防竊利器

警方逮捕竊賊、起出贓物,常找不到被害人,因此設置「貴重物品管理系統」,登錄民眾的財物。

台北市就曾破獲六個自行車竊盜集團,起出四百七十九輛贓車,絕大多數都找不到失主,警方根本無法追查。

針對單車「易偷易銷難查」的盲點,市刑大去年一月建置一套單車自願刻碼(烙碼)登錄系統,到警察機關進行單車刻碼的民眾,只要同意,警方會將資料建置進資料庫;原廠已有烙碼的高價單車,民眾也可到各分局、派出所填妥同意書,鍵進資料。

刑事局副局長林昆煌說,「自行車辨識碼」原由各縣市警局執行,但編碼方式、條碼貼紙不同,變成跨縣市就查不到資料,流於各自為政;刑事局今年爭取兩千萬元預算,五月發包招標,全國統一編碼,對民眾自行車防竊多一份保障。

黃明昭則說,刻碼建檔不一定可大幅提升破案數,但對防制竊案有相當效果,竊賊發現單車有烙碼、刻碼,下手意願通常會降低;就算單車被偷,事後也比較容易被找回。

另外,學校投影機等教學器材近幾年也頻頻遭竊,市警局與教育局協調後,對新採購設備都進行烙碼,再交由警方建檔入資料庫,同樣發揮防竊效果。

黃明昭表示,除了單車、教學器材之外,手機、手表等其他貴重物品,只要有完整序號,也考慮提供自願民眾建檔。

目前民眾最常拿來登記的物品是單車和手機,警方會拍照、註明特徵,只要一查資料庫,照片就會羅列出來。

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New Canadian Clinical Practice Guidelines for Acute and Chronic Rhinosinusitis are the first in the world to contain an evidence-based strategy for managing and treating chronic rhinosinusitis (CRS), a disease that is emerging as an area of unmet medical need.  The Guidelines, prepared by leading Canadian multidisciplinary medical experts, are co-published in the Allergy, Asthma & Clinical Immunology (http://www.aacijournal.com/content/7/1/2) and the Journal of Otolaryngology-Head and Neck Surgery.

Within the Guidelines development effort, learning tools are incorporated such as expert opinions, algorithms and mnemonics for immediate practical applications for the physician. To support the educational effort of rhinosinusitis, a new web site - www.sinuscanada.com - has been created to serve as a comprehensive resource on these conditions, including videos on learning how to conduct proper nasal examinations and slide kits.

 

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台灣為全世界首推新生兒全面接種B型肝炎疫苗的國家,成功降低B型肝炎帶原率,可說是台灣公衛史上的一大驕傲。不過前陣子陸續傳出曾接種疫苗者B肝抗體卻消失的新聞,嚇壞了不少人,更有媒體下聳動的「B肝疫苗失效?」標題。難道,這個令國人驕傲的政策、防止國人繼續受到B肝病毒侵擾的保護網,真的失靈了嗎?


B肝抗體消失  預料中的事

台灣是B型肝炎病毒的盛行國家,約百分之九十的人均曾遭到感染,其中百分之十五到二十的人終身帶原,亦即國內約有三百萬名帶原者。為了防治這個「國病」,不少醫界前輩自1980年代起積極研究肝炎,終於在1984年針對部分帶原者的新生兒施打B型肝炎疫苗,1986年7月開始全面對新生兒施打B肝疫苗,因此,民國75年7月以後出生的小孩,絕大多數都免於B肝病毒的感染,帶原率已下降到1%,也大幅減少日後因B肝帶原而引發肝硬化、肝癌的風險,締造了公共衛生史上最成功的一戰。

不過,B肝疫苗全面開打至今已經24年了,醫界對於接種B肝疫苗後保護力能維持多久也很關注,進行了多次追蹤調查。結果顯示,雖然確實有不少人體內已測不到B肝抗體,甚至連免疫記憶(即免疫系統是否還記得B肝病毒)都測不到,不過由於成人感染後成為B型肝炎病毒帶原者機率低,且監測顯示B肝疫苗全面開打後至今,國人B肝帶原率及急性肝炎發作率,並未隨著B肝抗體消失而提高,因此,專家學者多認為無需太過擔憂。除容易感染B肝病毒的高危險群,可考慮補接種疫苗外,一般人要不要補打,則視個人需求而定。

由於疫苗並非永久有效,抗體消失是預料中的事,只是不知何時會消失,因此,台大一直都在持續追蹤調查。一項針對台北市15~18歲打過疫苗的高中生調查顯示,有三分之二測不到抗體,三分之一沒有免疫記憶。最新發表的調查則顯示,127名18~23歲接種過B肝疫苗的大學生中,有八成已經測不到B肝抗體,而這些人裡面,有八成也無免疫記憶,解答了醫界一直以來對於免疫記憶可維持多久的疑惑。這項調查並發表在國際權威的《肝臟學》期刊中。

消失的免疫記憶

有無抗體不等同於保護力,重點在於免疫記憶,亦即細胞是否還記得B肝病毒。若有記憶,一旦B肝病毒入侵,免疫細胞仍能識得,並很快消滅它。有抗體就是有免疫記憶的保證,但沒有抗體,卻不代表免疫記憶也消失了。檢測是否還有免疫記憶的方式,是找一群小時候打過疫苗,但體內無B肝抗體也沒帶原的大學生進行檢測。一開始先補打一針疫苗,7~10天後抽血檢測,若有免疫記憶,抗體就會上升;沒有免疫記憶的人,抗體要到一個月以後才會出現,由抗體出現的速度來判定有無。檢測結果發現八成的人即使打了一針,在7~10天內仍測不到抗體,亦即沒有免疫記憶。

繼續追蹤這些人到七個月,並補打其他兩劑疫苗,發現7~10天內產生抗體的人,到七個月時抗體就非常高,7~10天內未產生抗體的人,七個月時的抗體就沒有那麼高,由此可知有免疫記憶者,抗體產生的速度快且濃度高。

為何免疫記憶會消失?B肝疫苗接種時機是在出生六個月以前,是免疫系統最不成熟的時候,免疫細胞能記憶10年以上,已經不錯了。所有疫苗都有效力有限的問題,所以像麻疹疫苗必須打兩次,日本腦炎疫苗每10年要打一次,百日咳疫苗國中階段要再打一次等。

綜合各項研究可歸納出,打完B肝疫苗前10年,沒有人免疫記憶消失,所以10歲以前無需擔心。10~15歲此一階段,有百分之二十的人免疫記憶消失;到了18歲,有八成的人免疫記憶都消失了,推測20歲以後可能都沒有免疫記憶了。

要不要補打疫苗?

至於要不要補打,可分成兩個層面來看。從國家防疫的角度而言,即使八成大學生體內無B肝抗體及免疫記憶,但根據台大小兒部張美惠教授研究,近年來國人的B肝帶原率或急性肝炎發生率,並未顯著上升,一般人無須擔憂,因此,衛生署預防接種委員會經過多次討論,確立了無須全面補接種的態度,但針對較可能暴露在B肝病毒環境下的高危險群,建議自行補種疫苗。

由於B肝主要傳染途徑是血液、體液和性行為,高危險群包括:血液透析病人、器官移植病人、接受血液製劑治療者、免疫不全者、多重性伴侶、注射藥癮者、同住者或性伴侶為B肝帶原者、身心發展遲緩收容機構之住民與工作者,以及可能接觸血液之醫療衛生等工作者。

如從個人的層面看,若人體細胞連免疫記憶都沒有,就跟沒有打過疫苗一樣,一旦接觸到B肝病毒,人體與B肝病毒作戰的結果,有可能贏也可能輸。目前實驗室偵測人體細胞免疫記憶的敏感度,是否能與人體免疫力畫上等號仍未知。雖然20歲以上的民眾一旦感染B肝病毒,會成為帶原者的機率只有百分之三至百分之五,發生猛爆性肝炎的機率則是千分之一,贏的機會較大,不需過度擔憂,但若真的不想承擔風險,補打一針求心安,倒也無妨。

不過,另有一族群則是由衛生署編列預算要補助需補打B肝疫苗的人。目前的B肝疫苗,約百分之五的人打完後無法產生足夠的抗體,但若未特地抽血檢測,一般人不會知道自己是否屬於那百分之五。因此,為了確保B肝帶原者的下一代免受B肝病毒入侵,若母親為B肝帶原且e抗原為陽性者,產下的新生兒接種三劑B肝疫苗後,一歲時需驗血檢測是否產生抗體,若無,則需補種第四劑,費用由政府負擔。

表:我是否該補打B肝疫苗?

假設一名十幾歲的年輕人,出生時已打過B肝疫苗,想知道自己有無B肝抗體?需不需要補打?建議可參考以下流程:
1. 抽血→B肝帶原(表面抗原陽性、表面抗體陰性)→定期每半年追蹤抽血及腹部超音波
2. 抽血→B型肝炎表面抗原陰性、表面抗體陽性→不用補打疫苗,等20歲以後再打, 或

                                                   →也可考慮打一針疫苗,讓保護力再延長10~15年,不用每年再去檢驗

3. 抽血→抗體陰性→打一針B肝疫苗→7~10天後抽血→抗體超過10 mIU/ml以上;保護力可維持10~15年
4. 抽血→表面抗原陰性且表面抗體陰性→打一針B肝疫苗→7~10天後抽血→抗體低於10 mIU/ml →再打兩針疫苗;保護力可能維持10~15年

                                                                 (本文轉載自好心肝會刊, 第53期)

 

新竹市清華診所  提供B型肝炎疫苗

電話:(03) 573-5050

地址:新竹市東區建功一路64號4樓〈清大夜市內〉

 

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I kind of figured that I would not get much disagreement with my previous post (at least from patients).  It is easy for me to criticize my own profession and feel fairly safe, but turning the spotlight on patients makes is riskier.

My purpose in writing these posts is to get both sides looking at things through the other’s perspective.  In this post I don’t want to get patients feeling sorry for doctors; I want them to understand how they can either help or harm that relationship.

So here are the Patient Rules:

Rule 1:  Your doctor can’t do it alone

The best doctor can do very little with patients who ignore instructions.  Sometimes noncompliance is partly due to physicians not explaining things well, but medical compliance is ultimately in the hands of the patient.

I am mystified as to why some patients will ignore nearly everything I say and yet continue coming in for regular appointments.  It is frustrating, causing some physicians to get angry with these patients (and even discharge them). I figure it is the patient’s dollar that is being spent, not mine.

Going to the doctor has no therapeutic benefit in and of itself.  If you disagree with what is recommended, don’t pretend you agree and then ignore your doctor’s advice.  I would much rather have a patient tell me “I am not going to take that medication” than have them accept the prescription and not get it filled.  Your doctor prescribes them for you, not for him/herself.

Rule 2:  Be Honest

Nobody likes to look silly.  I think the main reason most people are untruthful is that they are embarrassed about the truth.  But sometimes symptoms are strange, like the man having a heart attack who described it as “a cold feeling when I take a deep breath.”  Sometimes symptoms are embarrassing, like a testicular lump.  Sometimes you just don’t want to feel like a wimp, so you downplay your pain.

While I can sympathize with this feeling, I don’t see any good reason to be anything but truthful with your doctor.  Yes, your symptom might sound strange.  Yes, you may have flubbed up and not followed instructions properly.  Yes, you may be afraid of what some of your symptoms may mean.  But the goal is to fix (or prevent) problems, and trying to do that with bad information is an exercise in futility.

We physicians hear it all.  There are very few things a person can say to me in the exam room that will surprise me.  My job is to help people, not judge them as “weird”, “crazy”, “wimpy”, or “panicky.”  Don’t worry about making a good impression on your doctor.  Just give the facts.  That will give the best chance to get the desired outcome.

Rule 3:  I don’t play favorites

I have over three thousand patients.  I try to do right by all of them.  I build relationships over years and even develop quasi-friendships with some patients.  But I am professionally obligated to keep emotional distance.  Overly liking or disliking a patient will cloud my judgment, and so I try to treat everyone the same.

It drives me (and my staff) crazy when patients come in and demand “special treatment” because “Dr. Rob knows who I am.”  It is worse if people try to pretend they are my friends by using my first name.  Yes, there are special circumstances where I do see a patient who walks in, but that is dictated by the medical condition, not by how well I know the person.

Doctors I take care of can be the biggest offenders.  I try to make it clear from the outset that I will treat them like any other patient and not necessarily give them better access because they are doctors.  If I have to give them special access, then something is wrong with the system.  Besides, special access for some generally means worse access for others.

Rule 4: Don’t mess with the staff

My staff takes an incredible amount of abuse at the hands of some of my patients.  It surprises me what they are willing to say to my nurses and clerical staff but not to me.  In general, people see them as an obstruction to being able to see their doctor, and so have little patience for any delay.

There are certainly times that my staff is worthy of criticism, and I expect to hear some complaints.  But in general, it is not the individual staff’s fault for things not running well, it is our system that causes problems.  We have a system for the entire patient experience in our office, and it works most of the time.  There are times, however, when circumstance makes things fall apart.  There are also times when the deficiencies of the system are exposed.

My staff has a very demanding job.  Remember that you are not their only responsibility – you may be the 100th job for the day.  If they don’t meet your expectations, yelling at them won’t fix the problem.  Talk to me or my office manager.  Better yet, put it in writing so that I have ammunition to change things, because chances are really good that your frustration correlates to a frustration I have.

One of the only reasons patients are discharged from our office is when they abuse my staff.  A staff member is generally more valuable to me than a single patient, and I need to show my staff that they are valued by me.  It is my job to discipline (or fire) my staff, not my patients’.

Rule 5:  If you don’t trust, leave

Trust is the commodity we sell.  People go to the doctor because doctors have unique knowledge and experience.  The stakes are as high as they can get, so why would you go to someone you don’t trust?  I have seen many patients stick with doctors in whom they have lost faith “because I don’t want to hurt his feelings.”  That is ridiculous.

When you go to a doctor you don’t trust, you will be suspicious about every bad outcome and won’t even trust when things go well.  This  is a no-win situation for the physician.  It does not matter if everyone else says this is a good doctor; if you don’t trust him, find another doctor.

I have some specialists I trust a lot and send many patients to.  Invariably, some people won’t have a good experience – perhaps the doctor had a bad day, was in a bad mood, or the two just didn’t get along.  If I hear that mistrust, I always suggest either a second opinion or a change of doctors.  None of my colleagues want someone sticking with them if the trust is not there; it is a very high-risk situation from a malpractice standpoint and studies have shown that negative attitudes make bad outcomes much more likely.

Find a doctor you trust.

Please note that trusting a doctor does not mean you should not ask questions. In fact, I think a physician who does not want to be questioned is one you should not trust.  Questioning is often the only way to build trust.  Unanswered questions tend to undermine trust.

Rule 6: No news might be bad news

“No news is good news” can be a fatal assumption.  Never assume that your doctor will call you if there is a problem.  I get 50-60 new documents (labs, x-rays, consults, hospital notes) every day.  I order hundreds of tests every week.  I just cannot keep track of them all.  Some will get sent to the wrong doctor and some results never get sent at all.  Despite our best efforts to develop a system that will close this loop, there are some documents I just don’t get.

A doctor’s office is always on the brink of chaos – with an incredible amount of information coming in and going out, a large number of phone calls, insurance company headaches, and personnel situations that can throw the best system flat on its face.  People forget that there are hundreds of other patients with thousands of test results the office is dealing with.  We do what we can to tell patients test results (and with our computerized records, we do a better job than most), and I see that as our responsibility.

If you don’t get your test results, call.

One more point: we aren’t that much different from you.  We have good days and bad days.  My staff cry sometimes when they are mistreated by patients.  I get discouraged and emotionally drained.  It really helps to hear thanks.  I don’t expect it all the time, but when I do get a card or a nice phone call saying I am appreciated, it can really help.

********

It can happen.  Doctors and patients can get along.  Like any relationship, it takes effort and give-and-take on both sides.  The benefits of such a relationship are very satisfying and truly life-changing.

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Why are patients mad at their doctors?  In comments on my previous post, people expressed real frustration and distrust – mainly from a lack of listening and connection.  Those who loved their doctors (and there were some) expressed the opposite.  They had a relationship with their doctor.

Here the rules I have for getting along with my patients:

Rule 1:  They don’t want to be at your office

 It may seem odd to patients, but most doctors forget that going to the doctor is generally unnerving.  We Work there, and being in a doctor’s office is normal to us.

Not so with most patients.  The spotlight is on them and their health.  They stand on the scale, undress, tell intimate things about their lives, confess errors, are poked, prodded, shot with needles, lectured at, and then billed for the whole thing.  Yes, it seems that some patients are happy to be there – and I do my best to make my patients feel comfortable, but there is always an underlying fear and self-consciousness that pervades when a person is sitting on the exam table.

The best thing to do in response to that is to show compassion.  If you feel awkward, scared, or self-conscious, the thing you most want is for someone else to understand how you feel.  Patients are much more likely to follow a doctor’s advice when the feel that the doctor understands.  Identifying the fear and relating to it are the first steps at building trust.

Rule 2:  They have a reason to be at your office

People don’t like to waste time and money.  They don’t come to the office to waste the doctor’s time.  Yet early in my training I was incredulous at the reasons some of my patients were coming to see the doctor.  Why come in for a headache?  Why come in for a cold?  Doesn’t the person realize that a stomach bug won’t get any better by coming to the doctor?

It took me being in my own practice (and trying to keep my business going) to realize that there is (almost) always an underlying reason for a patient to come in.  Sometimes that reason is simple: they need an excuse from work, or they have terrible pain that needs to be treated.  Other times, however, the reason is more subtle.  When a person comes to my office with enlarged lymph nodes, for example, the real reason they are coming in is that they are afraid it is cancer.  When patients have chest pain, they are afraid it is their heart.

On every visit I try to identify the real reason (or the real fear) that brings them to see me.  I don’t end the visit until I have addressed that reason.  If they have an enlarged lymph node, I make sure and say “I don’t think this is cancer because….”  If they come in with chest pain, I say “This doesn’t sound like a heart attack because…..”  If I fail to do so, then they leave the office with the fear and feel ignored.

Rule 3:  They feel what they feel

Patients will often tell me their symptoms in a very apologetic tone.  They seem to think that they have to come to me with the “right” set of symptoms, and not having those symptoms is their fault.  Sometimes those symptoms make no sense to me at all and I am tempted to dismiss or ignore them.

But as a physician, you have to trust your patient.  Only the really crazy patients make up symptoms.  Yes, some may exaggerate what they feel out of anxiety or out of fear that you won’t hear them for lesser symptoms, but then your job is to uncover the anxiety, not ignore the complaint.  I have heard from many patients that their doctor “did not believe” their complaints because they did not make sense.  If you don’t trust them, why should they trust you?

If symptoms seem contradict what I know to be possible, I often openly tell them that this seems to contradict – but I make sure I don’t imply that they might not be being truthful.  A puzzle is a puzzle.  It is my job to undo a seeming contradiction.  I may not ever be able to do so, but at least I don’t make them feel bad for feeling what they feel.

Rule 4:  They don’t want to look stupid

I remember when I broke my shoulder – a compression fracture of the neck of the humerus bone – and went to the orthopedist office.  I always felt self-conscious about how much pain I was reporting.  A colleague had fractured his humerus the year before and had reported he was back to doing surgery within a few weeks.  Here I was, a few months out and couldn’t even lay down in bed.  I felt like a wimp.  Was this other guy just tougher than me?  My orthopedist made me feel much better when he explained that my colleague had a mid-shaft fracture, while mine was right in the shoulder joint – a much slower place to heal.

This event made me realize how many patients felt when they came into my office.  People are often worried that they are over-reacting.  They wonder what I must think for a person to come to the office with that symptom.  This is especially true of parents bringing their children in.  Nobody wants to be “that mother that over-reacts to everything.”  In response to this, I try to specifically say, “I am glad you came to the office for this because…” or “Yeah, I can see how that worried you because it could be….”

Rule 5: They pay for a plan

What do people pay for when they come to the medical office?  They pay for opinion, yes.  They pay for knowledge as well.  But what they really pay for is a plan of action based on their circumstance.  If they have an ear infection the plan is to use antibiotic (maybe) and treat the pain.  If they have abdominal pain, the plan may be much more complex.  They want to know what is going to be done and want what is done to help.

I try and give a plan, either verbal or written, to each patient that walks out of the exam room.  What medications are given and why?  What medications are to be stopped?  What tests are ordered and what will the results mean?  When is the next appointment?  What should they call for if they have problems?  The better I can answer these questions, the more confidently the patient will walk out of the exam room.  The days of paternalistic medicine are over – no handing a prescription and just saying “take it.”  Patients should know why they are putting things in their body.

Rule 6: The visit is about them

With all of the stresses in a doctor’s office, I get tempted to complain about things.  Who better to complain to than someone who feels much the same way?  But patients are paying for you to take care of their problems, not the reverse.  I keep my personal gripes or frustrations to myself as much as possible.

(本文轉載自 http://distractible.org/2008/08/06/getting-along-part-1-doctor-rules/)

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