(声明：刊用《中国新闻周刊》稿件务经书面授权) (statement:reproduced[China news weekly]For the manuscript written authorization)

原标题：疾病认知 医患的“暗战” Original title:Diseases of the cognitive patient"Dark war"

　　医院不仅是治病救人的场所，也是各种观念激烈碰撞的地方。现代医学的疾病观念体系和普通人的疾病认知框架，几乎无时无刻不在医患互动过程中“暗战”。在这种认知差异之中，往往酝酿着医患矛盾的爆发

The hospital is not only cure the sickness to save the place,Is also the place where ideas fierce collision.Modern medical disease concept system and ordinary people disease cognitive framework,Almost all the time to be absent in the process of doctor-patient interaction"Dark war".In this kind of cognitive differences between,Often ferment doctor-patient contradiction outbreak

　　大约一个月前，安徽和天津两地的医院，先后发生两起医护人员被杀案件。杀医案的频发表明：中国医患关系紧张的程度为世界所罕见。英国的《柳叶刀》杂志就曾专门刊登文章，讨论医患关系在中国的复杂现状。在不同的领域，学者们从社会、经济、法律等角度对医患关系的探讨虽然足够宏观概括，但却时常忽略了一个细微而内在的方面：医生和患者对疾病认知的不同，往往是医患矛盾发生的起点。

About a month ago,Anhui and tianjin two hospitals,Has occurred in the two medical staff were killed case.Kill the basis that frequent:China's intense doctor-patient relationship in the world rare.British[lancet]The magazine was published in this article,Discuss the doctor-patient relationship in China's complicated situation.In the different fields,Scholars from the society/economic/Legal aspects of the doctor-patient relationship discussion although enough macro generalization,But often overlooked a subtle and internal aspects:The doctors and patients to disease of the different cognitive,Often is the starting point of the doctor-patient conflicts occur.

　　谁都不会否认，医学是一门专业学科，但问题的另一方面是，几乎每个人都觉得自己“懂得”一点医学——起码了解自己的身体。因而，作为一门学科，人们对医学的认识会在“普知性”和“专业性”的双重属性之间频繁地游移，这是任何其他学科都没有的特点，它也决定了医患双方共同完成的诊疗过程，必然是一种思维的博弈。

No one denies that,Medicine is a professional discipline,But on the other hand is the problem,Almost everyone feel"know"A medical - at least understand your body.so,As a subject,People to the understanding of the medicine in"General intellectual"and"professional"The dual nature of moving between frequently,This is any other subjects are not characteristics,It also determines the doctor-patient joint complete diagnosis and treatment process,Will is a kind of thinking of the game.

　　我的朋友魏晰是一位不到30岁的电脑工程师，前不久，他找到我说，自己有多年的双侧膝关节疼痛，近期症状有所加重，因而想找一位权威的医生进行诊治。据魏晰自己分析，他自幼生活在南方山区潮湿的气候中，听说在他两个多月大的时候父母就给他洗过冷水澡，正是由于这个原因使他从小就得上了“风湿”，他坚信自己的关节痛正是由“风湿性关节炎”引起的。魏晰想去看病的目的，就是要对此进行确诊，并得到有效的治疗。

My friend WeiXi is a less than 30 years old computer engineer,Not long ago,He found me,He has many years of bilateral knee pain,The recent increased symptoms,And wants to find a doctor for diagnosis and treatment of authority.According to WeiXi his analysis,From his youth living in the south mountain damp climate,I heard that in his more than two months parents give him washed cold bath,It is for this reason that he grew up on the"rheumatism",He believes that their joint pain it is up to"Rheumatoid arthritis"cause.WeiXi want to go to the doctor's purpose,That is to be confirmed,And get the effective treatment.

　　熟人的介绍是中国社会人际关系中建立信任感几乎最可靠的途径。看病托熟人，更是会让医患之间脆弱的信任感得到有效的提升。

The introduction of acquaintances is China's social interpersonal relationships establishing trust almost the most reliable way.TuoShou people to see a doctor,But also will make the doctor-patient trust between fragile effectively improve.

　　然而，当魏晰通过我的介绍去国内最有名的骨科，找到以看关节病为专长的医生看过以后，诊断治疗的过程与结果，并没有令他感到信服和安心。据魏晰介绍，在短暂的十几分钟的看病过程中，医生只简单地问了一下他的症状，用手轻轻按压他两侧的膝关节做检查，就做出了“髌骨软化症”的诊断，并表示病情轻微，暂不需特殊治疗，只开了两支外用药让他每天涂抹。不仅魏晰预期中的拍片、验血等检查没做，吃药打针之类的治疗措施没采取，就连他支支吾吾提到的“风湿”问题，医生也没有和他进行讨论。

however,When WeiXi through my introduction to the domestic the most famous bone,Find to see arthropathy for specialty doctor read later,Diagnosis and treatment process and results,Did not make him feel at ease and convincing.According to WeiXi introduced,In the short period of ten minutes in the process of the doctor,The doctor just simply ask about his symptoms,Gently press him to check on both sides of the knee joint,We have to"Patella osteomalacia"diagnosis,Mild and said,Temporary needs no special treatment,Opened only two for external use let him out every day.Not only WeiXi expected shooting/Blood test and inspection didn't do,Give or take an injection take medicine in the treatment of such measures did not take,Even he hem and haw mentioned"rheumatism"problems,The doctor also have no and he is discussed.

　　我能够理解魏晰对这次看病经历的疑虑和失望；另一方面，我并不怀疑那位“怠慢”了魏晰的医生做出的诊断。作为一名旁观者，我能够清晰看到的，就是医患双方在不同思维框架下对疾病认知的差异。

I can understand WeiXi for the doctor experience doubts and disappointment;On the other hand,I don't doubt that"neglect"The WeiXi doctor make diagnosis.As a spectator,I can see clearly,Is the patient in different thinking framework to disease cognitive differences.

　　作为患者的魏晰，他对自己所患疾病是“风湿性关节炎”的猜想是一种长期的根深蒂固的观念。首先，自从他多年前开始出现关节痛症状之时，父母就讲了他幼时洗冷水澡的“故事”，并且把他的病症归因于此。对父母的信任感和信服，不可能对魏晰的判断不产生影响。其次，自幼生活在阴冷气候环境中的魏晰，其故乡向来多发关节疾病，当地人普遍地在这种疾病与特定的气候环境之间建立因果关系。不仅中医用“风寒湿热之邪”造成“气血痹阻”来解释风湿病，而且仅仅依据“风湿”两字的字面意思，也足以让人相信它是造成关节疾病的原因。

As WeiXi patients,He is the disease"Rheumatoid arthritis"Guess is a long-term deep-rooted idea.First of all,Since he began many years ago when the joint pain symptoms,Parents about his youth of cold shower"The story",And his illness due to this.To parents' sense of trust and convincing,Not likely to WeiXi judgment not impact.secondly,He lives in the cold climate WeiXi,The home have multiple joint disease,The local people generally in this disease and specific climate environment between a causal relationship.Not only in traditional Chinese medicine"The cold and dampness evil"cause"Blood bizu"To explain rheumatism,And just according to"rheumatism"Two words literally,Is enough to make people believe that it is caused by the reason of joint disease.

　　一项认知人类学研究认为，患者对疾病认知的基本模式包括自我感知、求医经历、社会文化、对生物医学的想象等因素。然而作为医生一方，这些经过了系统的现代医学教育、积累了长期临床经验的专业人员，他们对疾病的认知排除了个人和社会文化的因素，在医患互动中占据绝对的主动权，并保持着手术刀般的冷静和深刻。

A cognitive anthropology study says,With the basic pattern of cognitive disease including self perception/Seek experience/Social culture/For biomedical factors such as the imagination.However as a doctor a party,These through the system of modern medical education/The long-term accumulation of clinical experience of professionals,Their disease cognitive ruled out personal and social cultural factors,In the doctor-patient interaction occupies the absolute initiative,And keep the scalpel like calm and deep.

　　对于魏晰的关节痛，医生从他的年龄、症状、简单的体检结果等进行考察，经过程式化的临床过程，就很容易做出诊断(实际上，“髌骨软化症”也只是排除了其他关节疾病以后，与患者临床表现最符合的一个初步诊断)。

For WeiXi joint pain,The doctor from his age/symptoms/Simple medical results of investigation,After stylized clinical process,It is easy to make diagnosis(In fact,"Patella osteomalacia"Is ruled out other joint disease later,Patients with clinical manifestations of the most accord with a preliminary diagnosis).

　　至于患者本人所考虑的“风湿性关节炎”问题，“风湿”在现代医学中是“一组侵犯关节、骨骼、肌肉、血管及有关软组织或结缔组织为主的自身免疫性疾病”，西医只是由于历史原因而借用中医的说法来为其命名而已。对于“风湿”的确诊，西医有一套严格量化的诊断标准，所以魏晰对于“风湿”的任何猜想，都会被正规的西医“屏蔽”掉而不予讨论。

As for patients which I consider"Rheumatoid arthritis"problems,"rheumatism"In modern medicine is"A group of infringement of the joints/bone/muscle/Blood vessels and the soft tissue or connective tissue is given priority to autoimmune disease",Western medicine is just due to some historical reasons and use Chinese medicine saying to its name only.for"rheumatism"diagnosis,Western medicine has a set of strict quantitative diagnosis standard,So WeiXi for"rheumatism"Any guess,Will be regular western medicine"shielding"Off and not to discuss.

　　医院不仅是治病救人的场所，也是各种观念激烈碰撞的地方。现代医学的疾病观念体系和普通人多样化的疾病认知框架几乎无时无刻不在医患互动的过程中“暗战”。在这种认知差异之中往往酝酿着医患矛盾的爆发。魏晰和我的医生朋友之间，当然没有爆发任何冲突，这不仅是因为他们都会考虑“朋友面子”，而且因为求医者所患的不过是一种轻微的病症。假如是在危急症的诊治过程中，当医生的诊断治疗结果与患者及其家属的预期不一样时，医患认知上的差异难免会以激烈的方式表现出来。

The hospital is not only cure the sickness to save the place,Is also the place where ideas fierce collision.Modern medical disease concept system and ordinary people diverse disease cognitive framework almost all the time to be absent in the process of doctor-patient interaction"Dark war".In this cognitive difference of doctor-patient conflicts often ferment outbreak.WeiXi and my doctor friends,Of course not any conflict broke out,This is not only because they will consider"Friends face",And because QiuYiZhe had but is a mild disease.If be in danger of the diagnosis and treatment of disease in the process,When the doctor's diagnosis and treatment results with patients and their families as expected when,Doctor-patient cognitive differences will inevitably to the fierce way.

　　在对危重病人的抢救中，气管切开术是为了解除喉源性呼吸困难、呼吸机能失常或下呼吸道分泌物潴留所致呼吸困难的一种常见的紧急手术。医生会根据患者的病情来决定是否进行气管切开。然而在急诊抢救时，患者家属可能拒绝医生的建议。一位被抢救患儿的家长不同意对孩子施行气管切开的理由是“我心疼孩子，这个我绝对接受不了”“不行，我害怕，我会做噩梦的”。

In the critically ill patients in the rescue,Tracheotomy is to remove throat source sex difficulty breathing/Respiratory function disorder or lower respiratory tract secretion retention breathing difficulties caused by a common emergency surgery.The doctor will according to the patient's condition to decide whether to tracheotomy.However, in the emergency rescue,Patients family members may refuse to the doctor's advice.A be save the patient's parents don't agree with the children into the trachea incision reason is"I love children,This I absolutely can not accept""no,I'm afraid,I'll do nightmare".

　　在医学上，气管切开是一种有明确目的、操作规范和适用范围的治疗手段，气管、喉部无非是人体的一个器官。而在一般人的想象中，喉咙(气管)是生命的关键通道，而且它具有文化上的象征意义，切开这里不免令人联想到“见血封喉”之类的感性描述。

In the medical,Tracheotomy is a kind of have a clear purpose/Operation specifications and applicable range of treatments,tracheal/Throat is nothing but an organ of the body.And in the average person's imagination,throat(tracheal)Life is the key channel,And it has the cultural symbolic meaning,Open here not is associated with"upas"And so on perceptual description.

　　社会文化心理的影响不可能让普通人像医生一样完全冷静、理性地看待一项医疗措施。然而，如果医患双方未能消除认知差异，并就治疗措施达成一致，之后一旦产生严重后果，就会为医患冲突的发生埋下隐患。一位医生就抱怨说，“医生着实不易！家属不签字，先给你做手术出了问题是我们的错，不做手术贻误了治疗还是我们的错！”

The influence of social and cultural psychology can't let ordinary like a doctor completely calm/Rational at a medical measures.however,If the patient fails to eliminate the cognitive differences,And treatment measures to reach an agreement,Once produced after serious consequences,For the occurrence of doctor-patient conflicts buried hidden trouble.A doctor will complain,"The doctor is really not easy!Families do not sign,To become an operation to you out of the problem is our fault,Do not become an operation delay the treatment or our fault!"

　　很多人都相信“久病成良医”这句话。然而在许多医生看来，这句话也有误导性。就在今年的一桩杀医案发生之后，北京的一位资深医生感慨说：医生和患者存在严重的信息不对称这是事实，但是危急中的病人不可能边学习医疗知识边和医生进行“公平的交易”。医患关系应该是一种“信托关系”——信任并且托付。因为患者不了解医学，再多的医学知识普及也不能达到自己诊断的程度，所以只能把自己的身体托付给医生。从医生的角度来讲，在诊疗过程中他的利益与患者是一致的——共同的目的就是治好病。

Many people believe that"Into long illness;"This sentence.However, in many doctors it seems,This sentence is also a misleading.In this year's a pile basis after death occurred,Beijing said a senior doctor regrets:The doctors and patients have serious information asymmetry this is true,But the critical patients may not edge learning medical knowledge edge and doctors"Fair trade".The doctor-patient relationship should be a kind of"Trust relationship"- trust and trust.Because patients do not understand the medical,No amount of medical knowledge also cannot achieve their degree of diagnosis,So can only take his body entrusted to the doctor.From a doctor's point of view,In the process of diagnosis and treatment of his interest and is consistent with the patients, the common goal is to cure disease.

　　美国作家裘帕·拉希莉写过一本名为“疾病解说者”的书。一位医生在读过这本书以后说，“疾病的确是需要解释的，但是我要做的重点，不是把疾病的知识讲给你听，而是在交流过程中，能够使解释者和倾听者达到逻辑路径的一致，这样才能提高医患之间的信任度和治疗的依从性。”

American writer fur palmer shia labeouf and Sally wrote a book called"Disease voiceover"book.A doctor after reading the book said,"The disease is really need to explain,But I want to be the key,The disease is not the knowledge about it to you,But in the course of the exchange,Can make interpreter and the listener to logical path consistent,In order to improve the doctor-patient trust between and treatment compliance."

　　发表在《中国全科医学》杂志上的一篇论文在探讨医患双方对疾病认知的差距时指出，“医生和病人在法律上是平等的，然而事实上又是不平等的。医患双方在占有医学知识上的不平等是客观存在的。”首要的不是消除这种知识上的不平等，而是解决医患双方的认知差距。比如，病人需要理解医疗技术的局限性。

Published in[China's general medical]Magazine in an essay discusses the disease patient to cognitive gap out,"The doctor and patient in law are equal,But in fact it is not equal.The patient in medical knowledge of the inequality is the existing objective."The first is not eliminate the inequality in knowledge,But to solve medical both cognitive gap.Such as,Patients need to understand the limitations of medical technology.

　　临床上经常会遇到这种情况：尽管采用了各种现代化的检查，而且经过多级医生会诊，一些病人最后仍旧得不到确切的诊断，只能冠以发热、咯血、腹痛“原因待查”等。有的病人经过几天甚至数周、数月直至治愈，仍未能确诊；有的病人直到死亡甚至死后尸体解剖，也不能得出确切结论，这就意味着在对很多疾病的诊断上，现代医学仍处于束手无策的境地。

Clinical often encounter this kind of situation:Although the various modern inspection,And after multistage doctor consultation,Some patients finally still can not get the exact diagnosis,Only with fever/haemoptysis/Abdominal pain"Reason in dispute"etc.Some patients after several days or even weeks/Months until the cure,Failed to diagnose;Some patients until death even after her death autopsy,Also can't precise conclusion,This means that for many disease diagnosis,Modern medicine is still in the helpless situation.

　　同样，许多病人不切实际地渴望医护人员总是能“妙手回春”。他们会认为，住进医院，花了好多钱，就一定能治好自己的病，如果情况并不如自己所预期的那样，就会提出质疑：“这病怎么越治越重？”“我们病人是站着进来的， 最后是躺着出去的！”

The same,Many patients are unrealistically eager to medical personnel can always"Admirable skill".They may think,Checked into the hospital,Spent a lot of money,We will be able to cure his disease,If it is not as expected that,Will be questioned:"How long is the cure is heavier?""Our patient is standing in, Finally lay out!"

　　一项有关“病人是否在就诊时把想讲出来的话说出来”的调查显示，35名病人中，只有4人在就诊时讲出了本来想讲的话。作为信息不对称的双方，强势一方的医生显然应该负更多的责任。

A relevant"Whether the patient to see a doctor in the want to speak out the words out"Survey shows that,35 patients in the,Only four people in attending doctors tell the wanted to say.As the information asymmetry of both sides,Strong party doctor should obviously more responsibility.

　　同时，病人应该主动与医生保持良好沟通，沟通的重点，就是使医患双方达到认知逻辑上的一致，而医生应该鼓励这种做法。

At the same time,The patient should be active and maintain good communication with doctors,Communication key,Is the patient to cognitive logically consistent,But the doctor should encourage this practice.

　　我的医生朋友在和魏晰的沟通中显然没有做好这一点。但是看在他半天门诊要看四五十个病人的份儿上，我也不得不谅解他的“不够意思”。况且，如果不是看在我的面子上，魏晰要想挂上这位知名医生的专家号都很困难。

My doctor friend in and WeiXi communication obviously didn't make it.But look at his half clinic to see the love of odd change patients,I also have to understand his"Not enough meaning".besides,If not look in my face,WeiXi to hang the famous doctor's ZhuanGuHao is very difficult.

　　大夫也有大夫的牢骚。在一个私下的场合，我的这位骨科医生朋友说，“一般老百姓只想碰到好医生，但是，你是一个好病人吗？ ”(文/ 安然)

The doctor also have the doctor's complaints.In a private occasion,My friend said the orthopaedic surgeon,"Common people want to meet a good doctor,but,You are a good patient? "(Text/enron)