A doctor's case for medical marijuana | David Casarett

翻译人员: Wenyu Liu 校对人员: Lipeng Chen

I would like to tell you about the most embarrassing thing

我想要告诉你们 在我作为饱受疗法医生的许多年里，

that has ever happened to me in my years of working as a palliative care physician.

所发生过的最尴尬的事。

This happened a couple of years ago.

这发生在数年前，

I was asked as a consultant to see a woman in her 70s --

我受邀去会诊一位70高龄的女士。

retired English professor who had pancreatic cancer.

她是一位退休的英语教授 并患胰腺癌。

I was asked to see her because she had pain, nausea, vomiting ...

我受邀去看她， 因为她感到疼痛、恶心、呕吐...

When I went to see her, we talked about those symptoms

当我去看她时， 我们讨论了这些症状，

and in the course of that consultation,

在会诊的过程中，

she asked me whether I thought that medical marijuana might help her.

她问我是否觉得医用大麻能帮到她。

I thought back to everything

我回想在医学院里学到的

that I had learned in medical school about medical marijuana,

有关医用大麻的任何东西，

which didn't take very long because I had learned absolutely nothing.

这并没有花费我多长时间 因为我完全没学到什么东西。

And so I told her that as far as I knew,

所以我告诉她，据我所知，

medical marijuana had no benefits whatsoever.

医用大麻没有一点好处。

And she smiled and nodded and reached into the handbag next to the bed,

然后她微笑，点点头， 把手伸到了床边的手提包里，

and pulled out a stack of about a dozen randomized controlled trials

掏出了一叠大概十多个 随机对照实验的记录，

showing that medical marijuana has benefits

这些实验显示医用大麻对于诸如

for symptoms like nausea and pain and anxiety.

恶心、疼痛和焦虑 这样的症状有一定好处。

She handed me those articles and said,

她递给我这些文章，然后说，

"Maybe you should read these before offering an opinion ...

“在你发表意见之前 也许你应该读下这些文章...

doctor."

医生。”

(Laughter)

（观众笑声）

So I did.

所以我这样做了。

That night I read all of those articles and found a bunch more.

那天晚上我读完了那些文章， 同时也找到了更多的文章。

When I came to see her the next morning,

当我后一天去看她的时候，

I had to admit that it looks like there is some evidence

我必须承认 看起来是有些证据表明

that marijuana can offer medical benefits

大麻具有医疗效益。

and I suggested that if she really was interested,

然后我建议她， 如果真的感兴趣的话，

she should try it.

她应该去试一下。

You know what she said?

你知道她回答的什么吗？

This 73-year-old, retired English professor?

这位73岁的老太太， 退休的英语教授？

She said, "I did try it about six months ago.

她说我大约 六个月前就试过了，

It was amazing.

这种感觉太棒了。

I've been using it every day since.

此后我每天都抽一点。

It's the best drug I've discovered.

这是我发现的最好的药物。

I don't know why it took me 73 years to discover this stuff. It's amazing."

我不知道为什么自己73岁 才发现它，这实在太棒了。

(Laughter)

（笑声）

That was the moment at which I realized

在那一瞬间，我意识到

I needed to learn something about medical marijuana

我需要了解一下有关医用大麻的信息，

because what I was prepared for in medical school

因为我在医学院学到的东西

bore no relationship to reality.

与现实毫无联系。

So I started reading more articles, I started talking to researchers,

所以我开始阅读更多文章， 开始与研究人员交流，

I started talking to doctors,

我开始与医生交流，

and most importantly, I started listening to patients.

但最重要的是 我开始倾听病人的意见。

I ended up writing a book based on those conversations,

最后我基于这些对话写了一本书，

and that book really revolved around three surprises --

那本书实际上围绕着三个令人惊讶的点——

surprises to me, anyway.

总之这些东西对我来说很惊奇。

One I already alluded to --

一是我已经提到过的，

that there really are some benefits to medical marijuana.

医用大麻确实有一些优点存在。

Those benefits may not be as huge or as stunning

这些优点也许 没有那些医用大麻的热切拥护者

as some of the most avid proponents of medical marijuana

想要我们相信的那样

would have us believe,

效果显著，

but they are real.

但是这些优点确实存在。

Surprise number two:

第二点是：

medical marijuana does have some risks.

医用大麻确实有一些风险。

Those risks may not be as huge and as scary

这些风险也没有 那些反对者想要我们相信的那样

as some of the opponents of medical marijuana would have us believe,

危害巨大，

but they are real risks, nonetheless.

但确实是存在一定危险。

But it was the third surprise that was most ...

但是第三点是

surprising.

最令人意外的。

And that is that a lot of the patients I talked with

很多和我交谈过的

who've turned to medical marijuana for help,

曾经求助于医用大麻的患者，

weren't turning to medical marijuana because of its benefits

并不是因为医用大麻的效用，

or the balance of risks and benefits,

或者考虑其优点和风险的平衡，

or because they thought it was a wonder drug,

亦或者因为他们以为 这是奇药而求助于它，

but because it gave them control over their illness.

而是因为它能让病人控制他们的疾病。

It let them manage their health

让他们通过一种对他们来说高效的

in a way that was productive and efficient

易看到效果的并且感觉舒服的方式，

and effective and comfortable for them.

来管理自己的健康。

To show you what I mean, let me tell you about another patient.

为了让你理解我想说什么， 我再提一下另一个病人。

我见到罗宾时，她40多岁。

Robin was in her early 40s when I met her.

She looked though like she was in her late 60s.

但是她看起来却快70岁了。

She had suffered from rheumatoid arthritis for the last 20 years,

过去20年里， 她饱受类风湿性关节炎的折磨，

her hands were gnarled by arthritis,

她的手因为关节炎变的扭曲，

her spine was crooked,

并且还有驼背，

she had to rely on a wheelchair to get around.

必须依靠轮椅才能走动。

She looked weak and frail,

她看起来孱弱无力，

and I guess physically she probably was,

我想她的身体上或许确实如此，

but emotionally, cognitively, psychologically,

但是从感情上，认知上和心理上，

she was among the toughest people I've ever met.

她确是我所见过的最坚强的人之一。

And when I sat down next to her

在加州北部的一个医用大麻配药房里，

in a medical marijuana dispensary in Northern California

我坐在她旁边，

to ask her about why she turned to medical marijuana,

问她为什么使用医用大麻，

what it did for her and how it helped her,

它为她提供了什么，并如何帮助到她的。

she started out by telling me things

她开始告诉我一些东西，

that I had heard from many patients before.

一些我以前听许多病人讲述过的东西。

It helped with her anxiety;

它帮助她减轻焦虑；

it helped with her pain;

帮助她减少疼痛；

when her pain was better, she slept better.

当疼痛减轻些，睡眠就好多了。

And I'd heard all that before.

这些东西我都曾经听到过。

But then she said something that I'd never heard before,

但接着她又说了一些我从来没听过的东西，

and that is that it gave her control over her life

她说这能使她掌控自己的生命，

and over her health.

掌控自己的健康。

She could use it when she wanted,

当她想用时就能用，

in the way that she wanted,

并且以她喜欢的方式，

at the dose and frequency that worked for her.

以一种对她有效果的剂量和频次。

And if it didn't work for her, then she could make changes.

如果效果不大，她可以自己做些改变。

Everything was up to her.

一切事都是由她自己决定。

The most important thing she said

她说，最重要的是

was she didn't need anybody else's permission --

她并不需要得到其他人的允许——

not a clinic appointment, not a doctor's prescription,

没有就诊预约，没有医生的药方，

not a pharmacist's order.

没有药剂师的命令。

It was all up to her.

一切由她决定。

She was in control.

她是控制一切的人。

And if that seems like a little thing for somebody with chronic illness,

这似乎对患有慢性病的人来说是一件小事，

但并不是这样，一点也不。

it's not -- not at all.

When we face a chronic serious illness,

当我们面临着严重的慢性疾病，

whether it's rheumatoid arthritis or lupus or cancer or diabetes,

不管是类风湿关节炎，狼疮，癌症，糖尿病，

or cirrhosis,

或者是肝硬化，

we lose control.

我们就失去了掌控。

And note what I said: "when," not "if."

请注意我所说的，“当你得了疾病”，而不是“假设”。

All of us at some point in our lives will face a chronic serious illness

每个人在人生中某个节点都会面临严重的

that causes us to lose control.

我们无法控制的严重慢性疾病，

We'll see our function decline, some of us will see our cognition decline,

我们身体的功能会慢慢衰竭， 甚至有些人的认知能力也会下降，

we'll be no longer able to care for ourselves,

我们不再有能力自己照顾自己，

to do the things that we want to do.

也无法做自己想做的事情。

Our bodies will betray us,

我们的身体会背叛自己，

and in that process, we'll lose control.

在那个过程中， 我们将失去对自己身体的掌控。

And that's scary.

这非常可怕。

Not just scary -- that's frightening,

不仅是可怕——这令人惊恐，

it's terrifying.

让人吓破了胆。

When I talk to my patients, my palliative care patients,

当我和我使用保守疗法的病人交流时，

many of whom are facing illnesses that will end their lives,

他们许多人正面临着绝症，

they have a lot of be frightened of --

他们有很多感到害怕的东西——

pain, nausea, vomiting, constipation, fatigue,

疼痛，恶心，呕吐，便秘，疲乏，

their impending mortality.

以及迫近的死亡。

But what scares them more than anything else

但令他们更害怕的是，

is this possibility that at some point,

在某一刻，

tomorrow or a month from now,

明天，或者一个月后，

they're going to lose control of their health,

他们可能会不再能掌控对他们自己的健康，

of their lives,

自己的生活，

of their healthcare,

自己的医疗情况，

and they're going to become dependent on others,

他们将不得不依赖于其他人，

and that's terrifying.

这才是最恐怖的地方。

So it's no wonder really that patients like Robin,

所以不难想象为什么很多患者都像

who I just told you about,

那个我刚刚提到的

who I met in that clinic,

在小诊所遇到的罗宾一样，

turn to medical marijuana

会求助于医用大麻，

to try to claw back some semblance of control.

并尝试去夺回一些虚假的控制感。

How do they do it though?

那他们是如何做到的呢？

How do these medical marijuana dispensaries --

那些像我遇到罗宾的小诊所一样的

like the one where I met Robin --

提供医用大麻的药房，

how do they give patients like Robin back the sort of control that they need?

是如何提供给和罗宾一样的病人 以所需的控制感的？

And how do they do it

他们是通过什么方式做到的，

in a way that mainstream medical hospitals and clinics,

至少对罗宾来说，

at least for Robin, weren't able to?

主流药物医院和诊所都无法做到的东西？

What's their secret?

他们的秘密是什么？

So I decided to find out.

我决定去找出来。

I went to a seedy clinic in Venice Beach in California

我去了加州威尼斯滩的一个破旧的诊所，

and got a recommendation

并拿到了推荐信，

that would allow me to be a medical marijuana patient.

这会让我佯装一个使用医用大麻的病人。

I got a letter of recommendation that would let me buy medical marijuana.

我拿到了允许我购买医用大麻的推荐信。

I got that recommendation illegally,

我非法地拿到了那封信，

because I'm not a resident of California --

因为我不是加利福尼亚的居民——

I should note that.

我应该说明这件事情。

I should also note, for the record,

为了说清楚，我也应该说明，

that I never used that letter of recommendation to make a purchase,

我从来没有用那封建议信购买任何东西，

and to all of you DEA agents out there --

这是向缉毒局的人员说的——

(Laughter)

（笑声）

love the work that you're doing,

支持你们的工作，

keep it up.

继续努力。

(Laughter)

Even though it didn't let me make a purchase though,

（笑声）

尽管这不能让我购买东西，

that letter was priceless because it let me be a patient.

它仍是无价的， 因为这让我成为了一位病人。

It let me experience what patients like Robin experience

这让我经历到当像罗宾那样的病人，

when they go to a medical marijuana dispensary.

去医用大麻药房里时所经历的东西。

And what I experienced --

然后我所经历到的——

what they experience every day,

他们每天所经历的，

hundreds of thousands of people like Robin --

成百上千像罗宾一样的人所经历的——

was really amazing.

很让人惊奇。

I walked into the clinic,

我走进了小诊所，

and from the moment that I entered many of these clinics and dispensaries,

当我走进许多这样的诊所或药房的那一刻，

I felt like that dispensary, that clinic,

我就感觉到，那个药房，那个诊所

was there for me.

一直等待着我。

There were questions at the outset about who I am,

开始就问些关于我是谁，

what kind of work I do,

我做什么样的工作，

what my goals are in looking for a medical marijuana prescription,

我寻求医用大麻配方或者产品

or product,

的目的是什么，

what my goals are, what my preferences are,

我的目标是什么，我有什么偏好，

what my hopes are,

我的期望是什么，

how do I think, how do I hope this might help me,

我是怎么想的，我希望这能如何帮到自己，

what am I afraid of.

我害怕什么。

These are the sorts of questions

这类问题是像罗宾那样的患者

that patients like Robin get asked all the time.

一直被问的问题。

These are the sorts of questions that make me confident

这类问题使我确信

that the person I'm talking with really has my best interests at heart

和我谈话的人从心底考虑了我的利益，

and wants to get to know me.

并且想要了解我。

The second thing I learned in those clinics

我从这些诊所中所学到的第二件事是，

is the availability of education.

教育的可得性。

Education from the folks behind the counter,

柜台后面的人们提供的教育

but also education from folks in the waiting room.

和候诊室的人们提供的教育。

People I met were more than happy, as I was sitting next to them --

当我坐在他们旁边时，他们都非常高兴——

people like Robin --

像罗宾一样的人——

to tell me about who they are, why they use medical marijuana,

告诉我他们是谁，为什么使用医用大麻，

what helps them, how it helps them,

什么帮助了他们，是如何帮助的他们，

and to give me advice and suggestions.

并给我一些忠告和建议。

Those waiting rooms really are a hive of interaction, advice and support.

那些会诊室是充满互动 建议和支持的热闹场所。

And third, the folks behind the counter.

第三，柜台后的人们。

I was amazed at how willing those people were

我很惊讶这些人为何乐意去花一个小时

to spend sometimes an hour or more talking me through the nuances

或者更多时间去教我分辨，

of this strain versus that strain,

这种拉伤与另一种拉伤，

smoking versus vaporizing,

烟熏和蒸汽，

edibles versus tinctures --

食用品和酊剂的细微差别——

all, remember, without me making any purchase whatsoever.

请记住，我还没有购买任何东西。

Think about the last time you went to any hospital or clinic

回想一下你最后一次去医院或诊所，

and the last time anybody spent an hour explaining those sorts of things to you.

最后一次有人花一小时时间 对你解释这类事物。

The fact that patients like Robin are going to these clinics,

和罗宾一样的病人都去这些诊所，

are going to these dispensaries

去这些药房，

and getting that sort of personalized attention

得到的那些个人关注，

and education and service,

教育和服务，

really should be a wake-up call to the healthcare system.

这些事情应该成为现存医疗制度的警钟。

People like Robin are turning away from mainstream medicine,

像罗宾一样的人正远离主流医药救助，

turning to medical marijuana dispensaries

而转向医用大麻配药室，

because those dispensaries are giving them what they need.

因为这些药房给了他们所需要的东西。

If that's a wake-up call to the medical establishment,

如果这是对医疗机构的警钟，

it's a wake-up call that many of my colleagues are either not hearing

这是对我那些要么不倾听

or not wanting to hear.

要么不想听的同事们的警钟。

When I talk to my colleagues, physicians in particular,

当我和同事们 特别是内科医生

about medical marijuana,

讨论医用大麻时，

they say, "Oh, we need more evidence.

他们说，“喔，我们需要更多的证据。

We need more research into benefits, we need more evidence about risks."

我们需要对其益处和风险 做更多的调查获得更多的证据。”

And you know what? They're right.

你知道吗？他们是对的。

They're absolutely right.

他们完全正确。

We do need much more evidence about the benefits of medical marijuana.

针对医用大麻的好处， 我们确实需要更多证据。

We also need to ask the federal government to reschedule marijuana to Schedule II,

我们同样需要请求联邦政府 把大麻重新定义为二类药，

or to deschedule it entirely to make that research possible.

或者完全取消这类药， 让这种研究成为可能。

We also need more research into medical marijuana's risks.

我们同样需要对医用大麻的风险 做更多研究。

Medical marijuana's risks --

医用大麻的风险——

we know a lot about the risks of recreational use,

我们熟知大麻娱乐性用途的危害，

we know next to nothing about the risks of medical marijuana.

但我们几乎不了解医用大麻的风险。

So we absolutely do need research,

所以我们确实需要做调查研究，

but to say that we need research

但是要是说，我们需要做研究，

and not that we need to make any changes now

但我们现在不需要做出任何改变，

is to miss the point entirely.

就完全错失了重点了。

People like Robin aren't seeking out medical marijuana

像罗宾那样的人寻求医用大麻，

because they think it's a wonder drug,

并不是因为他们认为这是特效药，

or because they think it's entirely risk-free.

或者他们认为这完全没有风险，

They seek it out because the context in which it's delivered and administered

他们寻求它是因为，其递送、管理和使用

and used,

的环境，

gives them the sort of control they need over their lives.

给了他们一种所需要的 对于生活的掌控，

And that's a wake-up call we really need to pay attention to.

这才是我们需要注意的地方。

The good news though is that there are lessons we can learn today

好消息是那些医用大麻配药房身上，

from those medical marijuana dispensaries.

有我们现在可以学到的东西。

And those are lessons we really should learn.

那些我们真的应该学习的东西。

These are often small, mom-and-pop operations

那些诊所通常非常小，家庭经营，

run by people with no medical training.

由没有受过医疗训练的人来运营，

And while it's embarrassing to think

同时这是非常难堪的去考虑

that many of these clinics and dispensaries are providing services

许多这样的小诊所和药房提供的服务

and support and meeting patients' needs

和支持以及患者需要的满足，

in ways that billion-dollar healthcare systems aren't --

是有着十亿美金的 健康保障体系所没有提供的——

we should be embarrassed by that --

我们真应该感到难堪——

but we can also learn from that.

但我们仍能从中学到东西。

And there are probably three lessons at least

从那些小药房中，我们至少

that we can learn from those small dispensaries.

可以学到三个教训。

One: we need to find ways to give patients more control

一、我们需要找出给予病人 更多控制感的方式，

in small but important ways.

比较微小但又非常重要的方式。

How to interact with healthcare providers,

怎样与医疗保健提供者互动，

when to interact with healthcare providers,

什么时候与医疗保健者互动，

how to use medications in ways that work for them.

怎样以对他们有效的方式使用药物。

In my own practice,

以我的自身实践来说，

I've gotten much more creative and flexible

在支持我病人安全地使用药物

in supporting my patients in using drugs safely

去控制其症状方面，

to manage their symptoms --

我已经很有创造力且比较灵活——

with the emphasis on safely.

其重点是安全。

Many of the drugs I prescribe are drugs like opioids or benzodiazepines

我开出的药方很多都是阿片类 或苯二氮平类药物，

which can be dangerous if overused.

如果滥用将会非常危险。

But here's the point.

重点来了。

They can be dangerous if they're overused,

如果它们被滥用，将会变得危险，

but they can also be ineffective if they're not used in a way

但如果没按照病人想要并需要的方式使用，

that's consistent with what patients want and need.

它们将会失效。

So that flexibility, if it's delivered safely,

所以那种灵活性， 如果安全地使用药物，

can be extraordinarily valuable for patients and their families.

会对病人和他的家庭格外有价值。

That's number one.

这是第一点。

Number two: education.

第二点，教育。

Huge opportunities

这是一个大大的机会

to learn from some of the tricks of those medical marijuana dispensaries

去学习这些医用大麻药房的技巧，

to provide more education

去提供更多的

that doesn't require a lot of physician time necessarily,

不要求大量必需的

or any physician time,

或任何的医师时间的教育，

but opportunities to learn about what medications we're using

这是去了解我们正在使用何种药物，

and why,

为什么要用，

prognoses, trajectories of illness,

以及疾病的预示和轨迹的机会，

and most importantly,

最重要的是，

opportunities for patients to learn from each other.

对患者来说这也是彼此间互相学习的机会。

How can we replicate what goes on

我们怎样才能复制

in those clinic and medical dispensary waiting rooms?

在这些诊所和医药大麻药房等待室里 展现的场景？

How patients learn from each other, how people share with each other.

患者是如何互相学习的， 人们是如何与他人分享的。

And last but not least,

最后却很重要的一点是，

putting patients first the way those medical marijuana dispensaries do,

那些医疗大麻药房 把患者放在第一位，

making patients feel legitimately like what they want,

使患者自然的感觉到 他们想要什么，

what they need,

他们需要什么，

is why, as healthcare providers,

这也是为什么 作为医疗保障提供者，

we're here.

我们在这里的原因。

Asking patients about their hopes, their fears, their goals and preferences.

询问患者他们的希望、 恐惧、目标以及偏好。

As a palliative care provider,

作为一个保守治疗提供者，

I ask all my patients what they're hoping for and what they're afraid of.

我询问我的患者 什么是他们希望的及害怕的。

But here's the thing.

但是问题来了。

Patients shouldn't have to wait until they're chronically seriously ill,

患者不应该一直等待， 直到他们患严重慢性病

often near the end of life,

经常是接近生命尾声的时候，

they shouldn't have to wait until they're seeing a physician like me

他们也不应该一直等待， 直到他们遇到像我一样的医师的时候

before somebody asks them,

才被问到，

"What are you hoping for?"

“你的期望是什么？”

"What are you afraid of?"

“你的恐惧是什么？“

That should be baked into the way that healthcare is delivered.

这应该成为 医疗保健被传递的一种方式。

We can do this --

我们可以做到——

we really can.

我们真的可以。

Medical marijuana dispensaries and clinics all across the country

全美的医用大麻药房和诊所

are figuring this out.

正在尝试弄清楚这个问题。

They're figuring this out

他们通过大的主流健康体系

in ways that larger, more mainstream health systems are years behind.

远远落后于他们的方法解决了这个问题。

But we can learn from them,

但是我们可以从他们身上学习，

and we have to learn from them.

我们也不得不向他们学习。

All we have to do is swallow our pride --

我们所需要做的就是放下我们的骄傲——

put aside the thought for a minute

暂时把傲娇的想法放到一边，

that because we have lots of letters after our name,

因为我们有跟多跟随者，

because we're experts,

因为我们是专家，

because we're chief medical officers of a large healthcare system,

因为我们是主要的卫生保健体系的主要人员，

we know all there is to know about how to meet patients' needs.

我们知道如何满足我们患者的需要。

We need to swallow our pride.

我们需要放下我们的骄傲，

We need to go visit a few medical marijuana dispensaries.

我们需要去参观一些医用大麻药店。

We need to figure out what they're doing.

我们需要去了解他们在做什么。

We need to figure out why so many patients like Robin

我们需要弄清为什么 如此多的像罗宾一样的患者

are leaving our mainstream medical clinics

离开我们主流的医疗诊所，

and going to these medical marijuana dispensaries instead.

而去这些医疗大麻药店。

We need to figure out what their tricks are,

我们需要弄清这些药店的技巧是什么，

what their tools are,

它们的工具是什么，

and we need to learn from them.

并且我们需要向他们学习。

If we do,

如果我们这样做了，

and I think we can, and I absolutely think we have to,

我认为我们能并且绝对是必须这样做，

we can guarantee all of our patients will have a much better experience.

我们可以保证所有的患者 都会有更好的就诊经历。

Thank you.

谢谢大家。

(Applause)

（掌声 .