The Bias behind Your Undiagnosed Chronic Pain | Sheetal DeCaria | TED

翻译人员: Yin Wu 校对人员: Yan Li Xiao

As a doctor in the field of pain management,

作为疼痛管理领域 （麻醉科）的医生，

I work in a world where you bring us your pain

在我的世界里，你作为患者来到 我们的诊室，陈述你的疼痛症状，

and we treat it.

然后我们给你治疗。

We ask questions,

我们提出问题，

we take the symptoms you present,

我们了解你出现的症状，

we decide what tests to run.

我们决定进行哪些检查。

We listen with compassion and wisdom

我们带着同情和智慧倾听你，

and choose the best course of action

并基于我们的知识和经验， 结合科学考量，

based on our knowledge and experience combined with science.

为你选择最佳的治疗方案。

And sometimes in a very small window of time.

有时这一切都发生在很短的时间里。

As physicians, we took a sacred oath to do no harm.

作为医生，我们发下神圣誓言： 绝不伤害他人。

And the system has gone to great lengths to teach us

这个制度不遗余力地 教育和指导我们，

and set up guidelines to make sure that we treat every patient equally

以确保我们平等地对待每一位患者， 不掺杂个人情感。

and without judgment.

As we stand there in your moment of pain,

我们直面你的痛苦，

we run your situation through every filter we have

针对你的病情考虑 每一个可能的治疗手段

to give you the best care.

来给你最好的治疗。

And for most of us,

对于我们中的大多数来说，

this is more than just a job.

这不仅仅是一份工作，

It's a calling.

这是一种使命感。

But as we stand there in your moment,

但当我们设身处地地为患者着想时，

looking at your story from all the different angles

我们会从各个角度了解你的情况，

and all the different rational voices in our head

各种合理的方案 从我们的脑海中涌现出来，

run through the decision making process,

帮助我们最终做出决策，

there's another voice in the mix.

但在这一过程中， 另一种观念也参与了进来。

And this voice,

而这种观念，

well, it isn't rational or informed.

它既不理性也不明智，

Yet, it often dictates our decisions.

然而，它常常影响着我们的决策。

And we don't give it a second thought

我们从来没有考虑过这个问题，

because you see,

因为你看，这个观念早在我们 开始学习医学之前就存在了，

this voice existed long before we began studying medicine.

And so we accept it as truth.

所以我们已经把它当作事实接受了，

And this voice sometimes calls the shots.

而且这种观念 有时会主宰我们的决策。

It's what I refer to as the undiagnosed bias.

这就是我所说的“未确诊的偏见”。

And it's causing suffering and death for many with chronic pain.

它导致了许多慢性 疼痛患者的痛苦和死亡。

I have spent the last 15 years studying pain.

在过去的 15 年里， 我一直在研究疼痛：

Its cause, its treatment and its management.

它的成因、治疗方法和控制手段。

But it wasn't until I found myself sitting on the other side of the exam room

但直到我自己 坐在检查室的另一端时，

that I noticed the crack in the foundation of pain management.

我才意识到疼痛管理领域 存在的根本性的问题，

When I discovered that hidden voice that exists in all of us.

我才第一次发现了那个存在于 我们每个人心中的固有观念。

That hidden voice, which I termed the undiagnosed bias,

我将这个固有观念 称为“未确诊的偏见”，

is more commonly known as implicit bias,

通常它也被称作固有偏见，

which is a bias that exists based on our unconscious beliefs and associations.

这是一种基于 我们无意识的看法和联想而产生的偏见。

Implicit bias in health care was brought to light in 2003,

2003 年，当医学研究所发表了一份 题为“不平等的治疗”的报告时，

when the Institute of Medicine published a report titled "Unequal Treatment."

医疗行业中的 固有偏见被暴露了出来。

They found that regardless of insurance and income status,

他们发现，无论患者的医疗保险 和收入状况如何，

racial and ethnic minorities received worse care.

少数种族和少数族裔 得到的护理都更差。

And when it comes to pain,

当涉及疼痛时，

research shows that bias extends beyond minorities

研究表明这一偏见 并不局限于少数族裔，

to also include women and even children.

还包括妇女甚至儿童。

Dr. Susan Moore was a Black female physician

苏珊·摩尔博士是一位黑人女医生，

whose story was heard around the world in 2020.

她的故事在 2020 年 传遍了世界各地。

The story of a doctor who struggled to receive the care she knew she needed.

作为一名医生，她知道自己需要何种治疗， 但她却要拼尽全力才能获取这一治疗。

Her pain was due to a health issue that she fully understood

她清楚地知道 是什么健康问题导致了她的疼痛，

and described in medical lingo to her doctors.

并用医学术语向她的医生描述了，

Yet her pain was dismissed.

但她的疼痛却被忽视了。

When she posted her experience to a group of thousands of fellow physicians,

当她把她的经历发布到一个 有着数千名医生同行的群组中时，

there was an uproar of support.

响起了一片支持之声。

I mean, no one could accept that a doctor would treat a patient,

你懂的，没有人能够 接受一名医生基于患者的相貌，

let alone a fellow colleague like this,

就这样去对待一名患者，

更不用说这样 去对待一名医生同行了。

simply based on how they look.

But that's the problem with implicit bias.

但这就是固有偏见带来的问题。

Most of the time you are unaware you even have it.

大多数时候， 你甚至都意识不到你也有着这种偏见。

I remember the year I went from doctor to patient.

我记得我从医生 变成了患者的那一年。

It started off as a small pain in my foot that just wouldn't go away.

一开始我只是感到脚上有点痛， 怎么都不能缓解，

Well, it grew worse,

接着，疼痛变严重了，

to the point that it overshadowed my life.

甚至使我的生活都变得暗淡了。

It was this constant companion affecting my work and my family life.

这个无时无刻存在着的“伙伴” 影响了我的工作和家庭生活。

I finally went to go see a foot surgeon and was told,

最终我决定去看一位足外科医生，

他告诉我：“疼痛原因不明，

"Source not clear.

Probably tendons were inflamed," he said.

可能是肌腱发炎了。”

And he prescribed a boot and some physical therapy.

他推荐我使用一种 治疗用的靴子和一些物理疗法。

But the pain worsened, and it spread to my hip and my back.

但疼痛依旧在加剧， 并扩散到了我的臀部和背部。

I sought out more medical specialists, even holistic practitioners,

我向更多的医学专家， 甚至是整体治疗师求助，

all with different theories,

他们都有不同的理论，

but no clear diagnosis or source of pain.

但没有人能给出明确的诊断 或指出疼痛的来源。

I began to feel like I was going to have to live with this forever.

我开始觉得 我将不得不永远忍受这种疼痛。

And as the pain kept progressing with no clear diagnosis,

在没有明确诊断而疼痛 仍不断加剧的情况下，

I even thought to myself,

我甚至开始反问自己：

"Wait.

“等等，这是我编造的吗？ 我的疼痛是真的吗？”

Am I making this up?

Is my pain even real?"

In an online survey of 2,400 American women

在对 2400 名有着各种慢性疼痛疾病的 美国女性进行的在线调查中，

with a variety of chronic pain conditions,

91 percent felt that the health care system

91% 的人认为医疗系统歧视她们，

discriminated against them.

And nearly half were told that the pain was all in their heads.

近一半的人被告知， 这些疼痛都是她们脑海中的幻觉。

So let's go ahead and dispel that pain myth right away.

那么，让我们现在 就去消除这个有关疼痛的错误观点。

If you're worried that your pain is in your head,

如果你担心你的疼痛 是在你的脑子里，

you're right.

你是对的，

Because pain is in everyone's heads.

因为疼痛是在每个人的脑子里。

You see, pain can't take place without our brains.

你看，没有我们的大脑， 我们不会感觉到疼痛。

When you step on a nail, for example,

例如，当你踩到钉子时，

you stimulate nociceptors, or specialized nerve cells,

你的伤害感受器 或专门的神经细胞被激活，

that send a message through your spinal cord to your brain.

它们会通过脊髓向大脑发送信息，

Well, your brain then decides what it's going to do with that signal.

然后你的大脑 会决定如何去处理这个信号。

If it senses something dangerous,

如果它感觉到有危险，

it will process that experience as painful

它会将这个经历编码为疼痛，

to prevent you from further injury.

以防你受到进一步的伤害。

And the decision by the brain to process it as painful

大脑是否决定将其编码为疼痛， 取决于很多因素：

is based on environmental and social cues

环境和社会暗示、文化、 以及一个人过往的经历。

as well as by culture

and one's past experiences.

Now, contrary to popular belief,

现在，与流行的看法相反，

not all pain is related to tissue damage.

并非所有的疼痛 都与身体组织的损伤有关。

Pain is actually defined

疼痛实际上被定义为 一种不愉快的感官和情绪体验，

as an unpleasant sensory and emotional experience

that can be associated with actual

这可能与实际的 或潜在的组织损伤有关。

or potential tissue damage.

You can have real pain

你可以在没有身体伤害或诱因的 情况下感受到真正的疼痛。

with no physical injury

or source.

Pain is the one thing that can't be measured

疼痛是一个无法 用仪器或化验测量的东西，

by a monitor or lab test.

It's hard to quantify or qualify.

也很难被量化或限定。

It's measured on a scale of zero to 10

我们通常用一个 从 0 到 10 的等级衡量疼痛，

that is based on one's own perception of what they're experiencing.

而这基于人们 对他们经历的事情的主观感知。

Pain, then, is subjective.

所以，疼痛是主观的。

And as doctors,

作为医生，

our process of treating pain begins with identifying its source.

我们治疗疼痛的过程 从确定疼痛的来源开始。

Which presents a problem when there is no source.

当没有来源时， 就会出现如下的问题。

For when there's no source, it becomes open to interpretation.

因为当没有来源的时候， 疼痛就可以被任意解释，

And interpretation becomes open to that undiagnosed bias.

而我们的解释 就会被“未确诊的偏见”所影响。

Did you know that the different sexes experience pain differently?

你知道不同性别 对疼痛的体验是不同的吗？

Now, for the sake of this talk, when I say female versus male,

在这个演讲中，当我说女性或男性时， 我指的是人出生时的性别；

I'm referencing sex assigned at birth.

And when I say woman versus man or non-binary,

而当我说女人、男人或非二元性别时， 我指的是那个人的性别认同。

then gender identity is at the core of the point.

Females have more nerve fibers than men,

女性比男性拥有更多的神经纤维，

and there's a hormonal influence to a variety of chronic pain conditions.

而且荷尔蒙 会影响各种慢性疼痛病症。

At puberty, rates of chronic pain rise faster in girls than boys.

在青春期，女孩的慢性疼痛概率 比男孩上升得更快。

And as females approach menopause,

随着女性接近更年期，

sex differences in chronic pain begin to disappear.

慢性疼痛的性别差异开始消失。

Females experience more recurrent pain, longer-lasting pain

与男性相比，女性经历了更多的 复发性疼痛和更持久的疼痛，

and higher overall levels of chronic pain than men.

以及更高的慢性疼痛总体水平。

Yet the majority of studies on the treatment of chronic pain

然而，大多数 关于慢性疼痛治疗的研究

have only been conducted in men.

只在男性身上进行过。

Did you know that women are more likely than men

你知道吗， 当人们来到急诊科陈述剧烈腹痛时，

to be given anti-anxiety medications instead of painkillers

when they present to the emergency department

女性比男性更有可能 被给予抗焦虑药物而不是止痛药？

complaining of severe abdominal pain?

Even for extremely urgent conditions

即使对于极其紧急的状况，

such as chest pain from a heart attack,

如心脏病发作引起的胸痛，

women experience delays in life saving-interventions

女性也会更迟地得到 能够预防死亡的急救干预。

that can prevent death.

Research shows that clinicians more often suggest psychosocial causes

研究表明， 对于感到疼痛的女性患者，

临床医生更经常将疼痛归因于 社会心理因素，例如压力或家庭问题；

such as stress or family problems to women patients in pain

when they would more often order lab tests

而对于有着 完全相同的症状的男性患者，

for a male patient with the exact same symptoms.

他们经常会进行更多的化验。

For Black women such as Dr. Moore, they suffer two blows.

对于像摩尔医生这样的黑人女性， 她们遭受到了双重打击。

The insulting notion that they are overdramatic

因为她是女性，人们颇具 侮辱性地认为她反应过于夸张；

due to their gender,

along with the erroneous view that because their skin is Black,

与此同时，因为她有着黑色的皮肤， 人们错误地认为她并不会感受到疼痛。

they are impervious to pain.

2016 年的一项研究发现，

A 2016 study of a group of medical students found that nearly half believed

近一半的医学生 认为黑人的皮肤比白人更厚，

Black people have thicker skin than white people,

less sensitive nerve endings,

神经末梢敏感性较低，

or that their blood clots more quickly.

或者他们的血液凝结得更快。

The origin of these outrageous claims dates back to slavery

这些骇人说法的起源 可以追溯到奴隶制

and the 19th century experiments by Dr. Thomas Hamilton,

和 19 世纪 托马斯·汉密尔顿博士的实验：

who tortured Black slaves

他折磨黑人奴隶，

to prove that Black skin was deeper than white skin.

以此来证明黑人的皮肤比白人的更厚。

And Dr. James Sims, a gynecologist,

妇科医生詹姆斯·西姆斯

conducted experimental surgeries

在没有麻醉的情况下对 女性黑人奴隶进行了实验性手术——

on enslaved Black women without anesthesia,

contributing further to false beliefs

这进一步助长了错误的观念，

that Black women experience less pain.

即黑人女性会感受到较少的疼痛。

There were times that I found it ironic

有时我会发现这一切很有讽刺意味：

that as an anesthesiologist,

作为一名麻醉科医生，

whose livelihood is centered around managing pain,

一个将毕生精力 投入疼痛管理领域的人，

that I would suffer from chronic pain myself.

我自己也会受到慢性疼痛的困扰。

And so, like Dr. Moore, I became my own advocate

于是，像摩尔医生一样， 我成为了我自己的拥护者，

and dove deep into the root causes of my own pain.

并深入研究了我的疼痛的根源。

After five years, thousands of dollars and many hours spent in pain,

花费了五年时间， 数千美元和许多小时的疼痛，

I finally found the cause by diving into integrative and functional medicine.

我通过深入了解综合和机能医学， 终于找到了我的疼痛的原因。

Now my pain was due to physical imbalances triggered by childbirth,

我的疼痛来源于分娩引发的身体失衡，

years of stress and sleep deprivation,

多年的压力和睡眠短缺，

and a dietary sensitivity that had been triggering inflammation.

以及饮食敏感性引发的炎症。

Over time, I healed myself.

随着时间的推移， 我走上了自愈之路，

And finally, the pain began to ease.

最后，疼痛开始减轻。

But while my own pain did fade,

但是，虽然我自己的疼痛确实消退了，

my passion for other people with chronic pain grew stronger.

但我对其他慢性疼痛患者 的热情却越来越强烈。

Now doctors aren't the enemy.

我们知道，医生不是敌人。

If you ask physicians why they went into medicine,

如果你问医生他们为什么学医，

you would hear "to help people."

你总会听到“为了帮助别人”。

So much so, that during disasters and global pandemics,

在灾难和全球流行病期间， 我们一次又一次地目睹，

health care workers kiss their own families goodbye

医护人员与自己的家人深情告别，

to go take care of yours.

全心全意地去照顾你的家人。

They work tirelessly during codes to resuscitate your loved ones

他们在急救时刻不知疲倦地工作， 尽力使你爱的人苏醒过来，

and shed tears when they lose them.

也在患者去世时伤心流泪。

But with exhaustion, time pressures and overcrowded emergency rooms

但由于疲惫、 时间压力和人满为患的急诊室，

comes the ability for that hidden voice to take over our rational one.

那种固有观念 就可能会取代我们理性的决策。

Now the health care system has been teaching bias training,

现在，医疗系统一直 在对我们进行反偏见的培训，

and studies show little to no explicit bias in health care, which is great,

令人欣慰的是，研究表明 在医疗领域几乎没有明显的偏见，

but we continue to see implicit bias

但我们依然看到一定比例的 医疗行业从业者有着固有偏见。

in a percentage of health care practitioners.

Because it operates in an unintentional and unconscious manner,

因为它以一种无意 和无意识的方式存在，

implicit bias begins outside the walls of the hospital

固有偏见在医院之外产生，

and is brought in unknowingly.

并在不知不觉中蔓延到医院内部。

And it's not just doctors.

不仅仅是医生，

Bias exists in all of us.

我们每个人都有偏见，

We can all do better.

而我们都可以做得更好。

How?

要怎么做呢？

Well, the first step is awareness.

首先是要意识到偏见的存在。

We need to begin by identifying our stereotypes.

我们需要从发现 我们心中的刻板印象开始，

And then rewrite the stories of the people we meet.

然后重新书写我们遇到的人们的故事。

When a woman sits down next to us, ask ourselves:

当一个女人坐在我们旁边时， 问问自己：

What would we say if this were a man?

如果这是一个男人，我们会说什么？

Would our answer change?

我们的答案会改变吗？

And for those whose pain has been dismissed, fight to be heard.

对于有些患者来说， 他们的疼痛总是被忽视，

他们努力使自己的声音被听到，

Finding the right doctor can feel a little bit like dating.

他们找到合适的医生 就有点像是在约会。

You may need to swipe through a few to find the right one for you.

你可能需要尝试 好几个才能找到适合你的那个。

(Laughter)

（笑声）

But don't give up.

但不要放弃，

And don't delay seeking treatment.

也不要拖延寻求治疗。

The sooner you are properly diagnosed,

你越早得到正确的诊断，

the greater chance you have of breaking your pain cycle.

你越有可能结束这个痛苦的循环。

As physicians, we took an oath at our white coat ceremonies

作为医生， 我们在白大褂授予仪式上宣誓：

to first do no harm.

首先绝不伤害他人。

And most of us live by that sacred oath.

我们中的大多数 都信守着那神圣的誓言。

But part of that vow needs to include staying in check with that inner voice

但是，为了坚守誓言， 我们需要时时审视自己内心的声音，

to make sure that we aren't writing a story

以确保我们不会 在患者还没有告知我们病情之前，

that our patients haven't told us yet.

就擅自为他们写好了剧本。

Because it is our duty as physicians

因为作为医生，

to replace the undiagnosed bias with empathy.

我们有责任用同理心取代 “未确诊的偏见”。

And to all of you out there who are suffering with chronic pain,

对于所有的慢性疼痛患者，

we hear you.

我们听见了你们的声音，

And we're ready to listen.

而我们也会继续倾听。

Thank you.

谢谢各位。

(Applause)

（掌声）