What the US health care system assumes about you | Mitchell Katz

翻译人员: psjmz mz 校对人员: Jingdan Niu

A few years ago,

几年前，

I was taking care of a woman who was a victim of violence.

我曾接待过一个 遭受暴力对待的女士。

I wanted her to be seen in a clinic that specialized in trauma survivors.

我想让她去专门治疗 创伤幸存者的诊所。

I made the appointment myself because, being the director of the department,

我亲自为她预约， 因为作为这个部门的主管，

I knew if I did it,

我知道如果我去，

she would get an appointment right away.

她会立刻得到预约。

The clinic was about an hour and a half away from where she lived.

诊所离她住的地方大约 有一个半小时的路程。

But she took down the address and agreed to go.

她记住了地址并约定了会去。

Unfortunately, she didn't make it to the clinic.

但遗憾的是，她没有出现。

When I spoke to the psychiatrist, he explained to me

当我和精神病医生谈话时， 他向我解释说，

that trauma survivors are often resistant

创伤幸存者通常拒绝处理

to dealing with the difficult issues that they face

他们遇到的困难，

and often miss appointments.

并常常错过预约。

For this reason,

因为这个原因，

they don't generally allow the doctors to make appointments for the patients.

他们通常不让医生为病人预约。

They had made a special exception for me.

他们特地为我开了绿灯。

When I spoke to my patient,

当我跟我的病人交谈时，

she had a much simpler and less Freudian explanation

她对为什么没能赴约 有个简单得多，

of why she didn't go to that appointment:

而且不那么弗洛伊德式的解释：

her ride didn't show.

带她去的车没出现。

Now, some of you may be thinking,

现在，你们有些人可能在想，

"Didn't she have some other way of getting to that clinic appointment?"

“她没有别的办法去诊所吗？”

Couldn't she have taken an Uber or called another friend?

她不能打个优步或 叫另一个朋友送她去吗？

If you're thinking that,

如果你那样想，

it's probably because you have resources.

这可能是因为你有资源。

But she didn't have enough money for an Uber,

但她并没有足够的钱打优步，

and she didn't have another friend to call.

也没有另一个朋友可以叫。

But she did have me,

但她却有我，

and I was able to get her another appointment,

我能够让她得到另一个预约，

which she kept without difficulty.

并且可以毫不费力地保持。

She wasn't resistant,

她不是不愿意，

it's just that her ride didn't show.

只是她的车没有出现。

I wish I could say that this was an isolated incident,

我希望我能说这是一个孤立的事件，

but I know from running the safety net systems

但我从旧金山、洛杉矶 和现在的纽约市

in San Francisco, Los Angeles, and now New York City,

运行的安全网络系统中知道，

that health care is built on a middle-class model

医疗保健是建立在 中产阶级模式之上的，

that often doesn't meet the needs of low-income patients.

这种模式往往不能满足 低收入患者的需求。

That's one of the reasons why it's been so difficult

这就是为什么我们很难

for us to close the disparity in health care

缩小医疗保健方面存在的

that exists along economic lines,

经济差距的原因之一，

despite the expansion of health insurance

尽管平价医疗法案，也叫奥巴马医改，

under the ACA, or Obamacare.

扩大了医疗保险。

Health care in the United States

美国的医疗保健假设，

assumes that, besides getting across the large land expanse of Los Angeles,

除了可以跨越广阔的洛杉矶，

it also assumes that you can take off from work

它还假设你可以在中午离开工作

in the middle of the day to get care.

去看医生。

One of the patients who came to my East Los Angeles clinic

有个周四的下午，一位病人来到

on a Thursday afternoon

我在东洛杉矶的诊所，

presented with partial blindness in both eyes.

他的双眼出现了部分失明的症状。

Very concerned, I said to him,

我非常担心地对他说，

"When did this develop?"

“这种情况是什么时候出现的？”

He said, "Sunday."

他说，“星期天。”

I said, "Sunday?

我说，“星期天？”

Did you think of coming sooner to clinic?"

你想过早点来诊所吗？”

And he said, "Well, I have to work in order to pay the rent."

他说，“我得工作才能支付租金。”

A second patient to that same clinic,

第二病人来到同样的诊所，

a trucker,

一个卡车司机，

drove three days with a raging infection,

带着严重的感冒开了三天车，

only coming to see me after he had delivered his merchandise.

只能在他交付完货物后才来见我。

Both patients' care was jeopardized by their delays in seeking care.

这两名病人的健康都因 延误求医而受到损害。

Health care in the United States assumes that you speak English

美国的医疗保健假设你会说英语，

or can bring someone with you who can.

或者你可以带一个会说英语的人。

In San Francisco, I took care of a patient on the inpatient service

在旧金山，我在住院部 照顾过一个病人，

who was from West Africa and spoke a dialect so unusual

他来自西非，并且说 一种不常见的方言，

that we could only find one translator on the telephonic line

我们只能在电话系统上 找到一个翻译

who could understand him.

可以听懂他。

And that translator only worked one afternoon a week.

那个翻译一周只工作一个下午。

Unfortunately, my patient needed translation services every day.

遗憾的是，我的病人 每天都需要翻译服务。

Health care in the United States assumes that you are literate.

美国的医疗保健假设你有文化。

I learned that a patient of mine who spoke English without accent

我在一个说地道英语的病人

was illiterate,

请我马上为他签署一份

when he asked me to please sign a social security disability form for him

社会保障残疾表格时，

right away.

才知道他是文盲。

The form needed to go to the office that same day,

表格需要在当天交到办公室，

and I wasn't in clinic,

而我当时不在诊所，

so trying to help him out,

所以为了帮助他解决，

knowing that he was the sole caretaker of his son,

知道他是他儿子的唯一监护人，

I said, "Well, bring the form to my administrative office.

我说，“好吧，把表格带到 我的行政办公室。

I'll sign it and I'll fax it in for you."

我会签字并传真给你。”

He took the two buses to my office,

他坐了两趟公共汽车到我的办公室，

dropped off the form,

留下表格，

went back home to take care of his son ...

回到家照顾他的小孩…

I got to the office, and what did I find next to the big "X" on the form?

我回到办公室，在表格大大 的“X”旁边我发现了什么？

The word "applicant."

写着“申请人”。

He needed to sign the form.

他需要在表格上签字。

And so now I had to have him take the two buses back to the office

所以现在我不得不让他乘坐 两趟公交回到我的办公室，

and sign the form so that we could then fax it in for him.

再签字，这样我们就可以传真给他。

It completely changed how I took care of him.

这完全改变了我关照他的方式。

I made sure that I always went over instructions verbally with him.

我确保我总是和他一起 仔细口头检查指南。

It also made me think about all of the patients

这也让我想起所有的病人，

who receive reams and reams of paper

他们会收到我们现代

spit out by our modern electronic health record systems,

电子健康记录系统吐出的大量文件，

explaining their diagnoses and their treatments,

用于解释他们的诊断和治疗，

and wondering how many people actually can understand

我想知道有多少人能够真正理解

what's on those pieces of paper.

这些纸上写的是什么。

Health care in the United States assumes that you have a working telephone

美国的医疗保健假设你 有一部能用的电话

and an accurate address.

和一个准确的地址。

The proliferation of inexpensive cell phones

廉价手机的普及

has actually helped quite a lot.

确实帮了大忙。

But still, my patients run out of minutes,

但我的病人手机仍然会欠费，

and their phones get disconnected.

然后就联系不上了。

Low-income people often have to move around a lot by necessity.

低收入者经常不得不搬家。

I remember reviewing a chart of a woman with an abnormality on her mammogram.

我记得我看过一个乳房X光检查中 出现异常的女性的图表。

That chart assiduously documents that three letters were sent to her home,

那张图表详细记录了 有三封信已经寄到她家，

asking her to please come in for follow-up.

请她来跟进。

Of course, if the address isn't accurate,

当然，如果这个地址不准确，

it doesn't much matter how many letters you send to that same address.

你寄多少封信过去 那个地址都不重要。

Health care in the United States assumes that you have a steady supply of food.

美国的医疗保健假设 你有稳定的食物供应。

This is particularly an issue for diabetics.

这对糖尿病患者来说尤其是个问题。

We give them medications that lower their blood sugar.

我们给他们药物降低他们的血糖。

On days when they don't have enough food,

在他们没有足够食物的日子里，

it puts them at risk for a life-threatening side effect

这会让他们面临低血糖

of hypoglycemia, or low blood sugar.

或低血糖副作用的生命威胁。

Health care in the United States assumes that you have a home

美国医疗保健假设你家里

with a refrigerator for your insulin,

有冰箱可以储存你的胰岛素，

a bathroom where you can wash up,

有浴室可以洗漱，

a bed where you can sleep

有床可以睡觉，

without worrying about violence while you're resting.

休息时无需担心暴力。

But what if you don't have that?

但如果你没有这些呢？

What if you live on the street,

如果你住在街上，

you live under the freeway,

住在高速公路下面，

you live in a congregant shelter,

或者住在集体避难所，

where every morning you have to leave at 7 or 8am?

并且每天早上7点或8点 就必须离开哪里呢？

Where do you store your medicines?

你在哪里储存你的药物？

Where do you use the bathroom?

你在哪里使用你的浴室？

How do you put your legs up if you have congestive heart failure?

如果你有充血性心力衰竭， 你怎么抬腿？

Is it any wonder that providing people with health insurance who are homeless

为无家可归者提供医疗保险 并没有消除他们

does not erase the huge disparity

和被安置者之间的巨大差距，

between the homeless and the housed?

这有什么奇怪的吗？

Health care in the United States assumes that you prioritize your health care.

美国医疗保险假设你以看病为重。

But what about all of you?

但你们所有人呢？

Let me assume for a moment that you're all taking a medication.

让我假设一个场景， 你们都需要服药。

Maybe it's for high blood pressure.

也许是为了治疗高血压。

Maybe it's for diabetes or depression.

也许是为了治疗糖尿病和抑郁症。

What if tonight you had a choice:

如果你今晚有个选择：

you could have your medication but live on the street,

你可以服药，但要生活在街上，

or you could be housed in your home but not have your medication.

或者你可以住在家中，但不能服药。

Which would you choose?

你会怎么选？

I know which one I would choose.

我知道我会选择哪个。

This is just a graphic example of the kinds of choices

这就是低收入病人每天

that low-income patients have to make every day.

面临选择的一个例子。

So when my doctors shake their heads and say,

所以当我的医生摇头并说，

"I don't know why that patient didn't keep his follow-up appointments,"

“我不知道为什么那个病人 没有遵守他的跟进预约，”

"I don't know why she didn't go for that exam that I ordered,"

“我不知道为什么 他没来参与我预定的检查，”

I think, well, maybe her ride didn't show,

我想，可能是因为他的车没有出现，

or maybe he had to work.

或者他不得不工作。

But also, maybe there was something more important that day

但同样，也许那天有 比高血压或结肠镜检查

than their high blood pressure or a screening colonoscopy.

更重要的事情。

Maybe that patient was dealing with an abusive spouse

也许这个病人面对的是 一个有虐待倾向的配偶，

or a daughter who is pregnant and drug-addicted

或者是一个怀孕且吸毒成瘾的女儿，

or a son who was kicked out of school.

或者是一个被学校开除的儿子。

Or even maybe they were riding their bicycle through an intersection

或者甚至是他们的汽车 经过十字路口时

and got hit by a truck,

被卡车撞到了，

and now they're using a wheelchair and have very limited mobility.

现在他们只能坐着轮椅，行动不便。

Obviously, these things also happen to middle-class people.

显然，这些事情也会 发生在中产阶级身上。

But when they do,

但当它们发生时，

we have resources that enable us to deal with these problems.

我们有资源来应对这些问题。

We also have the belief that we will live out our normal lifespans.

我们也相信我们会活到正常寿命。

That's not true for low-income people.

这对于低收入群体则不现实。

They've seen their friends and relatives die young

他们见过他们的朋友和亲戚

of accidents,

因事故，

of violence,

暴力，

of cancers that should have been diagnosed at an earlier stage.

或本该在早期就能诊断出来 的癌症而死去。

It can lead to a sense of hopelessness,

这会导致无助感，

that it doesn't really matter what you do.

这真的跟你怎么做没有关系。

I know I've painted a bleak picture of the care of low-income patients.

我知道我描绘了一幅低收入 病人惨淡的画面。

But I want you to know how rewarding I find it

但我想让你们知道我认为 在安全的网络系统中

to work in a safety net system,

工作是多么值得，

and my deep belief is that we can make the system responsive

并且我深信我们 可以让这个系统

to the needs of low-income patients.

去响应低收入病人的需求。

The starting point has to be to meet patients where they are,

起点必须是到达病人所在的位置，

provide services without obstacles

无障碍地提供服务，

and provide patients what they need --

并且提供病人所需要的——

not what we think they need.

而非我们认为他们需要的。

It's impossible for me to take good care of a patient

我不可能照料好那些

who is homeless and living on the street.

无家可归或流落街头的人。

The right prescription for a homeless patient is housing.

无家可归的病人最好的药方是住房。

In Los Angeles,

在洛杉矶，

we housed 4,700 chronically homeless persons

我们收容了4700名患有疾病、

suffering from medical illness, mental illness, addiction.

精神疾病和毒瘾的长期无家可归者。

When we housed them, we found that overall health care costs,

当我们为他们提供住处时， 我们发现整体的医疗保健成本，

including the housing,

包括住处在内，

decreased.

降低了。

That's because they had many fewer hospital visits,

那是因为他们去医院的次数少了，

both in the emergency room and on the inpatient service.

不管是急诊室还是住院部。

And we gave them back their dignity.

我们还给他们了尊严，

No extra charge for that.

不需要额外的费用。

For people who do not have a steady supply of food,

对没有稳定食物供给的人，

especially those who are diabetic,

尤其是那些糖尿病患者，

safety net systems are experimenting with a variety of solutions,

安全保护网络 正在实验多种解决方案，

including food pantries at primary care clinics

包括初级保健诊所的食品分发，

and distributing maps of community food banks and soup kitchens.

以及社区食品银行和 热汤供点的分发地图。

And in New York City,

在纽约，

we've hired a bunch of enrollers

我们雇用了一群登记者

to get our patients into the supplemental nutrition program

来让我们的病人加入 补充营养援助计划，

known as "food stamps" to most people.

即为多数人所知的“食物券”。

When patients and doctors don't understand each other,

当病人和医生无法理解彼此时，

mistakes will occur.

错误就会出现。

For non-English-speaking patients,

对于母语非英语的病人，

translation is as important as a prescription pad.

翻译就如同处方笺一样重要，

Perhaps more important.

可能更加重要。

And, you know, it doesn't cost anything more

要知道，将所有的材料 按四年级阅读水品书写

to put all of the materials at the level of fourth-grade reading,

并不会增加多少成本，

so that everybody can understand what's being said.

这样每个人都能理解 上面说的是什么。

But more than anything else, I think low-income patients

但更重要的，我认为低收入病人

benefit from having a primary care doctor.

会受益于初级护理医生。

Mind you, I think middle-class people also benefit

提醒各位一下，我认为 中产阶级也会受益于

from having somebody to quarterback their care.

有人管理他们的医疗。

But when they don't, they have others who can advocate for them,

但当他们没有时， 他们有其他人可以为他们争取，

who can get them that disability placard

他们可以得到残疾的证明

or make sure the disability application is completed.

或确保残疾申请完成。

But low-income people really need a team of people who can help them

但低收入人群真的需要 一个团队来帮助他们

to access the medical and non-medical services that they need.

获取他们所需的医疗 和非医疗资源。

Also, many low-income people are disenfranchised

同样，很多低收入人群缺乏

from other community supports,

其他社区的支持，

and they really benefit from the care and continuity provided by primary care.

他们确实会受益于初级护理 及护理的连续性。

A primary care doctor I particularly admire

一位我尤其欣赏的初级护理医生，

once told me how she believed that her relationship with a patient

曾经告诉我，她相信她与一个病人

over a decade

长达10年的关系

was the only healthy relationship that that patient had in her life.

是这个病人在她一生中 唯一的健康关系。

The good news is, you don't actually have to be a doctor

好消息是，你不必 非得成为一个医生，

to provide that special sauce of care and continuity.

就能提供那种特别的关怀和连续性。

This was really brought home to me when one of my own long-term patients

当我的一位长期病人 在一家医院外去世时，

died at an outside hospital.

我才真正意识到这一点。

I had to tell the other doctors and nurses in my clinic

我需要告诉诊所里 的其他医生和护士，

that he had passed.

他去世了。

But I didn't know that in another part of our clinic,

但我不知道的是， 在我们诊所的其他地方，

on a different floor,

在不同的楼层，

there was a registration clerk

有一个登记员，

who had developed a very special relationship with my patient

他跟这个每次来挂号的病人

every time he came in for an appointment.

也发展了一段非常特别的关系。

When she learned three weeks later that he had died,

当她三周后听到他去世的消息时，

she came and found me in my examining room,

她来到我的检查室找我，

tears streaming down her cheeks,

眼泪顺着她的脸颊流下，

talking about my patient and the memories that she had of him,

她讲起我的病人和她对他的回忆，

the kinds of discussions that they had had about their lives together.

他们曾经一起讨论的那些话题。

My patient had a hard life.

我的病人生活艰难。

He was by his own admission a gangbanger.

他承认自己是个混混。

He had spent a substantial amount of time in prison.

他在监狱里呆了很长一段时间。

He suffered from a very serious illness.

他曾遭受一种非常严重疾病的折磨。

He was a drug addict.

他是瘾君子。

But despite all that, he rarely missed a visit,

尽管如此，他却很少错过 跟医生的预约，

and I like to believe that was because he knew at our clinic that he was loved.

我相信那是因为他知道 他在我们诊所是被爱的。

When our health care systems have the same commitment to low-income patients

当我们的医疗保健系统 对低收入病人拥有

that that man had to us,

像那个病人对我们同样的承诺时，

two things will happen.

两件事会发生。

First, the system will be responsive to the needs of low-income people.

首先，医疗系统能够响应 低收入病人的需求。

It will speak their language, it will meet their schedules,

它会说他们的语言， 它会顺应他们的日程安排，

it will fulfill their needs.

它会满足他们的需求。

Second, we will be providing the kind of care

第二，我们会提供 我们进入这个行业

that we went into this profession to do --

所要做的护理——

not just checking the boxes,

不仅只是检查表格，

but really taking care of those we serve.

而是真正照顾这些我们所服务的人。

Thank you.

谢谢。

(Applause)

（鼓掌）