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

譯者: Lilian Chiu 審譯者: Shelley Tsang 曾雯海

As a doctor in the field of pain management,

我是疼痛管理領域的醫生，

I work in a world where you bring us your pain

在我工作的世界裡， 你把你的疼痛帶來給我們，

and we treat it.

我們負責治療它。

We ask questions,

我們會問問題，

we take the symptoms you present,

我們根據你所呈現出來的症狀

we decide what tests to run.

決定要做哪些檢測。

We listen with compassion and wisdom

我們會帶著同情心和智慧來傾聽，

and choose the best course of action

選擇最好的行動方案，

based on our knowledge and experience combined with science.

選擇的基礎是我們的知識與經驗，

並與科學結合。

And sometimes in a very small window of time.

有時，還得在很短的時間完成。

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

醫生都會做神聖的宣誓， 保證不去傷害人。

And the system has gone to great lengths to teach us

體制也不遺餘力地教導我們，

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

並設立指引以確保

我們會平等對待每位病人，

and without judgment.

且不做評斷。

As we stand there in your moment of pain,

我們身處在你感到痛苦的時刻中，

we run your situation through every filter we have

我們用上一切所能來過濾你的情況，

to give you the best care.

以提供你最好的照護。

And for most of us,

對大多數醫生而言，

this is more than just a job.

這不只是一份工作。

It's a calling.

這是天職。

But as we stand there in your moment,

但，當我們身處在你的時刻中，

looking at your story from all the different angles

從各種不同角度去看你的故事，

and all the different rational voices in our head

思忖我們腦中各種不同的理性聲音，

run through the decision making process,

執行決策過程，

there's another voice in the mix.

卻有另一個聲音混在其中。

And this voice,

這個聲音，

well, it isn't rational or informed.

它不理性，

也不是以資訊為基礎。

Yet, it often dictates our decisions.

但它通常卻能支配我們的決策。

And we don't give it a second thought

而我們不會多想，因為，要知道，

because you see,

早在我們學醫之前， 這個聲音就存在了。

this voice existed long before we began studying medicine.

And so we accept it as truth.

我們就把它視為事實。

And this voice sometimes calls the shots.

有時，是這個聲音在發號施令。

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

我把它稱為未被診斷出來的偏見。

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

而它造成了許多 慢性病患者受苦及死亡。

I have spent the last 15 years studying pain.

我過去十五年都在研究疼痛。

Its cause, its treatment and its management.

它的成因、怎麼治療它， 以及怎麼管理它。

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

但，一直要到有一天， 我坐在檢查室的另一端，

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

我才注意到疼痛管理的 基礎有個裂痕。

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

那時，我發現我們每個人 都有這個隱藏的聲音。

That hidden voice, which I termed the undiagnosed bias,

這個隱藏的聲音，也就是 我所謂未診斷出來的偏見，

is more commonly known as implicit bias,

也就是一般所知的內隱偏見，

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

這種偏見來自於我們無意識的信念

和關聯連結。

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

2003 年，健康照護領域的 內隱偏見被搬上檯面，

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

那年，美國國家醫學院刊出了 一篇報告《不平等的治療》。

They found that regardless of insurance and income status,

他們發現，不論保險 和收入的狀況如何，

racial and ethnic minorities received worse care.

種族和人種的弱勢族群 得到的照護都比較差。

And when it comes to pain,

至於疼痛，

research shows that bias extends beyond minorities

研究顯示，偏見 會延伸到弱勢族群之外，

to also include women and even children.

連女性，甚至孩童，都無法倖免。

Dr. Susan Moore was a Black female physician

蘇珊‧摩爾醫生是黑人且是女性，

whose story was heard around the world in 2020.

2020 年，她的故事傳遍了全世界。

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

這個故事是，一個醫生苦苦 無法得到她知道她需要的照護。

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

造成她疼痛的是她清楚 了解的健康問題，

and described in medical lingo to her doctors.

她還用醫學語言對她的醫生 描述她的問題。

Yet her pain was dismissed.

但她的疼痛卻不被理會。

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

當她在數千名醫生的群組中 分享了她的經歷，

there was an uproar of support.

引發一波支持的聲浪。

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

畢竟，沒有人能接受 醫生治療病人時，

let alone a fellow colleague like this,

更不用說治療同業時， 竟會用這種方式，

simply based on how they look.

完全只根據外觀。

But that's the problem with implicit bias.

但，那就是內隱偏見的問題。

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

大部分的時候，你根本 不知道你有內隱偏見。

I remember the year I went from doctor to patient.

我記得有一年，我從醫生 變成病人的角色。

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

最初，只是我的腳 隱隱作痛且一直持續。

Well, it grew worse,

情況越來越糟，

to the point that it overshadowed my life.

糟到我的人生被蒙上陰影的程度。

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

它總是跟著我，

影響到我的工作和家庭生活。

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

我終於去看了足部醫生， 而醫生告訴我：

"Source not clear.

「源頭不清楚。

Probably tendons were inflamed," he said.

肌腱可能有發炎。」

And he prescribed a boot and some physical therapy.

他開的處方是靴子和一些物理治療。

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

但疼痛加劇了，還擴散到 我的髖部和背部。

I sought out more medical specialists, even holistic practitioners,

我向更多醫療專業人士求助， 甚至整合醫學的開業者，

all with different theories,

大家的理論都不同，

but no clear diagnosis or source of pain.

但都沒有清楚診斷出疼痛的來源。

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

我開始覺得，這疼痛 會一輩子跟著我。

And as the pain kept progressing with no clear diagnosis,

隨著疼痛越來越甚， 又沒有清楚的診斷，

I even thought to myself,

我甚至心想：「等等，

"Wait.

Am I making this up?

這是我捏造的嗎？

Is my pain even real?"

我的疼痛是真的嗎？」

In an online survey of 2,400 American women

有項線上調查，

對象是兩千四百名有各種 慢性疼痛病症的美國女性，

with a variety of chronic pain conditions,

91 percent felt that the health care system

有 91% 的人覺得健康照護體制

discriminated against them.

對她們有歧視。

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

有近半數的人得到的答案是， 疼痛根本只在她們的腦袋中。

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

咱們先立刻來澄清一下 這個疼痛謎思。

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

如果你擔心你的疼痛 是在你的腦袋中，

you're right.

你是對的。

Because pain is in everyone's heads.

因為疼痛的確在每個人的腦袋中。

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

要知道，沒有大腦就不會發生疼痛。

When you step on a nail, for example,

比如，當你踩到釘子，

you stimulate nociceptors, or specialized nerve cells,

就會刺激你的痛覺感受器 或特化神經細胞，

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

它會透過脊髓發送訊息給你的大腦。

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

你的大腦會決定要如何 處理這個訊號。

If it senses something dangerous,

如果大腦感覺到危險存在，

it will process that experience as painful

它就會把這段經歷當作 痛苦的經歷來處理，

to prevent you from further injury.

以避免你受到進一步的傷害。

And the decision by the brain to process it as painful

而大腦判斷要把它當作 痛苦經歷來處理的決定

is based on environmental and social cues

則是根據環境和社會線索，

as well as by culture

還有文化

and one's past experiences.

以及個人過去的經驗。

Now, contrary to popular belief,

和一般所相信的相反，

not all pain is related to tissue damage.

並非所有的疼痛都和組織受損有關。

Pain is actually defined

疼痛的定義其實是

as an unpleasant sensory and emotional experience

不愉悅的感官及情緒經歷，

that can be associated with actual

有可能會和實際的

or potential tissue damage.

或可能的組織受損有關。

You can have real pain

你有可能會有真實的疼痛，

with no physical injury

卻沒有身體的損傷

or source.

或源頭。

Pain is the one thing that can't be measured

疼痛無法用監測器 或實驗室檢測來測量。

by a monitor or lab test.

It's hard to quantify or qualify.

很難將它質化或量化。

It's measured on a scale of zero to 10

零分到十分的疼痛測量量表

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

根據的是受測者對自身經歷的感受。

Pain, then, is subjective.

因此，疼痛是主觀的。

And as doctors,

身為醫生，

our process of treating pain begins with identifying its source.

我們治療疼痛的流程 始於找出疼痛的來源。

Which presents a problem when there is no source.

找不到來源時，就麻煩了。

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

沒有來源時，要怎麼詮釋都可以。

And interpretation becomes open to that undiagnosed bias.

而詮釋就有可能受到 未診斷出的偏見所影響。

Did you know that the different sexes experience pain differently?

各位可知道，不同性別 對疼痛的感受不同？

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

在這場演說中，我所謂的女性和男性

I'm referencing sex assigned at birth.

指的是出生時指定的性別。

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

若我說女人、男人，或非二元性別，

then gender identity is at the core of the point.

核心重點就是性別認同。

Females have more nerve fibers than men,

女性的神經纖維比男性多，

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

且荷爾蒙對於許多 慢性疼痛病症都會有影響。

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

青春期時，女孩慢性疼痛的 比率比男孩提升得更快。

And as females approach menopause,

隨著女性接近更年期，

sex differences in chronic pain begin to disappear.

慢性疼痛的性別差異會開始消失。

Females experience more recurrent pain, longer-lasting pain

女性會經歷到更週期性的疼痛、

更持久的疼痛，

and higher overall levels of chronic pain than men.

以及整體程度更高的 慢性疼痛，男性則較輕微。

Yet the majority of studies on the treatment of chronic pain

然而，絕大多數關於 慢性疼痛治療的研究，

have only been conducted in men.

都只以男性為研究對象。

Did you know that women are more likely than men

各位可知道，比起男人， 女人更容易被給予

to be given anti-anxiety medications instead of painkillers

抗憂鬱藥物而非止痛藥，

when they present to the emergency department

且是當她們去掛急診， 主訴嚴重腹痛時？

complaining of severe abdominal pain?

Even for extremely urgent conditions

就連極度緊急的情況，

such as chest pain from a heart attack,

比如心臟病造成的胸痛，

women experience delays in life saving-interventions

女人也會比較晚才得到 能預防死亡的

that can prevent death.

救命介入治療。

研究顯示，臨床醫生比較常認為

Research shows that clinicians more often suggest psychosocial causes

社會心理的原因， 比如壓力或家庭問題，

such as stress or family problems to women patients in pain

是女病人感到疼痛的原因，

when they would more often order lab tests

相對的，比較常囑咐症狀

for a male patient with the exact same symptoms.

完全相同的男病人進行實驗室檢測。

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

像摩爾醫生這樣的黑種女人 會受到雙重打擊。

The insulting notion that they are overdramatic

侮辱的想法：因為她們的性別 就認為她們太過誇大的，

due to their gender,

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

以及錯誤的觀念：認為因為 她們的皮膚是黑色的，

they are impervious to pain.

她們就不會被疼痛影響。

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

2016 年，一群醫學院學生做的 研究發現有近半數的人相信

Black people have thicker skin than white people,

黑人的皮膚比白人厚，

less sensitive nerve endings,

神經末稍比較不敏感，

or that their blood clots more quickly.

或者血液凝結比較快。

The origin of these outrageous claims dates back to slavery

這些很讓人吃驚的主張 可追溯到奴隸制度，

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

以及湯瑪斯‧漢彌爾頓醫生 在十九世紀做的實驗，

who tortured Black slaves

他折磨黑奴來證明

to prove that Black skin was deeper than white skin.

黑皮膚比白皮膚更深。

And Dr. James Sims, a gynecologist,

而婦科醫生詹姆士‧西姆斯

conducted experimental surgeries

對被奴役的黑種女人 進行實驗性的手術，

on enslaved Black women without anesthesia,

還不用麻醉，

contributing further to false beliefs

更進一步加深認為黑種女人 比較不會感受到

that Black women experience less pain.

疼痛的錯誤觀念。

There were times that I found it ironic

有時我自己都覺得很諷刺，

that as an anesthesiologist,

我身為麻醉醫師，

whose livelihood is centered around managing pain,

靠管理疼痛維生，

that I would suffer from chronic pain myself.

自己卻為慢性疼痛所苦。

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

所以，和摩爾醫生一樣， 我也為自己發聲，

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

也去深入鑽研我自己的疼痛成因。

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

在疼痛上投入了五年時間、 數千美金，以及許多個小時，

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

我終於找到了原因，靠的是 鑽研整合及功能醫學。

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

我的疼痛來自於分娩時 所觸發的身體不平衡、

years of stress and sleep deprivation,

數年的壓力以及睡眠不足，

and a dietary sensitivity that had been triggering inflammation.

以及觸發發炎反應的食物敏感性。

Over time, I healed myself.

隨時間，我治癒了自己，

And finally, the pain began to ease.

終於，疼痛開始緩和。

But while my own pain did fade,

雖然我自己的疼痛已褪去，

my passion for other people with chronic pain grew stronger.

我卻更有熱情投入協助 其他為慢性疼痛所苦的人。

Now doctors aren't the enemy.

醫生不是敵人。

If you ask physicians why they went into medicine,

如果你問醫生他們 為何學醫，你會聽到

you would hear "to help people."

「為了助人」。

So much so, that during disasters and global pandemics,

程度到了在災難及全球疫情期間，

health care workers kiss their own families goodbye

健康照護從業人員揮別自己的家人，

to go take care of yours.

去照顧各位的家人。

They work tirelessly during codes to resuscitate your loved ones

在心臟停止時他們不斷努力 救回各位的家人，

and shed tears when they lose them.

在失去自己的家人時， 只能擦乾眼淚。

But with exhaustion, time pressures and overcrowded emergency rooms

但隨著精疲力竭、

時間壓力，以及過度擁擠的急診室，

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

讓那隱藏的聲音能夠 取代理性的聲音。

Now the health care system has been teaching bias training,

健康照護體制一直在教導偏見訓練，

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

研究顯示健康照護中只有一點 甚至沒有明確的偏見，這很棒，

but we continue to see implicit bias

但我們仍不斷在一定比例的 健康照護從業人員身上

in a percentage of health care practitioners.

看到內隱偏見。

Because it operates in an unintentional and unconscious manner,

因為它的運作方式 是無心的且無意識的，

implicit bias begins outside the walls of the hospital

內隱偏見始於醫院以外的地方，

and is brought in unknowingly.

不知不覺間被帶入醫院。

And it's not just doctors.

不只是醫生，

Bias exists in all of us.

我們全都有偏見。

We can all do better.

我們都能做得更好。

How?

怎麼做？

Well, the first step is awareness.

第一步是意識。

We need to begin by identifying our stereotypes.

首先，我們得要辨識出 我們的刻板印象。

And then rewrite the stories of the people we meet.

接著，重寫我們遇到的人的故事。

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

當一個女人在我們旁邊 坐下時，先捫心自問：

What would we say if this were a man?

如果換成是個男人，我們會說什麼？

Would our answer change?

我們的答案會改變嗎？

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

如果你的疼痛不被理會， 要奮戰讓你的聲音被聽見。

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

找到對的醫生就有點像是約會。

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

你得要滑滑手機多看幾個，

才能找到適合你的。

(Laughter)

（笑聲）

But don't give up.

但別放棄。

And don't delay seeking treatment.

尋求治療也不能拖。

The sooner you are properly diagnosed,

你越快得到妥當的診斷，

the greater chance you have of breaking your pain cycle.

就越有機會打破你的疼痛循環。

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

我們醫生在白袍典禮的時候立過誓，

to first do no harm.

首先就是不能傷害人。

And most of us live by that sacred oath.

我們大部分人也都 遵循著那神聖的誓言。

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

但那誓言有部分必須要靠 持續檢查那內在的聲音，

to make sure that we aren't writing a story

以確保我們不會在病人都還沒有

that our patients haven't told us yet.

告訴我們之前就自己寫好了故事。

Because it is our duty as physicians

因為我們醫生有責任

to replace the undiagnosed bias with empathy.

把未診斷出的偏見換成

同理心。

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

至於所有為慢性疼痛所苦的人，

we hear you.

我們聽見你們了。

And we're ready to listen.

且我們準備好傾聽了。

Thank you.

謝謝。

(Applause)

（掌聲）