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  • A few years ago,

    譯者: Lilian Chiu 審譯者: SF Huang

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

    幾年前,

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

    我在照顧一名受暴婦女。

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

    我希望她能去專門醫治 受創倖存者的診所看診。

  • I knew if I did it,

    我親自幫她預約, 因為我是該科的主管,

  • she would get an appointment right away.

    我知道如果我來預約, 她可以馬上排到時間。

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

    那間診所離她家大約 有一個半小時的路程。

  • But she took down the address and agreed to go.

    但她記下了地址並同意去那裡。

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

    遺憾的是,她並沒有去看診。

  • When I spoke to the psychiatrist, he explained to me

    當我跟那名精神科醫生談論時,

  • that trauma survivors are often resistant

    他向我解釋,

  • to dealing with the difficult issues that they face

    受創倖存者通常會抗拒

  • and often miss appointments.

    處理他們面對的困難議題,

  • For this reason,

    且通常不會依約出現。

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

    基於這個理由,

  • They had made a special exception for me.

    他們通常不會讓醫生 為他們的病人預約看診。

  • When I spoke to my patient,

    他們是為我開了特例。

  • she had a much simpler and less Freudian explanation

    當我找我的病人談時,

  • of why she didn't go to that appointment:

    她沒有依約前往的理由很簡單,

  • her ride didn't show.

    沒有那麼佛洛伊德的解釋:

  • Now, some of you may be thinking,

    載她去看診的車沒有來。

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

    有些人可能在想:

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

    「她沒有其他方式可以 依約去看診嗎?」

  • If you're thinking that,

    她不能叫 Uber 或打電話 找另一個朋友嗎?

  • it's probably because you have resources.

    如果你這麼想,

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

    可能是因為你有資源。

  • and she didn't have another friend to call.

    但她沒有足夠的錢搭 Uber,

  • But she did have me,

    她也沒有其他朋友可以幫忙。

  • and I was able to get her another appointment,

    但她有我,

  • which she kept without difficulty.

    我想辦法幫她再約了一次,

  • She wasn't resistant,

    這次她順利地準時出現。

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

    她並沒有抗拒,

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

    只是她的車沒有來。

  • but I know from running the safety net systems

    我真希望我能說 這只是個獨立的事件,

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

    但從我在舊金山、洛杉磯、

  • that health care is built on a middle-class model

    和現今在紐約所經營的 安全網系統的經驗得知,

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

    醫療保健是根據中產階級的模型所建,

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

    通常無法滿足低收入病人的需求。

  • for us to close the disparity in health care

    那就是為什麼要縮小經濟因素

  • that exists along economic lines,

    所引起的醫療保健差距,

  • despite the expansion of health insurance

    這麼困難的原因之一,

  • under the ACA, or Obamacare.

    雖然在「可負擔健保法案」 或俗稱歐巴馬健保之下,

  • Health care in the United States

    健康保險範圍已經擴大。

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

    美國的醫療保健

  • it also assumes that you can take off from work

    會假設你不但能跨越

  • in the middle of the day to get care.

    洛杉磯的廣闊土地,

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

    你也能在工作日請假

  • on a Thursday afternoon

    去看診接受醫療照護。

  • presented with partial blindness in both eyes.

    有位病人到我東洛杉磯診所看病,

  • Very concerned, I said to him,

    時間是星期四下午,

  • "When did this develop?"

    病症為雙眼皆部分失明。

  • He said, "Sunday."

    我非常擔心,對他說:

  • I said, "Sunday?

    「這是何時開始的?」

  • Did you think of coming sooner to clinic?"

    他說:「星期日。」

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

    我說:「星期日?

  • A second patient to that same clinic,

    你有想過早點來看診嗎?」

  • a trucker,

    他說:「我得工作才能付得起房租。」

  • drove three days with a raging infection,

    同一間診所,另一位病人,

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

    卡車司機,

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

    帶著嚴重的感染開了三天的車,

  • Health care in the United States assumes that you speak English

    在他把貨送完之後才來我這裡看病。

  • or can bring someone with you who can.

    兩位病人都因為延遲就醫

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

    而延誤了他們的最佳治療時機。

  • who was from West Africa and spoke a dialect so unusual

    美國醫療保健的假設是你會說英文,

  • that we could only find one translator on the telephonic line

    或有會說英文的人陪同。

  • who could understand him.

    在舊金山,我照顧的一名住院病人

  • And that translator only worked one afternoon a week.

    來自西非,說的方言非常罕見,

  • Unfortunately, my patient needed translation services every day.

    我們在電話線上只能找到一名

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

    能聽懂他語言的翻譯員。

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

    那名翻譯員的工作時間, 一週只有一個下午。

  • was illiterate,

    不幸的是,我的病人每天都需要翻譯。

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

    美國的醫療保健會假設你識字。

  • right away.

    我有一位說英文完全沒有口音的病人,

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

    卻是個文盲,

  • and I wasn't in clinic,

    他請我馬上幫他簽 社會安全失能表單時,

  • so trying to help him out,

    我才知道。

  • knowing that he was the sole caretaker of his son,

    那張表格在當天就得送到辦公室去,

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

    而我不在診所內,

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

    所以,為了幫他,

  • He took the two buses to my office,

    知道只有他一個人在照顧他兒子,

  • dropped off the form,

    我說:「把那張表單 帶到我的行政辦公室。

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

    我簽好後會幫你傳真。」

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

    他搭了兩班公車到我的辦公室,

  • The word "applicant."

    留下了表單,

  • He needed to sign the form.

    再返家照顧他的兒子……

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

    我到了辦公室,猜猜我在表格上 大大的「X」旁邊看到什麼?

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

    「申請人」這個詞。

  • It completely changed how I took care of him.

    他得在那張表單上簽名。

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

    所以我得請他再搭 兩班公車到辦公室來,

  • It also made me think about all of the patients

    在表單上簽名後我們才能為他傳真。

  • who receive reams and reams of paper

    這完全改變了我照顧他的方式。

  • spit out by our modern electronic health record systems,

    我會確保一定要口頭 跟他確認過所有的指示。

  • explaining their diagnoses and their treatments,

    這也讓我開始思考,所有這些病人

  • and wondering how many people actually can understand

    拿到一疊又一疊的紙張,

  • what's on those pieces of paper.

    都是我們的現代電子 病歷記錄系統印出的,

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

    上面解釋著他們的診斷和治療,

  • and an accurate address.

    我很納悶有多少人能真的了解

  • The proliferation of inexpensive cell phones

    那些紙上都寫了些什麼。

  • has actually helped quite a lot.

    美國的醫療保健 會假設你有能用的電話

  • But still, my patients run out of minutes,

    以及正確的地址。

  • and their phones get disconnected.

    便宜手機的激增,

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

    確實有不小的幫助。

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

    但我的病人還是會有通話時數用光,

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

    手機被斷訊的情形。

  • asking her to please come in for follow-up.

    低收入者很常會根據需求而到處跑。

  • Of course, if the address isn't accurate,

    我記得看過一名 乳房 X 光片異常女子的圖表。

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

    那張圖表很周到地記錄著,

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

    一共寄三封信到她家中,

  • This is particularly an issue for diabetics.

    請她來做後續追蹤。

  • We give them medications that lower their blood sugar.

    當然,如果地址並不正確,

  • On days when they don't have enough food,

    寄再多封信去那個地址都是枉然。

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

    美國的醫療保健會假設 你有穩定的食物供應。

  • of hypoglycemia, or low blood sugar.

    對糖尿病人來說,這個問題特別大。

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

    我們會給糖尿病人藥物 來降低他們的血糖。

  • with a refrigerator for your insulin,

    但在他們食物不足的日子,

  • a bathroom where you can wash up,

    他們就可能有低血糖的風險或

  • a bed where you can sleep

    面臨危及生命的低血糖症副作用。

  • without worrying about violence while you're resting.

    美國的醫療保健會假設你有個家,

  • But what if you don't have that?

    有冰箱可以擺放你的胰島素,

  • What if you live on the street,

    有浴室可以盥洗,

  • you live under the freeway,

    有床可以睡覺,

  • you live in a congregant shelter,

    在休息的時候不用擔心暴力。

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

    但,如果你沒有這些呢?

  • Where do you store your medicines?

    如果你住在街頭,

  • Where do you use the bathroom?

    你住在高速公路下,

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

    你住在聚會的庇護所中,

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

    每天早上七點或八點你就得要離開?

  • does not erase the huge disparity

    你要把你的藥品放在哪裡?

  • between the homeless and the housed?

    你要到哪裡使用浴室?

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

    如果你發生鬱血性心衰竭, 你要如何把你的腳抬高?

  • But what about all of you?

    無家可歸的人有了醫療保險,

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

    卻無法消除無家可歸的人

  • Maybe it's for high blood pressure.

    和有家可歸的人之間的巨大差距, 這就不足為奇了。

  • Maybe it's for diabetes or depression.

    美國的醫療保健會假設 你把你的健康照護視為優先。

  • What if tonight you had a choice:

    但你們都是嗎?

  • you could have your medication but live on the street,

    讓我先假設各位都有吃藥。

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

    也許是高血壓的藥。

  • Which would you choose?

    也許是糖尿病或憂鬱的藥。

  • I know which one I would choose.

    如果今晚你有一個選擇:

  • This is just a graphic example of the kinds of choices

    你可以擁有你的藥 但你得住在街頭,

  • that low-income patients have to make every day.

    或者你可以住在家裡 但沒有你的藥。

  • So when my doctors shake their heads and say,

    你會選哪一個?

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

    我知道我會選哪一個。

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

    這只是一個很寫實的例子,

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

    說明低收入病人每天 面臨的選擇是什麼。

  • or maybe he had to work.

    所以,當我的醫生搖頭說:

  • But also, maybe there was something more important that day

    「我不知道為什麼病人無法 依約前來瞭解他的後續追蹤」,

  • than their high blood pressure or a screening colonoscopy.

    「我不知道為什麼 她不去做我指定的檢測」,

  • Maybe that patient was dealing with an abusive spouse

    我想,也許是她的車沒來,

  • or a daughter who is pregnant and drug-addicted

    或者他得要去工作。

  • or a son who was kicked out of school.

    此外,也許那天有其他重要的事,

  • Or even maybe they were riding their bicycle through an intersection

    比他的高血壓 或結腸鏡檢查更重要。

  • and got hit by a truck,

    也許那位病人要面對配偶的虐待,

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

    或是處理懷孕且吸毒的女兒,

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

    或者處理被退學的兒子。

  • But when they do,

    或者甚至他騎腳踏車過十字路口時

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

    被卡車給撞了,

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

    現在要靠輪椅,所以行動力受限。

  • That's not true for low-income people.

    很顯然,中產階級的人 也會遇到這些事。

  • They've seen their friends and relatives die young

    但當遇到時,

  • of accidents,

    我們有資源可以處理這些問題。

  • of violence,

    我們也相信我們會活到平均的壽命。

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

    對低收入的人卻不是如此。

  • It can lead to a sense of hopelessness,

    他們見過自己的朋友、親人早逝,

  • that it doesn't really matter what you do.

    可能是因為意外,可能是暴力,

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

    可能是本來可以 早期診斷出來的癌症。

  • But I want you to know how rewarding I find it

    這有可能導致絕望的感覺,

  • to work in a safety net system,

    覺得不論怎麼做都無法改變。

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

    我知道我對低收入病人的 醫療照護做了很殘酷的描述。

  • to the needs of low-income patients.

    但我希望各位知道,我覺得

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

    在安全網系統中工作地非常值得,

  • provide services without obstacles

    我也深深相信,我們能讓這個系統

  • and provide patients what they need --

    針對低收入病人的需求做出因應之道。

  • not what we think they need.

    首先必須設身處地為病人 提供即時與所需的協助,

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

    提供沒有障礙的服務,

  • who is homeless and living on the street.

    提供病人他們所需要的——

  • The right prescription for a homeless patient is housing.

    而不是我們認為他們需要的。

  • In Los Angeles,

    我無法能夠將無家可歸

  • we housed 4,700 chronically homeless persons

    流落街頭的人照顧得很好。

  • suffering from medical illness, mental illness, addiction.

    無家可歸的病人 需要的處方箋是有房可住。

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

    在洛杉磯,

  • including the housing,

    我們收容安置了四千七百名

  • decreased.

    長期無家可歸的人,

  • That's because they had many fewer hospital visits,

    他們都飽受各種病痛、 心理疾病、成癮症所苦。

  • both in the emergency room and on the inpatient service.

    當我們提供住處給他們時, 我們發現整體的醫療保健成本,

  • And we gave them back their dignity.

    包含住房的成本,是下降的。

  • No extra charge for that.

    那是因為他們在急診和住院部分的

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

    就醫次數減少很多。

  • especially those who are diabetic,

    且我們把尊嚴還給他們。

  • safety net systems are experimenting with a variety of solutions,

    還不需為此額外付費。

  • including food pantries at primary care clinics

    對於沒有穩定食物供應的人,

  • and distributing maps of community food banks and soup kitchens.

    特別是糖尿病患者,

  • And in New York City,

    安全網系統正在實驗各種解決方案,

  • we've hired a bunch of enrollers

    包括在初級醫療診所提供食品貯藏櫃,

  • to get our patients into the supplemental nutrition program

    並分發社區食物銀行 和熱湯廚房的地圖。

  • known as "food stamps" to most people.

    在紐約市,

  • When patients and doctors don't understand each other,

    我們僱用了一群招募者,

  • mistakes will occur.

    負責讓我們的病人參加補充營養計畫,

  • For non-English-speaking patients,

    也就是大部分人所知的「食物券」。

  • translation is as important as a prescription pad.

    當病人和醫生彼此互不了解,

  • Perhaps more important.

    就會發生錯誤。

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

    對不會說英語的病人而言,

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

    翻譯和處方箋一樣重要。

  • so that everybody can understand what's being said.

    可能還更重要。

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

    要知道,把所有的資料 都以適合四年級閱讀的程度來表達,

  • benefit from having a primary care doctor.

    並不需額外的成本,

  • Mind you, I think middle-class people also benefit

    這樣人人都能了解那些資訊。

  • from having somebody to quarterback their care.

    但,最重要的是,我認為 若有一位初級醫療醫師

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

    對於低收入病人而言是很有益的。

  • who can get them that disability placard

    注意,我認為對中產階級而言,

  • or make sure the disability application is completed.

    若有人能管理他們的醫療照護, 他們也能從中受益。

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

    但若沒有,他們還有 其他人能協助他們,

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

    能幫他們取得那塊身心障礙小牌子,

  • Also, many low-income people are disenfranchised

    或確保失能的申請作業能完成。

  • from other community supports,

    但低收入的人真的需要 有一個團隊來協助他們

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

    取得他們所需的醫療和非醫療服務。

  • A primary care doctor I particularly admire

    此外,許多低收入的人被剝奪了

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

    取得其他社區支援的權利,

  • over a decade

    他們真能受惠於持續提供給 他們的初級醫療保健照護。

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

    我特別欣賞的一位初級醫療醫生

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

    曾告訴過我,她相信她和一位病人

  • to provide that special sauce of care and continuity.

    超過十年的關係,

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

    是那位病人人生中唯一的健康關係。

  • died at an outside hospital.

    好消息是,你不一定要是醫生,

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

    也能提供那種持續照顧的特殊醬料。

  • that he had passed.

    當我的一位長期病人 在外面的一間醫院過世時,

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

    讓我深刻地體認到這一點。

  • on a different floor,

    我得告訴診所內其他的醫護人員,

  • there was a registration clerk

    他已經過世了。

  • who had developed a very special relationship with my patient

    但我並不知道在我們診所的另一區,

  • every time he came in for an appointment.

    在另一層樓,

  • When she learned three weeks later that he had died,

    有一位掛號人員

  • she came and found me in my examining room,

    和我的病人發展了非常特殊的關係,

  • tears streaming down her cheeks,

    每次他依約來看診時所發展出來的。

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

    三週後,她得知他過世時,

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

    她來我的檢查室找我,

  • My patient had a hard life.

    眼淚流個不停,

  • He was by his own admission a gangbanger.

    談到我的病人以及她對他的記憶,

  • He had spent a substantial amount of time in prison.

    還有他們曾經一起討論過的人生議題。

  • He suffered from a very serious illness.

    我的病人過著很苦的生活。

  • He was a drug addict.

    他自己承認是個幫派份子。

  • But despite all that, he rarely missed a visit,

    他有很多時間都在監獄中度過。

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

    他受重病所苦。