【正文】 ract medication names. Often the doctor can make a rough estimate of medication pliance by the level of pills in the bottle although for ongoing prescriptions patients may bine bottles or refill prescriptions17 before beginning to take the medication in a particular bottle, thus making accurate pliance measurement impossible. Sometimes the physician discovers that the patient does not have one of the prescribed medicines. The doctor may discover that the patient is taking medication prescribed by another physician. For each medicine discussed, the doctor should ask how often the patient is taking it and if there are any problems. If the patient is taking the medicine incorrectly, the physician can determine whether the problem is misunderstanding of the dosage schedule, forgetfulness, an adverse side effect, the cost of the drug, or some other reasons. 為了幫助病人按處方用藥，醫(yī)生應(yīng)遵守如下一些常識性原則，其中最重要的決定因素是醫(yī)生開藥的種類，精簡用藥是關(guān)鍵。通常，特別是對一位同時服用多種藥物的病人來說，醫(yī)生應(yīng)盡可能使用最便宜但療效很好的藥物并簡化用藥方法（每日一到兩次）。在隨診中，用藥上的改變越少越好。對于那些不能記著按時服藥的病人來說，將用藥醫(yī)囑寫下來或借助于寫在藥瓶上提醒的做法會有用的。有時醫(yī)生可以將病人交給指定的藥房或列入特殊護理計劃中，以達到遵守醫(yī)囑的目的。To help the patient take prescribed medication, the physician should follow a few monsense rules. The most important determinant18 of medication pliance is the number of medicines prescribed. Parsimony19 is key. In general, and especially for a patient on multiple medications, the doctor should strive for simple (once or twice daily) dosage schedules of the least expensive effective medication. At followup visits, the fewer the medication changes the better. For patients who have trouble remembering to take their medicines, written instructions or pill containers with alarms can help. Sometimes the physician can refer the patient to special pharmacy or nursing programs for help with medicine pliance. [預(yù)防及保健] 預(yù)防及保健活動（如常規(guī)的乳腺X線照片、戒煙、流感疫苗接種）是按照病人的年齡、性別、臨床狀況為基礎(chǔ)而定期提示的。提示系統(tǒng)，比如一張預(yù)防檢查表，有助于將適當?shù)念A(yù)防措施融入醫(yī)患接觸中。如果沒有檢查表和其他可代替的系統(tǒng)，醫(yī)生應(yīng)簡要地考慮一下特定年齡、性別的病人應(yīng)該采用什么樣的預(yù)防措施以及如何實施。Prevention and Health Maintenance. Preventive and health maintenance activities [e. g., routine mammograms20, smoking cessation21, influenza vaccine22] are indicated periodically23 according to an algorithm24 based on age, gender, and clinical status. Prompting systems, such as a prevention checklist25, help incorporate appropriate prevention activities into the doctorpatient encounter. If there is no checklist or other system in place, the doctor should briefly consider what preventive activities are indicated in a patient of the given age and gender and perform them.醫(yī)生采取的預(yù)防保健措施有以下三種：為確定無癥狀疾病或致病危險因素而進行的篩查；為預(yù)防繼發(fā)性疾病而進行的預(yù)防接種；為戒除不良習慣、養(yǎng)成健康習慣而進行的生活方式咨詢。要讓一個病人改變?nèi)粘Ａ晳T比令其同意進行篩檢更為困難，那些想勸告病人改變生活方式的醫(yī)生應(yīng)做好失敗的準備。在咨詢之前，應(yīng)該確定病人有無做出改變的動機。如果病人有做出改變的動機，通常大多數(shù)病人是有的，咨詢則應(yīng)集中在病人應(yīng)采取的實際步驟上，隨訪尤為重要。許多病人在嘗試做出生活方式改變的最初幾次往往會失敗。一旦出現(xiàn)這種情況，醫(yī)生應(yīng)該鼓勵病人繼續(xù)努力，避免責難病人。病人所取得的哪怕一點點進步對他/她自己的健康都會產(chǎn)生實實在在的好處。如果醫(yī)生能幫助病人中的十分之一戒除吸煙習慣，那么就將挽救一百萬以上美國人的生命。Doctors perform three types of preventive and health maintenance activities: screening26 examinations to identify asymptomatic disease or risk factors, immunizations to prevent subsequent disease, and lifestyle counseling to stop harmful habits and promote healthful ones. It is much more difficult to get a patient to change daily habits than to agree to screening tests. Physicians who counsel patients to make lifestyle changes should expect many failures. Before beginning counseling, the patient’s motivation for change should be determined. If the patient is motivated, and most are, counseling should concentrate on the actual steps the patient should take. Followup is especially important. Most patients fail the first few times they attempt to make a lifestyle change. If that happens, the doctor should encourage the patient to keep trying and avoid being judgmental. Success with even a small percentage of patients can lead to substantial health benefits. If doctors succeed in helping only 10% of their patients who smoke to break the habit, it has been estimated that more than one million American lives would be saved. 小結(jié) 一次成功的醫(yī)生患者接觸需要醫(yī)生有很強的綜合及判斷能力。醫(yī)生必須在同一時間考慮諸多因素，不僅要考慮各種診斷的可能性，而且要考慮預(yù)后的問題，還有如何與病人溝通以及溝通的內(nèi)容，怎樣幫助病人盡可能感到舒適，選擇哪些實驗室檢查項目和治療措施，以及如何向病人解釋清楚等等。這些方面必須始終加以注意并在整個接觸中不斷地隨時更新。醫(yī)生必須將自己所有的思維過程轉(zhuǎn)化為與病人的有效互動，并致力促成醫(yī)患間的合作關(guān)系，從而使醫(yī)療診斷和治療方案得以接受、證實和執(zhí)行。醫(yī)生的工作還不僅于此，更為重要的是，醫(yī)生必須堅持探索加何改善和提高病人的健康狀況及如何改變病人的五個“D”的問題。 A successful doctorpatient encounter requires a great deal of synthesis27 and judgment on the doctor’s part. The physician must be thinking of many different elements at once, not only the diagnostic possibilities but also the prognostic28 implications, how and what to municate to the patient, how to help the patient feel as fortable as possible, which laboratory tests and therapy to choose, and how to explain them clearly to the patient. These elements must be addressed and updated constantly throughout the interview, often simultaneously29. The doctor must translate all thought processes into effective interactions with the patient and must work to develop a partnership with the patient so that medically indicated diagnostic tests and treatments that are acceptable to the patient are identified and used. Overriding30 all of these activities, the doctor must keep asking how to improve and enhance the health of the patient, how to change those five D’s. 與表面上相矛盾的是，雖然現(xiàn)代醫(yī)學擁有先進的診斷和治療技術(shù)，但它比以往任何時候都要求醫(yī)生強調(diào)醫(yī)學的一個最古老的活動——當好一名教師。更確切地講，社會要求醫(yī)生應(yīng)該與病人協(xié)作，而不是凌駕于病人之上。盡管醫(yī)生可能會對某些病人產(chǎn)生極大的影響，但最好小心避免施加這種影響。像過去那些偉大的醫(yī)生一樣，他們深知經(jīng)典格言的真諦：治療病人的秘訣在于關(guān)心和體貼病人。Paradoxically31, modern medicine, with its powerful technologies for diagnosis and treatment, requires more than ever that the physician emphasize one of medicine’s most ancient activities, that of being a teacher. Fittingly32, society requires that the doctor work with—not on—the patient. Although physicians may e to have a good deal of influence with some of their patients, the best carefully avoid trying to have power over their patients. Like great physicians of old times, they know the truth of the classic maxim33 that the secret of the care of the pat