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医学的温度(2020年中国好书、第十六届文津图书奖)
$34.35
读者对象:医学研究者、关注医学人文的大众读者
编辑推荐:
癌症早发现、早诊断、早治疗意义如何?
精准医学的时代到来了吗?
如何对待过度诊断、过度治疗?
怎样认识医学的来路与归途?
病理生理学家韩启德院士反思医学本质、践行人文精神、匡正俗解谬说、倡导价值医疗之作。
著名学者、病理生理与药理学家韩启德院士以“医学的温度”为主题,结集了近些年对医学的本质、医学史、叙事医学、精准医学等的人文思考,阐述了对癌症、传染病、中医、死亡等的独特看法,对癌症应该早发现、早诊断、早治疗等人们习以为常的医学观点提出质疑和建议,对全速发展的现代医学技术及其发展方向进行重新审视,提出应回归以病人为中心的价值医疗、不能忘记医学的来路和归途等观点。本书对人们重新认识现代医学乃至重新认识自我都极具启发意义。
韩启德,1945年出生于上海,病理生理与药理学家,中国科学院院士,发展中国家科学院院士,美国医学科学院外籍院士,北京大学教授。曾任九三学社中央主席、全国人大常委会副委员长、全国政协副主席、欧美同学会会长,北京大学常务副校长、研究生院院长、医学部主任等。现任中国科学技术协会名誉主席、中国科协-北京大学科学文化研究院院长。长期从事心血管基础研究,曾在α1肾上腺素受体研究领域获得重要成果。
目录
医学的温度(代序)···········································1
医学是什么·····················································8
传染病的历史告诉我们·····································41
20世纪现代医学进展·······································53
对控制疾病危险因素的考量·······························69
对癌症早发现、早诊断、早治疗方针的考量····················80
对精准医学的几点思考·····································97
审视医学技术的发展方向 ································104
我对循证医学的看法······································118
对现代医学的几点反思····································123
现代医学与中医应该和而不同···························143
加强医学史学习和研究····································147
始于医者仁心的叙事医学·································151
感悟死亡·····················································162
死亡如此多情···············································169
中国临床医学工作者肩负的重任 ·······················172
我们中国医生···············································177
北医的品格与使命·········································181
医学教师的课·········································189
附录 幸福就是为别人做事······························210
我10岁时得了猩红热,两周后继发严重风湿性关节炎和心包积液,住进一家小的私立医院,昏迷三天后被救了过来。除严重时用过几天青霉素外,没有其他什么治疗,护理却十分周到,卧床,连饭都由护士喂到嘴里。护士们都很喜欢我,一有空就轮着来给我讲故事。60多年过去了,我还记得那张病床,那间病房,窗外的那几棵大松树。在那里,我人生次感受到来自父母和家庭以外的温情。护士们长什么样我很快忘记了,但她们却在我幼小的心灵中留下了一片柔软的地方,留下了一种特别的美,一种爱的美丽。哦,医学是有温度的!
后来我学了医,1962年我考进上海医学院医学系,六年制。可惜,学完三年基础课,还没来得及进医院,就去参加了一年的“四清”运动,回来后又遇到“文革”,失去了所有学习临床医学的时间,仅在1968 年初获得过短短两周的所谓“复课闹革命”的机会。记得中山医院大内科副主任仅用四节课给我们讲完内科学总论,接着就让我们分组去门诊实习了,目的是学习物理检查。就在那里,我接诊了从医生涯的位病人。那是一位16 岁的农村女孩,主诉长期阵发性腹痛。我按课本里的要求,望触叩听,从头到脚做了全套物理检查,足足用了一个多小时,没有发现任何异常—由于没有学过任何别的临床课程,当然对诊断一头雾水。我把病人领到老师跟前,老师问了几句,摸了一下肚子,马上做出了肠道蛔虫症的诊断,给病人开出了只有驱蛔灵一种药的处方。带女孩来看病的老伯伯临别时对我千恩万谢,说从来没有遇到过一个医生能为病人检查得那么仔细、那么认真。他对我说,这回孩子的病肯定能治好了。50 年过去了,当时那位老伯伯的笑脸和他真挚的谢意仍然留在我的心里,使我懂得了医生的态度也是可以治病的。
1968 年底,我被分配到陕西农村一个公社卫生院工作。当时病人问得多的是两个问题:“大夫,我的病你治过吗?”“大夫,我的病你能治好吗?”那时,我的回答常常是:“我没有治过,你吃我的药试试看。”结果,不少奔着“上海医生”来的病人不再找我看病。而同事中有一位老医生——他仅在旧国民党部队当过几天卫生员,常常告诉病人心脏有五级杂音,注射葡萄糖加维C 就能治好——他的周围却总是围满了病人。慢慢地,我懂得了,病人需要的不仅是医术,还需要安慰和对医生的信任。我不能骗人,但必须学会沟通。我渐渐学会了如何跟病人说话。与此同时,我拼命地工作和学习,只要是有助于解除病人痛苦的事情,就竭尽全力去做。
当时的卫生院只有一间药房、一间注射室和一间面积稍大的门诊室,遇到中毒性痢疾、肺炎、消化不良导致严重脱水等患儿,我就让出自己的床,几天几夜连续观察治疗;没有抽吸泵,我就口对口把堵塞患儿呼吸道的浓痰吸出来;急性心力衰竭病人需要快速洋地黄化,我连续几天骑车去病人家里看着病人按时按量服药,用几毛钱挽回生命;农民牙病多,“牙疼不是病,来时要人命”,等到他们来看医生时往往到了只能拔牙的阶段,我买来一把牙挺和两把牙钳,自学了麻醉技术,给人拔牙;农村卫生条件差,脓疱疮病人多,且常常久治不愈,我从民间觅来单方,加上自制外用药,基本能药到病除;碰到脱臼病人,我对着《葛氏小外科学》给病人复位,一分钱不花,立竿见影;妇女产后乳汁不下,我看农妇多数身体壮实,主要为肝气郁结所致,就用中药逍遥散和针灸,加上心理疏导,效果很好,求助者络绎不绝;后来我到当地一家区级医院学了两个月外科,建起了手术室,开展了一些腹部和五官科的小手术。
总之,是病人的痛苦驱使我去努力做事,是病人促使我不断学习。说句实在话,也是在病人身上的实践,让我的临床能力不断提高,是病人让我成为一个合格的基层全科医生。我学会了沟通,增长了本领,越来越得到农民朋友的信任。病治好了,他们感激我;病没治好,他们说“韩先生都看过了,也就这样了”;我收治的病人死了,他们反过来安慰我:“大夫看得了病,救不了命。”有时早上起床,会在宿舍窗台上看到手绢里包着几个鸡蛋或者几个白面馒头,那是老乡们送我的,但没有留名,他们仅仅想表达对我的感谢。每当这种时候,我都感到无比幸福,天底下还有比这更加纯洁、更加珍贵的情感吗?赠人玫瑰,手有余香。为别人做好事,能得到情感上的回报,我很满足。久而久之,我心里就形成了一个理念:为他人做好事,获得人们的好口碑,就是幸福。回忆这些,常令我感叹:医学是有温度的!
改革开放,有了读研究生的机会,我选择了基础医学,从此进入了唯物论医学的天地。开始时,我主要从事病理生理学研究,还比较重视整体;1985 年去美国进修后,我改为分子药理学研究,更加沉浸于还原论和机械唯物论。不过,潜心其中,我不断体会到科学的求真求实和精微缜密,领略到科学的批判精神和神奇力量,享受到研究微观生命世界的美妙和魅力。科学是人类探索未知本能的体现,是人类文明发展的果实,特别是工业革命以来,已经成为直接造福人类的重要途径。基于我参与的α-1 肾上腺素受体亚型研究成果,新药坦索罗辛(哈乐)得以问世,给很多前列腺肥大病人的治疗带来了更好的效果。在神经肽Y 和β3 肾上腺素受体刚刚发现的时候,我就做过它们的基础研究,后来居然都与肥胖挂上了钩,未来有可能用于糖尿病和肥胖的治疗。20多年的实验室研究,使我对医学的科学属性有了更深的理解。我也体会到,基础医学不同于其他纯科学研究,甚至有异于一般的生命科学研究,它虽然不像临床工作那样面对活生生的人,但它直接关系到人类的健康和疾病,它同样是有温度的。
2002年底,我当选九三学社中央主席,后来相继在全国人大常委会和全国政协担任领导人15年。在此期间,我有幸在更高层面、以更广阔的视野观察和体验医学。当“非典”和新型流感来袭时,我不仅看到病魔的凶险,看到它们对整个社会的严重威胁,也看到医务界白衣战士的英雄本色,看到我们国家在党中央领导下重建传染病防控体系,并使其迅速达到世界先进水平。我到过很多老少边穷地区,看到因病致贫、因病返贫等令人心碎的情景,看到我国医疗事业发展极不充分、医疗资源分布极不均衡的状况。我有机会亲自参与我国医药卫生体制改革,到很多地方调查研究,发现难点痛点,寻找关键环节,为改革出谋划策。这些年的经历,使我对医学的社会属性有了更加深刻的理解,对人类医学发展的根本方向也有了一些思考。
一个多世纪以来,现代技术与医学的结合,使医学插上了翅膀,人类的寿命大大延长,众多曾经肆虐的传染病得到了有效控制,不少严重的疾病得到了明确诊断和有效治疗。但是与此同时,“技术至上”的观念不断蔓延,医学发展的目标和方向开始错乱。医学的重点放在了救治生命后阶段的病人上面,而不是为多数人的健康和减少病痛服务。医学的边界也开始模糊,被赋予了过度的使命,并常常把危险因素当作疾病治疗。人们过度相信技术,常常忘记了病人心理上的苦楚以及对医者关怀的期盼。
慢性病确实已经成为人类健康的主要威胁,但当今人们对慢性病的根本性质和成因缺乏正确的认识。人类的进化是以数十万年计的,从古猿进化到智人经历了200 多万年,脊柱仍然没有完全适应直立行走;十几万年前智人的脑容量已经达到1400ml,7 万年前智人经历了认知革命,而到今天,人类的脑容量并没有进一步增加。另一方面,智人从狩猎采集文明到农业文明花了6 万年,从农业文明到工业文明花了1 万年,而从工业社会到信息社会只用了几百年。生活方式在短时期内发生了如此巨大而迅速的变化,人类的遗传变异和进化远远跟不上,慢性病由此而生。对此,人类除了坦然接受之外,重要的是尽力改善自己的生活方式,而不应把主要责任加诸医药。
人类自有文明就有医术。从《黄帝内经》(东方)和希波克拉底开创医学(西方)以来,医学一直都是回应他人痛苦的努力,它闪烁着人性的光芒。今天,医学大大发展了,但人类对自身的认识与对宇宙的认识一样,还只是冰山一角。人类切不可妄自尊大,以为技术能解决所有的健康问题。医者能做的仍然是“有时去治愈,常常去帮助,总是去安慰”。生命是有限的,每个人从出生、成长、衰老到死亡的过程不可逆转,医学的任务只是保护这个正常的过程。我们不能把衰老当作疾病,不能把追求长生不老作为医学的目标,不能给生命无望的病人增加无谓的痛苦,不能不考虑医学的社会效应与公平公正。总之,我们时时不可忘记,医学是有温度的。
一个人生命的铸成,需要无数生命的支援、补充、滋润和蕴化。一个医者的合格与成熟,需要知识与实践的支撑,也需要与周围的人不断地沟通互动,建立起共同面对疾病的医道。我感谢生命中的许多“偶遇”,这些“偶遇”让我悟到医道中的一些基本情理。60多年前照看我的护士,50年前感谢我的那位农民老伯伯,40多年前我在农村遇到的那些病人,大概许多都已经离开人间了,但是他们留给我的记忆,已经变成了我对医学温度的体验和理解。
医学是人学,医道重温度。
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