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1、Chapter 1 Patient-Physician Interaction 医患沟通The patient-physician interaction proceeds through many phases of clinical reasoning and decision making. 医患沟通在临床诊断和治疗决策的许多时期进行着。The interaction begins with an elucidation of complaints or concerns, followed by inquiries or evaluation to address these conc
2、erns in increasingly precise ways.这种沟通开始于病人主诉或所关注问题的述说，然后通过交流、评估不断精确地确定这些问题。The process commonly requires a careful history or physical examination, ordering of diagnostic tests, integration of clinical findings with the test results, understanding of the risks and benefits of the possible courses o
3、f action, and careful consultation with the patient and family to develop future plans.这个过程通常需要细致的病史询问和体格检查，开具诊断性化验医嘱，综合临床发现和化验结果，理解分析拟行治疗过程中的风险和疗效，然后与病人及家属反复磋商以完善治疗方案Physicians increasingly can call on a growing literature of evidence-based medicine to guide the process so that benefit is maximized
4、,while respecting individual variations among different patients尽管考虑到不同病人中个体差异是存在的，但医生们越来越容易查阅不断增长的循证医学文献来指导这个过程，使得疗效最大化。The increasing availability of randomized trials to guide the approach to diagnosis and therapy should not be equated with “cookbook” medicine但是，不断增多的可用于指导临床诊断与治疗的随机试验资料不应当作“烹调书”使
5、用。Evidence and the guidelines that are derived from it emphasize proven approaches for patients with specific characteristics.因为随机试验获得的现象和思路是侧重于求证具有某些特征病人而来的。Substantial clinical judgment is required to determine whether the evidence and guidelines apply to individual patients and to recognize the o
6、ccasional. 实际的临床判断需要确定这些临床表现和诊断标准是否能应用于病人个体，并能找出例外。Even more judgment is required in the many situations in which evidence is absent or inconclusive.在许多情况下，临床表现缺乏或不典型，需要考虑更多的判断。Evidence also must be tempered by patients preferences, although it is a physicians responsibility to emphasize when presen
7、ting alternative options to the patient. 虽然医生有责任要提出选择性问题让病人回答，但病人肯定会根据自己的倾向调节临床症状。The adherence of a patient to a specific regimen is likely to be enhanced if the patient also understands the rationale and evidence behind the recommended option.假如病人懂得基本原理和表现，对医生提出的问题，有特殊生活方式病人的固执容易被强化。To care for a
8、patient as an individual, the physician must understand the patient as a person. 为了把病人作为一个个体进行治疗，医生必须理解病人是一个人（不是一群人）。This fundamental precept of doctoring includes an understanding of the patients social situation, family issues,financial concerns, and preferences for different types of care and out
9、comes, ranging from maximum prolongation of life to the relief of pain and suffering. 这个最基本的行医原则包括了解病人的社会地位，家庭问题，资金状况以及正确理解病人对不同治疗方法、不同治疗结果的选择，从最大限度地延长生命到临时缓解疼痛和折磨。If the physician does not appreciate and address these issues, the science of medicine cannot be applied appropriately, and even the mos
10、t knowledgeable physician fails to achieve appropriate outcomes. 假如医生没有正确理解和重视这个问题，医学就不可能恰当地应用于临床，甚至一个知识渊博的医生也不能取得理想的治疗结果。Even as physicians become increasingly aware of new discoveries, patients can obtain their own information from a variety of sources, some of which are of questionable reliabilit
11、y.甚至，当医生越来越容易知道新发现的同时，病人也能够通过各种资源得到他们的信息，当然，某些信息是不可靠的。The increasing use of alternative and complementary therapies is an example of patients frequent dissatisfaction with prescribed medical therapy.替代疗法和辅助疗法的应用不断增加就是病人对常规疗法经常不满意的一个例子。Physicians should keep an open mind regarding unproven options bu
12、t must advise their patients carefully if such options may carry any degree of potential risks, including the risk that they may relied on to substitute for proven approaches医生对未证实的疗法应该保持开放的思想，但是，如果这些疗法具有任何程度的潜在风险，都必须细致地告知病人，包括可能需要用已证实的常规疗法去替代的风险。It is crucial for the physician to have an open dialo
13、gue with the patient and family regarding the full range of options that either may consider对医生来说，对病人及家属开诚布公地介绍所有可考虑的治疗选择，是非常重要的。The physician does not exist in a vacuum but rather as part of a complicated and extensive system of medical care and pubic health.医生不是生存在真空中，而是复杂而庞大的医疗和公共健康体系中的一部分。In pre
14、modern times and even today in some developing countries, basic hygiene, clean water, and adequate nutrition have been the most important ways to promote health and reduce disease.在未发达时代，甚至当今在一些发展中国家，基本卫生条件、清洁饮用水和最低营养保障是促进健康减少疾病的最重要方法。In developed countries, the adoption of healthy lifestyles, inclu
15、ding better diet and appropriate exercise, are cornorstones to reducing the epidemics of obesity, coronary disease, and diabetes.在发达国家中，健康的生活方式包括合理饮食和适当锻练，是减少肥胖、冠心病和糖尿病盛行的基础。Public health interventions to provide immunizations and to reduce injuries and the use of tobacco, illicit drugs, and excess
16、alcohol collectively can produce more health benefit than nearly any other imaginable health intervention.公共健康干预如进行疫苗接种、减少损伤、减少吸烟、减少吸毒、减少酗酒等措施共同产生的健康效果几乎比可想象的任何其它健康干预措施都要好得多。Chapter 5 Clinical Preventive Services 临床预防服务Clinical preventive services include counseling, immunization, screening tests, and reduction of the susceptibility to disease by interventions such as therapeutic lifestyle changes and pharmacotherapy.临床预防服务包括对疾病的咨询、防疫、筛查和通过治疗性的生活习惯改变和药物治疗来减少易感
