医院医学中的健康公平性：基础、人群和行动

English | 2023 | ISBN-10: 3031449983 | 158 pages| Epub PDF (True) | 6 MB

Hospital-based physicians are privy to some of the most meaningful moments of people’s lives, including life-changing diagnoses, pivotal medical procedures, complex medical decisions, and critical end-of-life decisions. Yet, hospitalists have no framework for how to incorporate the varied social factors that impact care such as race, gender identity, cultural background, immigration status, sexual orientation, primary language, housing status, and poverty into clinical decision-making. As hospital physicians, we may use interpreters for our limited English proficiency patients, or try to incorporate questions about cultural practices into our admission histories, or even ask our patients about the ways in which they feel racism has affected their care, but these practices are inconsistently applied and lack a systematic framework for ensuring that the hospital care we provide is truly equitable. In my own practice as a hospital-based physician, I can recall scores of hospitalized patients where we tried hard to provide equitable care, but fell short. I remember the Spanish-speaking patient with multiple comorbidities who received neurosurgery and was on the road to recovery on an acute care unit, when on day three, he complained of vague abdominal discomfort and ended up dying of a perforated bowel. No interpreter was used by the team to fully delve into the details of the pain he was experiencing. I remember the young Black patient with terminal malignancy who had multiple repeated conversations with physicians recommending hospice care but refused until he saw a physician who was able to explain hospice within the context of racism that has historically defined clinical care for Black people, and was able to present hospice not as a way to hasten death but rather as a way to live the remainder of his days in comfort. I remember the elderly Pakistani female patient whose demanding son antagonized staff and clinicians alike until he was banned from visiting because of his aggressiveness with staff and whose inability to visit his mother caused her extreme distress as she felt that she had lost the unique voice that only her oldest son could provide.

医院的医生们能够接触到人们生活中的一些最深刻和有意义的时刻，包括改变一生的诊断、关键性的医疗程序、复杂的医学决定以及生死攸关的生命末期决策。然而，住院医师并没有一套框架来处理各种社会因素对护理的影响，比如种族、性别认同、文化背景、移民状态、性取向、母语、居住状况和贫困等方面的问题，并将其融入临床决策过程中。作为医院的医生，我们可能会使用口译服务来帮助有限英语能力的患者，或者将关于文化习俗的问题纳入患者的病史中，甚至询问患者他们认为种族主义如何影响了他们的护理过程，但这些做法并没有得到一致的应用，并且缺乏一个系统化的框架以确保我们所提供的医疗服务是真正公平的。在我的实际工作中作为医院医生，我可以回忆起许多住院的患者，我们在尽力提供公平的护理方面努力过头，但还是没能如愿。我记得一位有多重合并症的西班牙语病人，在重症监护病房中接受神经外科手术，并且正在康复的路上。但是在第三天的时候他因为不明确的腹部不适而感到不适，最后因小肠穿孔而死亡。医疗团队并没有使用口译员来深入了解他对疼痛的感受细节。我还记得那位患有晚期恶性肿瘤的年轻黑人患者，他反复与医生交谈直至推荐临终关怀服务，但是直到有一位能够将临终关怀置于种族主义这一历史性的护理框架中解释给他听的医生出现后，他才拒绝了这项建议。这位医生解释说临终关怀并非为了加速死亡而是为了让病人在接下来的日子里得以舒适地度过余生。我还记得那位来自巴基斯坦的年长女性患者，她的强势儿子与医疗团队和医护人员产生了过多的矛盾和冲突直到他因为对工作人员过于粗暴而被禁止探视。无法去探望她的母亲令她感到极为痛苦，因为她觉得只有自己最大的孩子才能带来她所独有的声音。

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