Treating Medically Unexplained Symptoms Empirically: Ethical Implications for Concurrent Diagnosis.
Treating Medically Unexplained Symptoms Empirically: Ethical Implications for Concurrent Diagnosis.
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经验性治疗医学上无法解释的症状：同时诊断的伦理意义。
DOI：
10.1080/15265161.2018.1445320
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发表时间：
2018
期刊：
影响因子：
--
通讯作者：
Ford,PaulJ
中科院分区：
文献类型：
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作者：
Sankary,LaurenR;Ford,PaulJ
在对医学无法解释的症状 (MUS) 的伦理重要性进行细致入微的分析时，O’Leary 呼吁人们关注影响门诊临床实践的最重要问题之一：评估和透明地解决 MUS 的困难 (O’Leary 2018)。 O’Leary 强调了 MUS 表征中概念模糊的根源，这些根源阻碍了临床决策、伦理分析和获得优质护理。鉴于目前研究的重点是过度治疗的潜在危害，她批评了对 MUS 患者生物症状的治疗不足。这种讨论因对普遍存在的“经验治疗”医疗实践的更多认识而得到加强，特别是当干预措施风险较低时。此外，心因性 MUS 伴随医学上解释的“器质性”疾病的生物学症状的实例挑战了 MUS 临床和伦理讨论中的二元概念。在这篇评论中，我们基于 O’Leary 的 MUS 分析框架，考虑了以下方面的伦理含义：(1) 诊断和干预之间的模糊区别，描述为在没有明确诊断的情况下倾向于“凭经验治疗”；(2) 可归因于可识别的生物学原因的心因性症状和器质性症状同时发生。奥利里认为，在当前的医疗实践模式下，临床医生在确定疾病或疾病的明确生物标志物的基础上从诊断到治疗。虽然奥利里将诊断不确定性引入了这种医疗实践模型，但她的分析基本上假设诊断和治疗之间可以明确区分。此外，她认为临床医生在诊断不确定的情况下倾向于停止治疗。这种临床决策的特征低估了“经验治疗”在大多数医疗实践中的主导地位。通常，临床医生在缺乏对症状表现背后的生物学机制的明确诊断的情况下启动治疗干预。抗菌治疗为这种经验性方法提供了一个说明性的例子：观察感染症状的临床医生可能会在诊断测试之前或不进行诊断测试以确定特定病原体时开出广谱抗生素。很多时候，实验室测试只是保证抗生素的使用应该继续或建议更换抗生素。皮肤病学、局部治疗可作为一线治疗。如果局部治疗失败，该信息有助于鉴别诊断。然而，如果在使用局部治疗后症状得到解决，那么患者的问题就解决了，可能不需要进一步的诊断询问来确认医生的判断是否正确。患者的症状随着时间的推移或由于局部治疗而得到解决，因此提供者会务实地转向下一位需要解决症状的患者。在做出临床判断时，医疗保健提供者会权衡成本密集、繁重且可能不确定的诊断测试的诊断价值，以应对延迟开始治疗、效率和实用主义引起的发病率的担忧。即使经验性抗菌治疗实现了症状减轻或解决，特定干预措施的发病机制和治疗作用机制可能仍不清楚。当推荐治疗用于诊断和治疗目的时，在设定治疗反应预期和为疾病提供诊断标签方面会出现一系列不同的伦理挑战。这可能会导致患者和其他临床医生做出以下假设……
In a nuanced analysis of the ethical importance of medically unexplained symptoms (MUS), O’Leary calls attention to one of the most significant issues affecting outpatient clinical practice: the difficulty of evaluating and transparently addressing MUS (O’Leary 2018). O’Leary highlights sources of conceptual ambiguity in the characterization of MUS that hinder clinical decision making, ethical analysis, and access to quality care. She criticizes the undertreatment of biological symptoms in patients with MUS in light of the current emphasis in research on potential harms of overtreatment. This discussion is enhanced by greater recognition of the ubiquitous medical practice of “treating empirically,” particularly when interventions present low risks. Further, instances in which psychogenic MUS accompany biological symptoms of medically explained,“organic” disorders challenge binary notions in clinical and ethical discourse on MUS. In this commentary, we build on O’Leary’s framework for the analysis of MUS by considering the ethical implications of (1) the blurred distinction between diagnosis and intervention, described in the tendency to “treat empirically” in the absence of a definitive diagnosis, and (2) the co-occurrence of both psychogenic symptoms and organic symptoms attributable to identifiable biological causes. O’Leary posits that, under the current model of medical practice, clinicians proceed from diagnosis to treatment on thebasisoftheidentificationofdefinitivebiologicalmarkers ofanillnessordisease. WhileO’Learyintroducesdiagnostic uncertainty into this model of medical practice, her analysis foundationally assumes a clear distinction can be made between diagnosis and therapy. In addition, she posits that clinicians have a tendency to withhold treatment in cases of diagnostic uncertainty. This characterization of clinical decision making underestimates the predominance in most medicalpracticeof “treatingempirically.” Frequently, clinicians initiate therapeutic interventions in the absence of a definitive diagnosis of the biological mechanisms underlyingsymptompresentation. Antimicrobialtherapyprovides an illustrative example of this empiric approach: Clinicians observing symptoms of an infection may prescribe broadspectrum antibiotics before or without diagnostic testing to identify a specific pathogen. Many times, lab tests simply provide assurance that antibiotic use should continue or suggestaneedtochangetheantibiotic. Indermatology, topical treatment may be prescribed as a first-line treatment. If topical treatment fails, this information aids in the differentialdiagnosis. However, ifsymptomsresolveafteruseofthe topical treatment, then the problem is solved for the patient and no further diagnostic inquiry may be necessary to confirmthatthephysicianjudgedcorrectly. Thepatient’ssymptoms resolved either over time or due to the topical treatment, so the provider pragmatically moves on to the next patient whose symptoms need to be resolved. In makingclinicaljudgments, healthcareprovidersweighthediagnostic value of cost-intensive, burdensome, and potentially inconclusivediagnostictestingagainstconcernsaboutmorbidityindelayinginitiationoftherapy, efficiency, andpragmatism. Evenwhenempiricantimicrobialtherapyachieves symptom reduction or resolution, pathogenesis and the therapeutic mechanism of action of a given intervention mayremainunclear.When therapy is recommended for both diagnostic and therapeutic purposes, a different set of ethical challenges arises in relation to setting expectations for therapeutic response and providing a diagnostic label to the illness. This can cause both patients and other clinicians to make assumptions about …