Southwick Frederick S, Spear Steven J
Department of Medicine/Division of Infectious Diseases, University of Florida College of Medicine, Gainesville, Florida 32610, USA.
Acad Med. 2009 Dec;84(12):1648-50. doi: 10.1097/ACM.0b013e3181bf9f80.
Over 15 years have passed since Mary's near death (Annals of Internal Medicine. 1993;118:146-148). Disappointment in the care by fellow academic physicians persists; however, a reanalysis of her case through the lens of complex systems design and performance yields a more accurate and actionable perspective. Mary's suffering was not due to human failure alone. Human failure was provoked and exacerbated by broken processes including ambiguous assignments of responsibility; inadequate transfers of information and authority; unreliable or unavailable protocols for providing safe, effective treatment; and a failure to integrate the deep but narrow perspectives of individual specialists into a complete picture of Mary's condition. Her case exemplifies, in personal terms, many of the system challenges academic medical centers face: Faculty have other missions that can conflict with patient care; disease complexity is high, requiring input from multiple subspecialists; clinical departments serve as roadblocks to communication; and novice physicians, requiring close supervision, have primary responsibility for the day-to-day care of acutely ill patients. The academic physicians who first cared for Mary unwittingly accepted flawed systems, and they failed to work around them. At great monetary and emotional expense, last-minute heroics saved Mary. In a dysfunctional system, even the most conscientious physician may be viewed as uncaring. As Mary's case so clearly illustrates, patients and their families see the system and the physician as one. Only by working to improve the systems of delivery will academic physicians again be consistently viewed as caring.
自玛丽濒死事件发生至今已过去15年有余（《内科学年鉴》，1993年；118卷：146 - 148页）。她对同行学术医生的治疗仍感到失望；然而，通过复杂系统设计与性能的视角对她的病例进行重新分析，能得出更准确且可付诸行动的观点。玛丽所遭受的痛苦并非仅仅源于人为失误。人为失误是由诸多有缺陷的流程引发并加剧的，这些流程包括职责分配不明确；信息与权力传递不足；缺乏可靠或可用的安全、有效治疗方案；以及未能将各个专科医生深入但片面的观点整合为玛丽病情的全貌。她的病例以个人经历为例，体现了学术医疗中心面临的诸多系统挑战：教员身负其他可能与患者护理相冲突的任务；疾病复杂性高，需要多个亚专科医生的参与；临床科室成为沟通的障碍；而需要密切监督的新手医生却对急症患者的日常护理负有主要责任。最初照料玛丽的学术医生无意间接受了有缺陷的系统，且未能绕过这些系统。付出了巨大的金钱和情感代价后，最后时刻的奋力抢救挽救了玛丽。在一个功能失调的系统中，即便最尽责的医生也可能被视为冷漠无情。正如玛丽的病例清晰表明的那样，患者及其家属将系统和医生视为一体。只有努力改进医疗服务系统，学术医生才会再次被一致视为关爱患者的群体。
