1、Motivating Ourselves and Our Patients to be Healthy鼓励我们自己和病人保持健康,Marie Shieh, M.D. 2008 October 24,谢医师简介,American board-certified family physician practicing medicine in Beijing for the last 6 years at BJU. I had 3 years experience before that in the U.S. and New Zealand in private practice. I am ma
2、rried with 2 sons. I have wanted to be a family physician since I was 4 years old. 美国家庭医学科专科医师，近六年在BJU工作。 曾在美国和新西兰从事私人医生职业3年。 我已经结婚并有2个儿子，我从4岁起就想成为一名家庭医生了。,Patient story病人的故事,40 year old Asian woman40岁亚裔女性 Full time job and 2 children全职工作和两个孩子 Non smoker and no ETOH不吸烟不喝酒 Diet: less than 5 vegetable
3、s and fruits daily食谱：每天少于5种蔬菜水果 Activity: once per week运动：每周一次 Wellbeing: stressed and tired much of the time健康状态：压力很大，大部分时间困倦 BMI 23.5BMI 23.5 Not taking regular medication for chronic condition未因慢性病规律服药,What is a healthy lifestyle?怎样才是一种健康的生活方式?,Not smoking不吸烟 Good diet良好饮食 Physical activity体育活动 W
4、ellbeing安康快乐 Following Doctors advice听从医生的建议,Smoking and Tobacco Use 吸烟与烟草制品使用,How may men worldwide smoke?世界上有多少男性吸烟？ 1 out of 3 men三分之一的男性 How many teens (13-15 yo) smoke?有多少未成年人（13-15虽）吸烟？ 1 in 5 teens五分之一未成年人 How many children start smoking everyday?每天有多少孩子开始吸烟？ 80-100,000 1/2 of these are in As
5、ia其中一半是在亚洲,Multiple Health Risks to Self and Family对自身和家人的多重健康威胁 Bad Breath口臭 Early wrinkles早生皱纹 Yellow Teeth黄牙 Money耗费钱财,Healthy Diet健康饮食,Colorful and variety色彩鲜艳且种类多 Vegetables and fruits - 5 servings (7-9 ideal)蔬菜与水果5份（ 7-9份最理想） Whole grains全谷类 Not much fatty foods like meats and dairy没有太多脂类食物例如肉
6、类与乳制品 2-3 portions of fish2-3份鱼 Limit saturated fat - if frying use olive, canola, sunflower or rapeseed oil限量的饱和脂肪酸-如果油炸使用橄榄、油菜籽、向日葵或者油菜油来烹饪 USPTF 1996 and JAMA 2002;288:2569 and www,patient.co.uk,Vegetables and Fruits蔬菜与水果,Whole grains全谷类,Dairy乳制品,Processed food加工食品,Beans and Meats豆类与肉类,Physical A
7、ctivity体育运动,Aging老年 Heart Disease and Diabetes心血管疾病以及糖尿病 Colon and Breast Cancer结肠和乳腺癌 Musculoskeletal Problems and Osteoporosis肌肉骨骼问题与骨质疏松 Depression and Anxiety抑郁和焦虑 Most Americans - no physical activity大部分美国人-没有体育运动 Australians: 65% do not meet minimal activity 澳大利亚人：65%没有达到最低运动量 China?中国？ What i
8、s minimum activity?什么是最低运动量,Breast cancer and exercise 乳腺癌与运动,Archives Int Med 2007: 110,000 women, 20-79 years old. 6 year study. 110,000名年龄2079岁的妇女，长达6年的研究 5 hours walking per week vs less than 0.5 hours per week 每周5小时不行 vs 不足0.5小时 20% reduction in breast cancer (RR 0.8) 乳腺癌风险降低20%（RR风险比0.8） Less
9、invasive cancer - ER + in exercise group 较低度恶性肿瘤在运动组中ER JAMA 2003 Prospective study70,000 women. 50-79 years old. 5 year study. 前瞻研究70,000女性5079岁，5年研究 14-18% reduction in breast cancer 乳腺癌减少1418% Best if women were below BMI 24.1 体重指数低于24.1最佳 Overweight women also benefited 超重妇女同样收益于运动 10 hours per
10、week brisk walking best 每周10小时快走最佳 1.25-2.5 hours also beneficial 1.252.5小时同样有益,Pancreatic Cancer and Exercise 胰腺癌与运动,JAMA 2001 - cohort trial 队列研究 46,000 men and 100,000 women 46,000男性和10,000女性 For those with BMI over 25, exercise significantly reduced risk of pancreatic cancer 对于体重指数高于25者，运动显著减少胰腺
11、癌的风险,Colon Cancer 结肠癌与运动,Cancer Causes Control 1997 - meta analysis癌症病因控制1997荟萃分析 Inverse relation of exercise to colon cancer 运动和结肠癌之间的反比例关系 50% reduction in incidence of colon cancer in the most active participants 最积极运动者结肠癌发病率降低50% British Journal of Cancer 2001- prospective study 不列颠癌症杂志2001前瞻研究
12、 75,000 Norwegians 75,000挪威人 12 years follow up 12年随访 Inverse relation of exercise to colon cancer 运动和结肠癌之间的反比例关系 BMI not correlated with colon cancer risk 体重指数和结肠癌风险之间不相关,Depression and Exercise 抑郁与运动,Psychosomatic Medicine 2000 身心医学2000 156 adults with Major Depressive Disorder 156名重度抑郁成人 Hamilton
13、 and Becks scores over 10 months 进行10个月Hamilton和Beck评分 3 groups: Equally effective 3组同等有效 Sertraline(zoloft) - fastest response舍曲林反应最快 Exercise - lower relapse rate 运动复发率低 Sertraline and exercise二者联合,How much physical activity? 多大的运动量合适？ (National Physical Activity Guidelines for Australians and US
14、CDC 澳大利亚国家体育运动指南）,Intensity of Exercise 运动强度,60-75% of maximum heart rate 最大心率的6075% “Maximum heart rate = 220-age最大心率220年龄 75% of maximum heart rate is the desired rate for moderate to heavy intensity exercise“75%最大心率是中度到剧烈运动的目标心率,Link between fitness and longevity健康与长寿之间的联系,In the largest study to
15、 examine the link between exercise capacity and mortality risk in a racially mixed cohort, mortality dropped 12% to 15% with every 1 metabolic equivalent in exercise capacity在混杂人种队列中调查运动能力与死亡风险的最大的研究中发现，运动能力每增加1代谢当量，死亡率下降12%-15% (Circulation. Published online January 22, 2008 NEJM 2002 study with 60
16、00 men: 12% improvement in survival with every 1 MET of exercise capacity。NEJM2002年对6000人的研究：运动能力每增加1代谢当量生存率提高12%。 Fitness or MET exercise capacity is directly linked to amount of exercise健康或者代谢当量运动能力与运动量直接相关。 Stress treadmill to check our MET capacity踏旋器应力试验可测量我们的代谢当量能力。,Circulation 2003,Actual yea
17、rs gained实际可多活的年数,Health and Wellbeing健康福祉,Hostility and Heart Disease敌意与心脏病 Hostility and Lung Function敌意与肺功能 Also associated with more days off work也与更多假日相关,Hostility Questions敌意问询,At times I feel like smashing things有时候我想要把东西砸碎 I easily become impatient with people我很容易对人失去耐心 Ive been so angry at
18、times, Ive hurt people in a fight.有时候我非常生气以至于在打架时伤害了别人。,Characteristics of Physicians that Increase Risk for Burnout 增加医生对工作失去兴趣机会的特质,Perfectionism and compulsiveness完美主义和强迫人格 Need for control什么都要管 Exaggerated sense of responsibility过分的责任感 Difficulty asking for help较难求助于人 Excessive, unrealistic guil
19、t过多的不现实的内疚 Suppression of feelings情感的压抑 Difficulty taking vacations and enjoying leisure time较难休假和享受闲暇时光,Following Doctors Recommendations 听从医生的推荐,Lifestyle changes生活方式改变 Follow up appointments回诊 Other remedies其他疗法 Prescribed courses of medications开几个疗程的药 Surgery手术,Can we make a difference? 我们能起作用么？
20、,Evidence supports doctors intervention in quitting smoking有证据支持医生帮助戒烟的作用 Evidence supports physician counseling about exercise有证据支持医生建议运动的作用 Evidence supports physician counseling about diet有证据支持医生建议饮食的作用 Evidence supports physician counseling about wellbeing有证据支持医生建议福祉的作用 Evidence supports physici
21、an supported healthcare有证据支持医生参与的医疗保健,Motivation动机,Intrinsic内部的 Internal satisfaction - feeling better内心满足-感觉更好 Better health更健康 Love and Acceptance internal自身的爱与接受Extrinsic外部的 External reward - looking better外部奖励-看起来更好 Approval - love and acceptance external 鼓励-外人的爱与接受 Connection关系 Positive Feedbac
22、k正性反馈,Five As五个A,ASK询问 ADVISE建议 ASSESS评估 ASSIST协助 ARRANGE安排 Australian Family Physician and American Family Physician Journals 2008 Whitlock, EP, Orleans, CT, Pender, N, Allan, J. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med 2002; 22:267,ASK
23、and LISTEN 询问与倾听,Do you smoke?您吸烟么？ Do you eat at least 5 vegetables and fruits a day? Breakfast, Lunch and Dinner您每天至少吃5种蔬菜水果么？包括早、中、晚餐 How much activity do you get in a typical week? What kind? How vigorous?您一般一周做多少运动？哪种？多激烈？ How is life? How is work? How is your marriage going? How is your family
24、? Do you have good supports around you?Balance?生活怎样？工作怎样？您的婚姻生活怎样？您的家庭怎样？您身边有很好的支持么？生活平衡否？ Are you following your doctors advice?您是否听从您的医生的建议？ Anything else?还有其他问题么？,ADVISE建议,EDUCATE教育 Handouts印刷品 CDs CD DVDs DVD Websites 网页 Local resources 当地资源BE SUPPORTIVE AND NONJUDGMENTAL ( of yourself and your
25、patients)要支持不要评判（对你自己和你的病人）,ASSESS评估,How willing are you or your patient to make changes?您或者您的病人有多愿意做改变？ Do you want to quit smoking?您是否愿意戒烟？ Do you want to be more active?您是否希望更积极？ Are you ready to change your diet?您是否准备改变您的饮食？ How balanced is your life?您的生活有多平横？ Questionnaires and Tools问卷与用具,Quest
26、ionaires and Tools 问卷与用具,Transtheoretical Model跨理论模式 Precontemplation预期前 Contemplation预期 Preparation准备 Action (20%)行动（20%） Motivation动机 Relapse回复 Wheel of Life生命之轮 Howsyourhealth.org Pyramid.gov American Lung Association questionnaire 美国肺脏协会问卷,Smoking questions吸烟的问题,Do you smoke your first cigarette
27、 withing 30 minutes of waking up in the morning?您是否在早晨醒后30分钟之内吸您的第一根香烟？ Do you smoke 20 cigarettes or more a day?您是否每天吸烟20支或者更多？ At times when yo cant smoke or do not have cigarettes, do you crave one?有时候当你不能吸烟或者没有烟，你是否会渴望获得一支？ Is it tough for you to keep from smoking for more than a few hours?几个小时不
28、吸烟对你来说是不是很难？ When you are sick enough to stay in bed, do you still smoke?当你卧病在床时候是否仍然要吸烟？ Yes to 2 or more, addicted to cigarettes.2个以上回答是即为吸烟成瘾。,Smoking Triggers吸烟的触因,Eating饮食 Alcohol喝酒 After Sex性交之后 Coffee咖啡 Driving驾驶 Ask your patient about their triggers询问您的病人他们的触因,ASSIST and AGREE协助与赞同,Barriers
29、to lifestyle change (Risk)生活方式改变的障碍（危险） Benefits to lifestyle change (Benefit) 生活方式改变的收益（ 收益） SMART goal SMART目标 Contracts and Rewards and Consequences合同、奖励与后果 Lifestyle prescriptions生活方式处方 Help from family and friends and community来自家庭、朋友和社区的帮助 Homework for patients 病人的家庭作业 Medication to help quit
30、smoking or help with their disease帮助戒烟或治疗病人疾病的药物,Barriers障碍,Negative thoughts负面的想法 Fear恐惧 Habit习惯 Laziness懒惰 Fatigue疲劳 Lack of Time没有时间 Lack of Money缺钱 Not Knowing不知道,Benefits收益,Imagine how you feel?想象一下你的感觉 Imagine how you look?想象一下你看起来会怎样 Imagine how you smell?想象一下你闻起来会怎样 Health and Longevity健康长寿
31、Rewards ceremony奖励-庆典 Imagine what your friends and family will say想象一下你的家人朋友会怎样说 Imagine what your doctor will say想象一下你的医生会说什么 Financial Benefits经济收益,SMART GOALS SMART目标,Specific详尽 Measurable可测 Achievable可达 Accountable可靠 Results/Reward Oriented 结果/奖励为导向 Time Specific时间具体,Lifestyle prescriptions and
32、 Contracts生活方式处方与合同,Write on prescription pad 书写于处方笺 1 copy to patient, another to chart一联给病人一联留在病历 Contract with a reward or punishment签订一个奖励或处罚合同 http:/ Contract to do something为做某事签的合同 Appoint referee任命裁判 If you do not fulfill your contract, money is donated to charity or organization 如果没有履行自己的合约
33、，钱会被捐往慈善事业或者机构 Red Cross, CARE, Doctors Without Borders, Feed the Children, Nature Conservancy and more红十字会，CARE，无国界医生等等,Contracts and Social Psychology 合同与社会心理学,http:/ - founded by Yale Economics Professor Dean Karlan Contract to do something为做某事签的合同 Appoint referee任命裁判 If you do not fulfill your c
34、ontract, money is donated to charity or organization 如果没有履行自己的合约，钱会被捐往慈善事业或者机构 Red Cross, CARE, Doctors Without Borders, Feed the Children, Nature Conservancy and more红十字会，CARE，无国界医生等等 Money can also be given to organization you oppose 金钱也可交给你反对的组织 Based on Behavioral Economics 建立在行为经济学上 1.People do
35、nt always do what they claim they want to do, and 人们并不总能做到他们宣称想做的事，并且 2.Incentives get people to do things 诱因或刺激物促使人们行动起来,Community resources社区资源,Accountability可靠性 Fellow workmates同伴同事 Friends朋友 Family家庭 You你 Your boss你的老板 Group supports like 类似AA的支持小组 Your doctor你的医生 Wellness Program健康计划,ARRANGE安排,
36、Follow up随诊 Asymmetrical Paternalism非对称性家长主义 Set up Next Appointment, Now现在就定好下次回诊时间 Set up Next Blood Test, Now现在就定好下次血检 Make Referral Appointment NOW现在就定好转诊看病时间 MAKE IT HARDER TO DO THE UNHEALTHY THING (Patient has to cancel appointment.)使不健康的事情做起来更困难（病人必须取消预约）,Patient story病人的故事,40 year old Asian
37、 woman40岁亚裔女性 Full time job and 2 children全职工作和两个孩子 Non smoker and no ETOH不吸烟不喝酒 Diet: less than 5 vegetables and fruits daily食谱：每天少于5种蔬菜水果 Activity: once per week运动：每周一次 Wellbeing: stressed and tired much of the time健康状态：压力很大，大部分时间困倦 BMI 23.5BMI 23.5 Not taking regular medication for chronic condit
38、ion未因慢性病规律服药,Patient Story病人的故事,Diet increased in veggies and fruits增加饮食中的蔬菜和水果 Activity increased with walking daily and yoga daily and tennis once a week运动增加每天走路和瑜伽，每周一次网球 Spent more time with family and friends 与家人和朋友待更多时间 Happier and more energetic更快乐更有活力 BMI 22 BMI 22,Ask and Listen问询与倾听 Smokin
39、g吸烟 Diet饮食 Exercise运动 Wellbeing福祉 Advise建议 Assess评估 Assist协助 Arrange安排,A Healthier and Happier Me 一个更健康更快乐的我,Putting Prevention into Practice将预防贯彻于实践,Prepare office staff 教育办公室人员 Clinician reminders 临床医生提醒 Provide patient education resources 提供病人教育的资源 Referral network for intensive counseling集中咨询的转介网络 Network of role models行为榜样网络 Prevention counseling notes in the medical record医疗记录中的预防性咨询记录 Adequate follow-up足够的随诊,United States Public Health Service Office of Prevention,Thanks and Questions,
