布朗医生日记
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Out of the bar
Sanford J.Brown（著）
Roger was a 56-year-old new patient who had just finished his wellness exam. Outside of smoking and not getting enough exercise， he had no unfavorable health factors in his life. In fact，he was feeling pretty good. His blood work was unremarkable， but I did detect microscopic hematuria on his urinalysis. "I think this is going to end up being benign，" I said， " but because of your age and history of smoking， we should work it up and rule out some bad characters in your kidney and bladder." He agreed to go for a renal ultrasound and cystoscopy.
Despite my limited request， an overzealous tech scanned Roger’s entire abdomen. The report was ominous： "The liver is filled with poorly marginated， hypoechoic foci. This pattern is characteristic of metastatic disease." I never like calling patients with adverse results， and I downplayed the findings until we could get more definitive tests. After years of delivering bad news， you get a feel for how much a patient wants to know and can handle， and Roger was not yet ready for a worst-case scenario. However， a chest， abdominal and pelvic CT corroborated the liver findings，pointed to a mediastinal hilar mass and suggested a tumor in the colon as well. A curbside with a nearby oncologist had me scheduling Roger for a colonoscopy； the greatest likelihood was a large bowel cancer that had spread to his liver and lung. Roger walked on air when the gastroenterologist told him his colon was clean， but he wasn’t out of the woods yet. Next up was a liver needle biopsy under ultrasound guidance， which confirmed our worst fears： "Metastatic， poorly differentiated carcinoma，" read the path report.
Roger’s now an oncology patient looking at his first round of chemo-therapy for what is most likely an incurable affliction. And I cannot help but wonder whether we did him a favor or a disservice. Had the ultrasound tech not exceeded her authority， he’d probably not be obsessing about his disease， not worrying about nausea，vomiting and hair loss as a side effect of his chemo， and not contemplating his imminent mortality. Have we added to the quality or quantity of his years with our technology？ I doubt it. Sometimes the horse belongs out of the barn.
失马之后锁马厩
中国石油天然气集团公司中心医院 周淑新（编译）
Roger是位新病人，56岁，刚做完健康检查。除了吸烟和未做足够的运动外，他生活中不存在其他不利于健康的因素。他感觉非常好，血液没有明显变化，但做尿液分析时显微镜下可见血尿。“我想这可能是良性的，”我说，“但是考虑到你的年龄和吸烟史，我们还需做一下检查c 排除肾脏和膀胱恶性病变的可能。”他同意做肾超声和膀胱镜检查。
虽然我的要求有限，可这位热心的技师给Roger做了全腹扫描。结果不太好，肝脏充满了边缘不清的低回声区。这是转移病灶的特点。如果检查结果不好，我是不会打电话告诉病人的。对这种检测结果不予与重视，直到有了确诊性检测。传递了几年坏消息后，你会觉察出病人想知道什么，能够承受多少。Roger对自己病情的严重性还没有思想准备。然而胸部、腹部和骨盆CT均可以检查肝脏的体征，提示纵隔、肺门肿块，还有结肠肿瘤。邻街的胃肠科医生让我给Roger安排结肠镜检查，最有可能的是大肠癌向肝脏和肺扩散了。当胃肠科医生告诉他结肠是好的，Roger轻松了许多，不过还是没从困境中摆脱出来。后来又在超声波的引导下做了肝穿刺活检，证实了我们所担心的。“转移病灶，分化不良的肿瘤，”病理报告上这样写着。
Roger现在成为了一名肿瘤病人，要忍受巨大的痛苦接受第一次化疗。我感到有点束手无策。不过，我还是想知道我们是否为他做到了最好。如果做超声的技师不超越他的权限，或许他还不会为他的病感到困扰，也不为恶心、呕吐和脱发的化疗副作用所担心，也不必考虑即将来临的死亡。随着时间的推移，我们的技术给他的生命增添了质量或数量了吗？我对此感到困惑。这有点像失马之后锁马厩（"horse is out of the barn"失马之后锁马厩或亡羊补牢的意思，用来比喻由于太晚了以致无法使情况变得好一点。也就是形容医疗技术发展的太慢了而无法帮助癌症病人，所以Brown将其比喻为"horse is out of the barn"）。