GENERAL APPROACH TO THE PATIENT
对病人的一般治疗方法
The medical interview serves several functions.
医疗面谈有几个功能。
It is used to collect information to assist in diagnosis (the “history” of the present illness), to understand patient values, to assess and communicate prognosis, to establish a therapeutic relationship, and to reach agreement with the patient about further diagnostic procedures and therapeutic options.
医疗面谈被用于收集信息，以帮助诊断（当前疾病的“病史”），了解患者的价值观，评估和沟通预后，建立治疗关系，并与患者就进一步的诊断程序和治疗方案达成一致。
It also serves as an opportunity to influence patient behavior, such as in motivational discussions about smoking cessation or medication adherence.
医疗面谈也可以作为一个影响患者行为的机会，例如在关于戒烟或坚持服药的激励性讨论中影响患者行为。
Interviewing techniques that avoid domination by the clinician increase patient involvement in care and patient satisfaction.
避免被临床医生支配的访谈技巧增加了病人对疾病治疗参与度和满意度。
Effective clinician-patient communication and increased patient involvement can improve health outcomes.
有效的医-患沟通以及增加患者参与度可以改善健康状况结局。
Patient Adherence
患者依从性
For many illnesses, treatment depends on difficult fundamental behavioral changes, including alterating diet, taking up exercise, giving up smoking, cutting down drinking, and adhering to medication regimens that are often complex.
对于许多疾病，治疗取决于困难的基本行为改变，包括改变饮食、进行锻炼、戒烟、减少饮酒，以及坚持通常很复杂的药物治疗方案。
Adherence is a problem in every practice; up to 50% of patients fail to achieve full adherence, and one-third never take their medicines.
依从性在每一种医疗活动中都是一个问题；多达50%的患者未能达到完全的依从性，三分之一的患者从未服药。
Many patients with medical problems, even those with access to care, do not seek appropriate care or may drop out of care prematurely.
许多有医疗问题的病人，即使是那些能够获得护理的病人，也没有寻求适当的护理，或可能过早地退出护理。
Adherence rates for short-term, self-administered therapies are higher than for long-term therapies and are inversely correlated with the number of interventions, their complexity and cost, and the patient’s perception of overmedication.
短期、自我给药治疗的依从率高于长期治疗，并且与干预措施的数量、其复杂性和成本以及患者对过度用药的认知呈负相关。
As an example, in HIV-infected patients, adherence to antiretroviral therapy is a
crucial determinant of treatment success.
例如，在艾滋病毒感染患者中，坚持抗逆转录病毒治疗是治疗成功的关键决定因素。
Studies have unequivocally demonstrated a close relationship between patient adherence and plasma HIV RNA levels, CD4 cell counts, and mortality.
研究已经明确地证明了患者依从性与血浆HIVRNA水平、CD4细胞计数和死亡率之间的密切关系。
Adherence levels of more than 95% are needed to maintain virologic suppression.
需要超过95%的依从水平才能维持病毒学抑制。
However, studies show that over 60% of patients are less than 90% adherent and that adherence tends to decrease over time.
然而，研究表明，超过60%的患者的依从性低于90%，而且依从性往往随着时间的推移而下降。
Patient reasons for nonadherence include simple forgetfulness, being away from
home, being busy, and changing daily routine.
病人不坚持治疗的原因包括纯粹忘记，远离家园，忙碌，改变日常生活。
Other reasons include psychiatric disorders (depression or substance misuse), uncertainty about the effectiveness of treatment, lack of knowledge about the consequences of poor adherence, regimen complexity, and treatment side effects.
其他原因包括精神障碍（抑郁或药物滥用）、治疗有效性的不确定性、缺乏对依从性差的后果的了解、治疗方案的复杂性和治疗副作用。
The rising costs of medications, including generic drugs, and the increase in patient cost-sharing burden, has made adherence even more difficult, particularly for those with lower incomes.
包括仿制药在内的药物成本的上升，以及患者成本分摊负担的增加，使得坚持治疗更加困难，尤其是对那些收入较低的人。
Patients seem better able to take prescribed medications than to adhere to recommendations to change their diet, exercise habits, or alcohol intake or to perform various self-care activities (such as monitoring blood glucose levels at home).
患者服用处方药物似乎比坚持改变饮食、锻炼习惯的建议，或饮酒，或进行各种自我护理活动（如在家监测血糖水平）更好。
For short-term regimens, adherence to medications can be improved by giving clear instructions.
对于短期治疗方案，可以通过给予明确的指导来改善对药物的依从性。
Writing out advice to patients, including changes in medication, may be helpful.
给病人写一些建议，包括改变药物治疗，可能是给予帮助的。
Because low functional health literacy is common (almost half of English- speaking US patients are unable to read and understand standard health education materials), other forms of communication—such as illustrated simple text, videotapes, or oral instructions—may be more effective.
由于低实用性健康素养很常见（几乎一半的讲英语的美国患者无法阅读和理解标准的健康教育材料），其他形式的交流——如有说明的简单文本、录像带或口头指示——可能更有效。
For non–English-speaking patients, clinicians and health care delivery systems can work to provide culturally and linguistically appropriate health services.
对于不讲英语的患者，临床医生和卫生保健提供系统可以努力提供适合文化和语言的卫生服务。
To help improve adherence to long-term regimens, clinicians can work with patients to reach agreement on the goals for therapy, provide information about the regimen, ensure understanding by using the “teach-back” method, counsel about the importance of adherence and how to organize medication-taking, reinforce self-monitoring, provide more convenient care, prescribe a simple dosage regimen for all medications (preferably one or two doses daily), suggest ways to help in remembering to take doses (time of day, mealtime, alarms) and to keep appointments, and provide ways to simplify dosing (medication boxes).
为了帮助提高长期方案的依从性，临床医生可以与患者就治疗目标达成一致，提供有关方案的信息，确保理解使用“回馈教学”方法，建议关于坚持的重要性和如何组织服药，加强自我监控，提供更方便的护理，开一个简单的剂量方案（最好是每天一个或两个剂量），建议如何帮助记住服用剂量（一天的时间、用餐时间、警报）和保持预约，并提供简化给药的方法（药物盒）。
Single-unit doses supplied in foil wrappers can increase adherence but should be avoided for patients who have difficulty opening them.
用箔包装提供的单单位剂量可以增加粘附性，但对于难以打开它们的患者应避免。
Medication boxes with compartments (eg, Medisets) that are filled weekly are useful.
含隔间的可以填满一周用药量的药盒(如Medisets)是有用的。
Microelectronic devices can provide feedback to show patients whether they have taken doses as scheduled or to notify patients within a day if doses are skipped.
微电子设备可以提供反馈，显示患者是否按计划服用了剂量，或者如果跳过剂量，可以在一天内通知患者。
Reminders, including cell phone text messages, are another effective means of encouraging adherence.
提醒，包括手机短信，是鼓励人们坚持不懈的另一种有效手段。
The clinician can also enlist social support from family and friends, recruit an adherence monitor, provide a more convenient care environment, and provide rewards and recognition for the patient’s efforts to follow the regimen.
临床医生还可以从家人和朋友那里获得社会支持，招募一个依从性监测者，提供一个更方便的护理环境，并提供奖励和认可患者努力遵循方案的认可。
Collaborative programs that utilize pharmacists to help ensure adherence are also effective.
利用药剂师来帮助确保坚持治疗的合作项目也是有效的。
Adherence is also improved when a trusting doctor-patient relationship has been
established and when patients actively participate in their care.
当一种信任的医患关系已经存在时，依从性也会得到改善当病人积极参与他们的护理时。
Clinicians can improve patient adherence by inquiring specifically about the behaviors in question.
临床医生可以通过具体询问相关行为来提高患者的依从性。
When asked, many patients admit to incomplete adherence with medication regimens, with advice about giving up cigarettes, or with engaging only in “safer sex” practices.
当被问及这个问题时，许多患者承认他们不完全坚持用药方案，有关于戒烟的建议，或只从事“安全性行为”的实践。
Although difficult, sufficient time must be made available for communication of health messages.
虽然很困难，但必须有足够的时间来传播健康信息。
Medication adherence can be assessed generally with a single question: “In the past month, how often did you take your medications as the doctor prescribed?” Other ways of assessing medication adherence include pill counts and refill records; monitoring serum, urine, or saliva levels of drugs or metabolites; watching for appointment nonattendance and treatment nonresponse; and assessing predictable drug effects, such as weight changes with diuretics or bradycardia from beta-blockers.
药物依从性一般可以通过一个问题来评估：“在过去的一个月里，你多久按照医生的处方服用一次药物？”其他评估服药依从性的方法包括药丸数量和再填充记录；监测血清、尿液或唾液中药物或代谢物的水平；观察预约缺席和治疗无反应；评估可预测的药物影响，如利尿剂的体重变化或受体阻滞剂引起的心动过缓。
In some conditions, even partial adherence, as with drug treatment of hypertension and diabetes mellitus, improves outcomes compared with nonadherence; in other cases, such as HIV antiretroviral therapy or tuberculosis treatment, partial adherence may be worse than complete nonadherence.
在某些情况下，即使是部分依从性，如高血压和糖尿病的药物治疗，比不依从性改善结果；在其他情况下，如艾滋病毒抗逆转录病毒治疗或结核病治疗，部分依从性可能比完全不依从性更差。