I would like to tell you about the most embarrassing thing that has ever happened to me in my years of working as a palliative care physician. This happened a couple of years ago. I was asked as a consultant to see a woman in her 70s -- retired English professor who had pancreatic cancer. I was asked to see her because she had pain, nausea, vomiting ... When I went to see her, we talked about those symptoms and in the course of that consultation, she asked me whether I thought that medical marijuana might help her. I thought back to everything that I had learned in medical school about medical marijuana, which didn't take very long because I had learned absolutely nothing. And so I told her that as far as I knew, medical marijuana had no benefits whatsoever. And she smiled and nodded and reached into the handbag next to the bed, and pulled out a stack of about a dozen randomized controlled trials showing that medical marijuana has benefits for symptoms like nausea and pain and anxiety. She handed me those articles and said, "Maybe you should read these before offering an opinion ... doctor."
我想要告诉你们 在我作为饱受疗法医生的许多年里, 所发生过的最尴尬的事。 这发生在数年前, 我受邀去会诊一位70高龄的女士。 她是一位退休的英语教授 并患胰腺癌。 我受邀去看她, 因为她感到疼痛、恶心、呕吐... 当我去看她时, 我们讨论了这些症状, 在会诊的过程中, 她问我是否觉得医用大麻能帮到她。 我回想在医学院里学到的 有关医用大麻的任何东西, 这并没有花费我多长时间 因为我完全没学到什么东西。 所以我告诉她,据我所知, 医用大麻没有一点好处。 然后她微笑,点点头, 把手伸到了床边的手提包里, 掏出了一叠大概十多个 随机对照实验的记录, 这些实验显示医用大麻对于诸如 恶心、疼痛和焦虑 这样的症状有一定好处。 她递给我这些文章,然后说, “在你发表意见之前 也许你应该读下这些文章... 医生。”
(Laughter)
(观众笑声)
So I did. That night I read all of those articles and found a bunch more. When I came to see her the next morning, I had to admit that it looks like there is some evidence that marijuana can offer medical benefits and I suggested that if she really was interested, she should try it. You know what she said? This 73-year-old, retired English professor? She said, "I did try it about six months ago. It was amazing. I've been using it every day since. It's the best drug I've discovered. I don't know why it took me 73 years to discover this stuff. It's amazing."
所以我这样做了。 那天晚上我读完了那些文章, 同时也找到了更多的文章。 当我后一天去看她的时候, 我必须承认 看起来是有些证据表明 大麻具有医疗效益。 然后我建议她, 如果真的感兴趣的话, 她应该去试一下。 你知道她回答的什么吗? 这位73岁的老太太, 退休的英语教授? 她说我大约 六个月前就试过了, 这种感觉太棒了。 此后我每天都抽一点。 这是我发现的最好的药物。 我不知道为什么自己73岁 才发现它,这实在太棒了。
(Laughter)
(笑声)
That was the moment at which I realized I needed to learn something about medical marijuana because what I was prepared for in medical school bore no relationship to reality.
在那一瞬间,我意识到 我需要了解一下有关医用大麻的信息, 因为我在医学院学到的东西 与现实毫无联系。
So I started reading more articles, I started talking to researchers, I started talking to doctors, and most importantly, I started listening to patients. I ended up writing a book based on those conversations, and that book really revolved around three surprises -- surprises to me, anyway. One I already alluded to -- that there really are some benefits to medical marijuana. Those benefits may not be as huge or as stunning as some of the most avid proponents of medical marijuana would have us believe, but they are real. Surprise number two: medical marijuana does have some risks. Those risks may not be as huge and as scary as some of the opponents of medical marijuana would have us believe, but they are real risks, nonetheless. But it was the third surprise that was most ... surprising. And that is that a lot of the patients I talked with who've turned to medical marijuana for help, weren't turning to medical marijuana because of its benefits or the balance of risks and benefits, or because they thought it was a wonder drug, but because it gave them control over their illness. It let them manage their health in a way that was productive and efficient and effective and comfortable for them.
所以我开始阅读更多文章, 开始与研究人员交流, 我开始与医生交流, 但最重要的是 我开始倾听病人的意见。 最后我基于这些对话写了一本书, 那本书实际上围绕着三个令人惊讶的点—— 总之这些东西对我来说很惊奇。 一是我已经提到过的, 医用大麻确实有一些优点存在。 这些优点也许 没有那些医用大麻的热切拥护者 想要我们相信的那样 效果显著, 但是这些优点确实存在。 第二点是: 医用大麻确实有一些风险。 这些风险也没有 那些反对者想要我们相信的那样 危害巨大, 但确实是存在一定危险。 但是第三点是 最令人意外的。 很多和我交谈过的 曾经求助于医用大麻的患者, 并不是因为医用大麻的效用, 或者考虑其优点和风险的平衡, 亦或者因为他们以为 这是奇药而求助于它, 而是因为它能让病人控制他们的疾病。 让他们通过一种对他们来说高效的 易看到效果的并且感觉舒服的方式, 来管理自己的健康。
To show you what I mean, let me tell you about another patient. Robin was in her early 40s when I met her. She looked though like she was in her late 60s. She had suffered from rheumatoid arthritis for the last 20 years, her hands were gnarled by arthritis, her spine was crooked, she had to rely on a wheelchair to get around. She looked weak and frail, and I guess physically she probably was, but emotionally, cognitively, psychologically, she was among the toughest people I've ever met. And when I sat down next to her in a medical marijuana dispensary in Northern California to ask her about why she turned to medical marijuana, what it did for her and how it helped her, she started out by telling me things that I had heard from many patients before. It helped with her anxiety; it helped with her pain; when her pain was better, she slept better. And I'd heard all that before. But then she said something that I'd never heard before, and that is that it gave her control over her life and over her health. She could use it when she wanted, in the way that she wanted, at the dose and frequency that worked for her. And if it didn't work for her, then she could make changes. Everything was up to her. The most important thing she said was she didn't need anybody else's permission -- not a clinic appointment, not a doctor's prescription, not a pharmacist's order. It was all up to her. She was in control.
为了让你理解我想说什么, 我再提一下另一个病人。 我见到罗宾时,她40多岁。 但是她看起来却快70岁了。 过去20年里, 她饱受类风湿性关节炎的折磨, 她的手因为关节炎变的扭曲, 并且还有驼背, 必须依靠轮椅才能走动。 她看起来孱弱无力, 我想她的身体上或许确实如此, 但是从感情上,认知上和心理上, 她确是我所见过的最坚强的人之一。 在加州北部的一个医用大麻配药房里, 我坐在她旁边, 问她为什么使用医用大麻, 它为她提供了什么,并如何帮助到她的。 她开始告诉我一些东西, 一些我以前听许多病人讲述过的东西。 它帮助她减轻焦虑; 帮助她减少疼痛; 当疼痛减轻些,睡眠就好多了。 这些东西我都曾经听到过。 但接着她又说了一些我从来没听过的东西, 她说这能使她掌控自己的生命, 掌控自己的健康。 当她想用时就能用, 并且以她喜欢的方式, 以一种对她有效果的剂量和频次。 如果效果不大,她可以自己做些改变。 一切事都是由她自己决定。 她说,最重要的是 她并不需要得到其他人的允许—— 没有就诊预约,没有医生的药方, 没有药剂师的命令。 一切由她决定。 她是控制一切的人。
And if that seems like a little thing for somebody with chronic illness, it's not -- not at all. When we face a chronic serious illness, whether it's rheumatoid arthritis or lupus or cancer or diabetes, or cirrhosis, we lose control. And note what I said: "when," not "if." All of us at some point in our lives will face a chronic serious illness that causes us to lose control. We'll see our function decline, some of us will see our cognition decline, we'll be no longer able to care for ourselves, to do the things that we want to do. Our bodies will betray us, and in that process, we'll lose control. And that's scary. Not just scary -- that's frightening, it's terrifying. When I talk to my patients, my palliative care patients, many of whom are facing illnesses that will end their lives, they have a lot of be frightened of -- pain, nausea, vomiting, constipation, fatigue, their impending mortality. But what scares them more than anything else is this possibility that at some point, tomorrow or a month from now, they're going to lose control of their health, of their lives, of their healthcare, and they're going to become dependent on others, and that's terrifying.
这似乎对患有慢性病的人来说是一件小事, 但并不是这样,一点也不。 当我们面临着严重的慢性疾病, 不管是类风湿关节炎,狼疮,癌症,糖尿病, 或者是肝硬化, 我们就失去了掌控。 请注意我所说的,“当你得了疾病”,而不是“假设”。 每个人在人生中某个节点都会面临严重的 我们无法控制的严重慢性疾病, 我们身体的功能会慢慢衰竭, 甚至有些人的认知能力也会下降, 我们不再有能力自己照顾自己, 也无法做自己想做的事情。 我们的身体会背叛自己, 在那个过程中, 我们将失去对自己身体的掌控。 这非常可怕。 不仅是可怕——这令人惊恐, 让人吓破了胆。 当我和我使用保守疗法的病人交流时, 他们许多人正面临着绝症, 他们有很多感到害怕的东西—— 疼痛,恶心,呕吐,便秘,疲乏, 以及迫近的死亡。 但令他们更害怕的是, 在某一刻, 明天,或者一个月后, 他们可能会不再能掌控对他们自己的健康, 自己的生活, 自己的医疗情况, 他们将不得不依赖于其他人, 这才是最恐怖的地方。
So it's no wonder really that patients like Robin, who I just told you about, who I met in that clinic, turn to medical marijuana to try to claw back some semblance of control. How do they do it though? How do these medical marijuana dispensaries -- like the one where I met Robin -- how do they give patients like Robin back the sort of control that they need? And how do they do it in a way that mainstream medical hospitals and clinics, at least for Robin, weren't able to? What's their secret? So I decided to find out.
所以不难想象为什么很多患者都像 那个我刚刚提到的 在小诊所遇到的罗宾一样, 会求助于医用大麻, 并尝试去夺回一些虚假的控制感。 那他们是如何做到的呢? 那些像我遇到罗宾的小诊所一样的 提供医用大麻的药房, 是如何提供给和罗宾一样的病人 以所需的控制感的? 他们是通过什么方式做到的, 至少对罗宾来说, 主流药物医院和诊所都无法做到的东西? 他们的秘密是什么? 我决定去找出来。
I went to a seedy clinic in Venice Beach in California and got a recommendation that would allow me to be a medical marijuana patient. I got a letter of recommendation that would let me buy medical marijuana. I got that recommendation illegally, because I'm not a resident of California -- I should note that. I should also note, for the record, that I never used that letter of recommendation to make a purchase, and to all of you DEA agents out there --
我去了加州威尼斯滩的一个破旧的诊所, 并拿到了推荐信, 这会让我佯装一个使用医用大麻的病人。 我拿到了允许我购买医用大麻的推荐信。 我非法地拿到了那封信, 因为我不是加利福尼亚的居民—— 我应该说明这件事情。 为了说清楚,我也应该说明, 我从来没有用那封建议信购买任何东西, 这是向缉毒局的人员说的——
(Laughter)
(笑声)
love the work that you're doing, keep it up.
支持你们的工作, 继续努力。
(Laughter)
(笑声)
Even though it didn't let me make a purchase though, that letter was priceless because it let me be a patient. It let me experience what patients like Robin experience when they go to a medical marijuana dispensary. And what I experienced -- what they experience every day, hundreds of thousands of people like Robin -- was really amazing. I walked into the clinic, and from the moment that I entered many of these clinics and dispensaries, I felt like that dispensary, that clinic, was there for me. There were questions at the outset about who I am, what kind of work I do, what my goals are in looking for a medical marijuana prescription, or product, what my goals are, what my preferences are, what my hopes are, how do I think, how do I hope this might help me, what am I afraid of. These are the sorts of questions that patients like Robin get asked all the time. These are the sorts of questions that make me confident that the person I'm talking with really has my best interests at heart and wants to get to know me.
尽管这不能让我购买东西, 它仍是无价的, 因为这让我成为了一位病人。 这让我经历到当像罗宾那样的病人, 去医用大麻药房里时所经历的东西。 然后我所经历到的—— 他们每天所经历的, 成百上千像罗宾一样的人所经历的—— 很让人惊奇。 我走进了小诊所, 当我走进许多这样的诊所或药房的那一刻, 我就感觉到,那个药房,那个诊所 一直等待着我。 开始就问些关于我是谁, 我做什么样的工作, 我寻求医用大麻配方或者产品 的目的是什么, 我的目标是什么,我有什么偏好, 我的期望是什么, 我是怎么想的,我希望这能如何帮到自己, 我害怕什么。 这类问题是像罗宾那样的患者 一直被问的问题。 这类问题使我确信 和我谈话的人从心底考虑了我的利益, 并且想要了解我。
The second thing I learned in those clinics is the availability of education. Education from the folks behind the counter, but also education from folks in the waiting room. People I met were more than happy, as I was sitting next to them -- people like Robin -- to tell me about who they are, why they use medical marijuana, what helps them, how it helps them, and to give me advice and suggestions. Those waiting rooms really are a hive of interaction, advice and support.
我从这些诊所中所学到的第二件事是, 教育的可得性。 柜台后面的人们提供的教育 和候诊室的人们提供的教育。 当我坐在他们旁边时,他们都非常高兴—— 像罗宾一样的人—— 告诉我他们是谁,为什么使用医用大麻, 什么帮助了他们,是如何帮助的他们, 并给我一些忠告和建议。 那些会诊室是充满互动 建议和支持的热闹场所。
And third, the folks behind the counter. I was amazed at how willing those people were to spend sometimes an hour or more talking me through the nuances of this strain versus that strain, smoking versus vaporizing, edibles versus tinctures -- all, remember, without me making any purchase whatsoever. Think about the last time you went to any hospital or clinic and the last time anybody spent an hour explaining those sorts of things to you. The fact that patients like Robin are going to these clinics, are going to these dispensaries and getting that sort of personalized attention and education and service, really should be a wake-up call to the healthcare system. People like Robin are turning away from mainstream medicine, turning to medical marijuana dispensaries because those dispensaries are giving them what they need.
第三,柜台后的人们。 我很惊讶这些人为何乐意去花一个小时 或者更多时间去教我分辨, 这种拉伤与另一种拉伤, 烟熏和蒸汽, 食用品和酊剂的细微差别—— 请记住,我还没有购买任何东西。 回想一下你最后一次去医院或诊所, 最后一次有人花一小时时间 对你解释这类事物。 和罗宾一样的病人都去这些诊所, 去这些药房, 得到的那些个人关注, 教育和服务, 这些事情应该成为现存医疗制度的警钟。 像罗宾一样的人正远离主流医药救助, 而转向医用大麻配药室, 因为这些药房给了他们所需要的东西。
If that's a wake-up call to the medical establishment, it's a wake-up call that many of my colleagues are either not hearing or not wanting to hear. When I talk to my colleagues, physicians in particular, about medical marijuana, they say, "Oh, we need more evidence. We need more research into benefits, we need more evidence about risks." And you know what? They're right. They're absolutely right. We do need much more evidence about the benefits of medical marijuana. We also need to ask the federal government to reschedule marijuana to Schedule II, or to deschedule it entirely to make that research possible. We also need more research into medical marijuana's risks. Medical marijuana's risks -- we know a lot about the risks of recreational use, we know next to nothing about the risks of medical marijuana. So we absolutely do need research, but to say that we need research and not that we need to make any changes now is to miss the point entirely. People like Robin aren't seeking out medical marijuana because they think it's a wonder drug, or because they think it's entirely risk-free. They seek it out because the context in which it's delivered and administered and used, gives them the sort of control they need over their lives. And that's a wake-up call we really need to pay attention to.
如果这是对医疗机构的警钟, 这是对我那些要么不倾听 要么不想听的同事们的警钟。 当我和同事们 特别是内科医生 讨论医用大麻时, 他们说,“喔,我们需要更多的证据。 我们需要对其益处和风险 做更多的调查获得更多的证据。” 你知道吗?他们是对的。 他们完全正确。 针对医用大麻的好处, 我们确实需要更多证据。 我们同样需要请求联邦政府 把大麻重新定义为二类药, 或者完全取消这类药, 让这种研究成为可能。 我们同样需要对医用大麻的风险 做更多研究。 医用大麻的风险—— 我们熟知大麻娱乐性用途的危害, 但我们几乎不了解医用大麻的风险。 所以我们确实需要做调查研究, 但是要是说,我们需要做研究, 但我们现在不需要做出任何改变, 就完全错失了重点了。 像罗宾那样的人寻求医用大麻, 并不是因为他们认为这是特效药, 或者他们认为这完全没有风险, 他们寻求它是因为,其递送、管理和使用 的环境, 给了他们一种所需要的 对于生活的掌控, 这才是我们需要注意的地方。
The good news though is that there are lessons we can learn today from those medical marijuana dispensaries. And those are lessons we really should learn. These are often small, mom-and-pop operations run by people with no medical training. And while it's embarrassing to think that many of these clinics and dispensaries are providing services and support and meeting patients' needs in ways that billion-dollar healthcare systems aren't -- we should be embarrassed by that -- but we can also learn from that. And there are probably three lessons at least that we can learn from those small dispensaries.
好消息是那些医用大麻配药房身上, 有我们现在可以学到的东西。 那些我们真的应该学习的东西。 那些诊所通常非常小,家庭经营, 由没有受过医疗训练的人来运营, 同时这是非常难堪的去考虑 许多这样的小诊所和药房提供的服务 和支持以及患者需要的满足, 是有着十亿美金的 健康保障体系所没有提供的—— 我们真应该感到难堪—— 但我们仍能从中学到东西。 从那些小药房中,我们至少 可以学到三个教训。
One: we need to find ways to give patients more control in small but important ways. How to interact with healthcare providers, when to interact with healthcare providers, how to use medications in ways that work for them. In my own practice, I've gotten much more creative and flexible in supporting my patients in using drugs safely to manage their symptoms -- with the emphasis on safely. Many of the drugs I prescribe are drugs like opioids or benzodiazepines which can be dangerous if overused. But here's the point. They can be dangerous if they're overused, but they can also be ineffective if they're not used in a way that's consistent with what patients want and need. So that flexibility, if it's delivered safely, can be extraordinarily valuable for patients and their families. That's number one.
一、我们需要找出给予病人 更多控制感的方式, 比较微小但又非常重要的方式。 怎样与医疗保健提供者互动, 什么时候与医疗保健者互动, 怎样以对他们有效的方式使用药物。 以我的自身实践来说, 在支持我病人安全地使用药物 去控制其症状方面, 我已经很有创造力且比较灵活—— 其重点是安全。 我开出的药方很多都是阿片类 或苯二氮平类药物, 如果滥用将会非常危险。 重点来了。 如果它们被滥用,将会变得危险, 但如果没按照病人想要并需要的方式使用, 它们将会失效。 所以那种灵活性, 如果安全地使用药物, 会对病人和他的家庭格外有价值。 这是第一点。
Number two: education. Huge opportunities to learn from some of the tricks of those medical marijuana dispensaries to provide more education that doesn't require a lot of physician time necessarily, or any physician time, but opportunities to learn about what medications we're using and why, prognoses, trajectories of illness, and most importantly, opportunities for patients to learn from each other. How can we replicate what goes on in those clinic and medical dispensary waiting rooms? How patients learn from each other, how people share with each other.
第二点,教育。 这是一个大大的机会 去学习这些医用大麻药房的技巧, 去提供更多的 不要求大量必需的 或任何的医师时间的教育, 这是去了解我们正在使用何种药物, 为什么要用, 以及疾病的预示和轨迹的机会, 最重要的是, 对患者来说这也是彼此间互相学习的机会。 我们怎样才能复制 在这些诊所和医药大麻药房等待室里 展现的场景? 患者是如何互相学习的, 人们是如何与他人分享的。
And last but not least, putting patients first the way those medical marijuana dispensaries do, making patients feel legitimately like what they want, what they need, is why, as healthcare providers, we're here. Asking patients about their hopes, their fears, their goals and preferences. As a palliative care provider, I ask all my patients what they're hoping for and what they're afraid of. But here's the thing. Patients shouldn't have to wait until they're chronically seriously ill, often near the end of life, they shouldn't have to wait until they're seeing a physician like me before somebody asks them, "What are you hoping for?" "What are you afraid of?" That should be baked into the way that healthcare is delivered.
最后却很重要的一点是, 那些医疗大麻药房 把患者放在第一位, 使患者自然的感觉到 他们想要什么, 他们需要什么, 这也是为什么 作为医疗保障提供者, 我们在这里的原因。 询问患者他们的希望、 恐惧、目标以及偏好。 作为一个保守治疗提供者, 我询问我的患者 什么是他们希望的及害怕的。 但是问题来了。 患者不应该一直等待, 直到他们患严重慢性病 经常是接近生命尾声的时候, 他们也不应该一直等待, 直到他们遇到像我一样的医师的时候 才被问到, “你的期望是什么?” “你的恐惧是什么?“ 这应该成为 医疗保健被传递的一种方式。
We can do this -- we really can. Medical marijuana dispensaries and clinics all across the country are figuring this out. They're figuring this out in ways that larger, more mainstream health systems are years behind. But we can learn from them, and we have to learn from them. All we have to do is swallow our pride -- put aside the thought for a minute that because we have lots of letters after our name, because we're experts, because we're chief medical officers of a large healthcare system, we know all there is to know about how to meet patients' needs.
我们可以做到—— 我们真的可以。 全美的医用大麻药房和诊所 正在尝试弄清楚这个问题。 他们通过大的主流健康体系 远远落后于他们的方法解决了这个问题。 但是我们可以从他们身上学习, 我们也不得不向他们学习。 我们所需要做的就是放下我们的骄傲—— 暂时把傲娇的想法放到一边, 因为我们有跟多跟随者, 因为我们是专家, 因为我们是主要的卫生保健体系的主要人员, 我们知道如何满足我们患者的需要。
We need to swallow our pride. We need to go visit a few medical marijuana dispensaries. We need to figure out what they're doing. We need to figure out why so many patients like Robin are leaving our mainstream medical clinics and going to these medical marijuana dispensaries instead. We need to figure out what their tricks are, what their tools are, and we need to learn from them. If we do, and I think we can, and I absolutely think we have to, we can guarantee all of our patients will have a much better experience.
我们需要放下我们的骄傲, 我们需要去参观一些医用大麻药店。 我们需要去了解他们在做什么。 我们需要弄清为什么 如此多的像罗宾一样的患者 离开我们主流的医疗诊所, 而去这些医疗大麻药店。 我们需要弄清这些药店的技巧是什么, 它们的工具是什么, 并且我们需要向他们学习。 如果我们这样做了, 我认为我们能并且绝对是必须这样做, 我们可以保证所有的患者 都会有更好的就诊经历。
Thank you.
谢谢大家。
(Applause)
(掌声 .