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."
我想跟你們說說, 在我擔任臨終關懷治療師的時候, 曾經發生過最尷尬的一件事。 那是在好幾年前發生的。 我受託去見一位 70 多歲的女士, 擔任她的醫療顧問── 她是一位退休的英文教授, 罹患胰腺癌。 我被找去是因為她覺得 疼痛、噁心、想吐...... 當我去見她的時候, 我們談論了這些症狀; 而在諮詢的過程中, 她問我是否認為 藥用大麻能幫助到她。 我回想了所有在醫學院學過的, 關於藥用大麻的知識; 這並不需要很多時間, 因為我完全沒學過 任何藥用大麻的知識。 所以我告訴她: 據我所知,藥用大麻 並沒有什麼用處。 她微笑並點點頭, 然後從床邊的提袋裡, 拿出將近一打的 隨機對照試驗報告, 結果都顯示藥用大麻有助於減緩 噁心、疼痛、焦慮等症狀。 她把那些報告遞給我,並且說: 「或許你應該先讀讀這些, 再發表意見......醫生。」 (笑聲)
(Laughter)
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."
於是我照做了。 那天晚上,我把那些報告全讀過了, 還找到了更多的資料。 當我第二天去見她的時候, 我不得不承認, 看起來的確有一些證據, 支持大麻具有醫療效果; 於是我建議, 如果她真的有意願的話, 她應該試一試。 你知道她怎麼回答嗎? 那位 73 歲的退休英文教授? 她說:「我大約六個月前就試過了。 它超級棒。 之後我每天都用, 這是我所發現過最棒的藥。 我不曉得為何花了 73 年 才發現這個東西,它棒極了。」
(Laughter)
(笑聲)
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.
那時我才意識到, 我需要學習藥用大麻相關的知識, 因為我在醫學院裡所學到的, 已經和現實脫節了。
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.
於是我開始閱讀更多資料, 開始和研究人員交流, 開始和醫生們交流, 更重要的是, 我開始傾聽患者的聲音。 基於那些對話,我後來寫了一本書, 那本書以三件 「意料之外」的事件為中心── 反正對我來說是意料之外的, 第一件事我剛剛已經提到了── 藥用大麻的確是有一些效果的。 或許那些藥用大麻的成效, 並不像某些積極擁護者 所希望我們相信的── 藥用大麻具有顯著或者驚人的效果, 但是它真的有效。 第二個意料之外是: 藥用大麻也具有某些危害。 但那些危害並沒有嚴重或者恐怖到, 藥用大麻的反對者 想讓我們相信的程度, 儘管如此,它的確具有危害。 但第三個意料之外, 是最令人驚訝的。 許多我曾經接觸過, 求助於藥用大麻的患者, 並不是為了療效而使用藥用大麻的, 也不是基於危害和效用的平衡, 更不是因為他們覺得 那是一種特效藥, 而是因為能給予他們 對疾病的控制感, 讓他們能用有效果、有效率、 有效益、覺得舒服的方式, 來管控自己的健康。
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.
為了表達的更清楚, 讓我來聊聊另一位患者。 我遇到羅繽的時候她 40 多歲, 但她看起來像是快要 70 歲了。 過去的 20 年,她受到 類風濕性關節炎的折磨, 她的手因為關節炎扭曲, 脊柱也彎了, 她必須靠輪椅來移動。 她在外表上、身體上 看起來很虛弱,一碰即碎; 但是在精神上、意識上、心理上, 她是我所遇到過最堅強的人。 當我在她身邊坐下, 那是在加州北部 一間藥用大麻藥局裡, 我問她為什麼開始使用藥用大麻, 這對她有什麼作用?如何幫助了她? 她告訴我一些事, 那些也是我從許多患者那裡聽過的: 它有助於解決焦慮; 有助於解決疼痛; 當疼痛減緩時,她就能睡得比較好。 這些原因都是我聽過的。 然而她接下來說的, 我卻從來沒聽過: 藥用大麻讓她能掌控 自己的生活和健康。 她可以在想用的時候就用, 以她想要的方式、 以適合她的用量和頻率使用。 如果沒有效果,她可以做出調整。 所有的事她都能自己作主。 最重要的就是,她說: 她不需要得到其他人的允許── 不需要預約診所, 不需要醫生的處方, 不需要向藥劑師購買。 一切都由她作主。 她說了算。
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.
對於罹患慢性病的人來說, 這是一件小事嗎? 不是的,完全不是。 當我們面對嚴重的慢性疾病時, 不論是類風濕性關節炎、 狼瘡、癌症、糖尿病 還是肝硬化, 我們都失去了控制權。 注意我是說「當」你患病的時候, 而不是用「如果」。 我們所有人,到了人生的某個階段, 都要面對嚴重的慢性病, 這導致我們失去控制權。 我們看著自己的機能衰退, 有的人還會經歷智力衰退, 我們不再有能力照顧自己, 做我們自己想做的事。 我們的身體終將背叛我們, 而在那個過程中, 我們失去了控制權。 這挺嚇人的。 不止是嚇人,簡直令人恐懼, 寢食難安。 我和我的病患, 也就是臨終關懷患者交流時, 他們之中有許多人 正面臨將奪走他們生命的疾病, 他們對很多事情感到恐懼── 痛楚、噁心、嘔吐、便秘、疲倦、 即將到來的死亡。 但和其他所有事相比, 他們更恐懼的事情, 是可能在某個時候, 也許是明天,或是下個月, 他們將會失去對自己健康的控制權, 對生活的控制權, 對醫療的控制權, 他們變得必須依賴他人, 這是很可怕的。
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.
所以像羅繽這樣的患者, 就是我剛剛告訴過你們的, 在診所裡遇到的那一位, 不意外的,她會選擇使用藥用大麻, 是為了試圖抓住 一些表面上的控制權。 但他們怎麼做到的呢? 這些販售藥用大麻的藥局, 例如我遇到羅繽的那一間, 他們是如何讓羅繽這樣的患者 獲得所需要的控制權呢? 他們是如何做到那些, 主流的醫院和診所 無法對羅繽做的? 他們的秘密是什麼? 我決定要搞清楚。
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 --
我去了位於加州威尼斯海灘 一間破破的診所, 拿到一份同意書, 允許我成為一名使用 藥用大麻的病患。 我拿到了一份同意書, 能讓我購買藥用大麻。 我用不合法的方式拿到同意書, 因為我並不是加州居民── 我應該先聲明這點。 我還要聲明,以供紀錄, 就是我從未使用 那份同意書購買大麻, 以上的聲明是要給 美國緝毒局的調查員的──
(Laughter)
(笑聲)
love the work that you're doing, keep it up.
要熱愛你們的工作, 繼續堅持下去!
(Laughter)
(笑聲)
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.
儘管我並沒有 用這份同意書進行購買, 但是它仍然無比珍貴, 因為它讓我成為一名患者, 讓我體驗到, 像羅繽這樣的患者所經歷的, 體驗到她們在藥用大麻藥局 所得到的經驗。 而我所體驗到的── 就如同成百上千位 像羅繽一樣的人, 每天都在經歷的── 簡直是棒極了。 我走進了藥局, 從我走進這些 診所和藥局的那一刻起, 我感覺到,這間藥局、這間診所, 是為我設立的。 一開始的時候, 他們會詢問一些問題, 例如我是誰?我從事什麼工作? 我希望藉由藥用大麻處方或產品 達到什麼效果? 我的目標是什麼?喜好是什麼? 我的期望是什麼? 我是怎麼想的? 我期望帶來什麼幫助? 我擔心什麼? 像羅繽這樣的患者, 會不斷地被問到這些類型的問題。 像這樣的問題,會讓我有信心, 覺得這個和我談話的人, 是從內心關注我的利益, 並且想要更瞭解我。
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.
我從這些診所學到的第二件事, 是可以獲得許多指導。 除了從櫃台裡的人得到指導, 也從等候室裡的其他人得到指導。 當我坐在他們旁邊時, 這些人都很高興── 他們都是像羅繽那樣的人── 他們告訴我:他們是誰, 為什麼使用藥用大麻? 什麼幫助了他們?如何幫助了他們? 並給我意見和建議。 那些等候室就像是提供交流、 建議和支持的場所。
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,坐在櫃檯裡面的人, 讓我驚訝的是, 他們非常心甘情願的, 願意花一個小時甚至更多時間, 跟我討論許多細節, 像是這個品種和那個品種的比較, 透過吸菸還是霧化方式, 食用的還是酊劑── 還記得嗎,這是在我還沒有 購買任何東西的情況下。 回憶一下你上次去醫院或診所, 以及上一次有人花了一個小時 向你詳細解釋,是什麼樣的情況? 實際上像羅繽這樣的患者, 會去這些診所, 會去這些藥局, 得到這種程度的關注、 指導和服務, 真是現今醫療系統的警鐘。 像羅繽這樣的人,會放棄主流醫療, 轉向藥用大麻藥局尋求協助, 是因為那些藥局 能給予他們真正需要的。
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.
如果那是對於現今醫療機構的警鐘, 那也是針對我那些不去聆聽, 或是不願聆聽的同僚。 當我告訴我的同僚,特別是內科醫生 關於藥用大麻的事, 他們總是說: 「哦!我們需要更多證據。 我們需要更多關於成效的研究, 以及更多關於危害的證據。」 你知道嗎,他們是對的。 他們絕對正確。 我們的確需要更多證據, 來證明藥用大麻的成效。 我們也需要要求聯邦政府, 把大麻重訂為二類藥物, 甚至是完全取消限制, 才能讓研究進行。 我們也需要針對藥用大麻的危害 進行更多研究。 關於藥用大麻的危害── 對於一般娛樂用大麻的危害, 我們了解很多, 但是對於藥用大麻的危害, 我們幾乎一無所知。 所以我們當然需要進行研究, 但話說回來,我們需要研究 並不等於現在就不必做出改變, 這是完全忽略了重點。 像羅繽那樣的人使用藥用大麻, 不是因為他們認為那是萬能藥, 也不是因為他們覺得沒有風險。 他們追求的原因, 是由於大麻被遞送、發放, 以及使用的環境, 這樣的環境給予他們所需要的── 對生活的掌控權。 而這是我們真正需要關注的警鐘。
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,今天我們能從 藥用大麻的藥局學到這一課。 而那些正是我們應該學習的。 這些藥局通常是小型的、家庭式的, 由未曾受過醫療訓練的人士所經營。 想到就令我們感到羞愧, 這些診所和藥局 一直在為患者提供服務、支持, 並滿足他們的需求, 以一種數百億規模的醫療系統 都做不到的方式── 我們應該對此感到羞愧── 但我們也應該向它學習。 我們能向這些小型藥局學習的 至少有三個課題:
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.
第一,我們需要找到 小巧但是重要的方法, 來給予患者更多的控制權。 例如如何與醫療人員溝通, 什麼時候溝通, 如何以對患者有效的方式開藥。 在我自己的診間裡, 我已經找出更有創意和彈性的方式, 支持患者安全地使用藥物 來控制他們的症狀── 同時能強調安全性。 我所開立的很多處方, 是屬於鴉片類或苯二氮䓬類藥物, 這些藥物過量使用會有危險。 但這就是重點。 當他們過量使用時,會造成危險; 但如果不能依照 患者的意願與需求來使用, 結果也是無效的。 所以在安全使用的前提下, 「提供彈性」對於患者和家屬, 具有非常重要的意義。 以上是第一點。
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.
第二個課題:指導。 這是個大好機會, 去向藥用大麻藥局學習 如何提供更多指導的技巧; 這並不會佔用醫師太多時間, 甚至根本不會佔用任何時間, 卻能給我們一個機會了解: 我們正在用什麼藥物, 以及為何用這些藥物, 如何預測判斷疾病的預後, 以及最重要的, 這是患者之間彼此學習的機會。 我們如何複製出 在藥用大麻藥局等候室 所出現的情境呢? 病人如何互相學習? 人們如何彼此分享?
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.
最後但同樣重要的一點, 就是像那些藥用大麻藥局所做的, 把病患放在第一位, 讓病患能感覺到, 我們這些醫療從業人員, 正是為了他們的期待 和他們的需求而存在的。 向患者詢問他們的 期望、恐懼、目標和偏好。 身為臨終關懷從業人員, 我會詢問所有的患者: 他們想要什麼?擔心什麼? 而這就是重點。 病人們不該等到罹患慢性絕症, 不該等到接近生命的盡頭, 不該等到他們需要尋求 像我這類的醫師, 才有人問他們: 「你想要什麼?」 「你擔心什麼?」 這應該融入整個醫療體系的 提供項目之中。
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.
我們可以做到這些── 真的可以。 全國各地的藥用大麻藥局和診所 都很清楚這件事。 規模更大、更主流的醫療系統 在這方面落後他們許多。 但我們可以向他們學習, 而且我們必須向他們學習。 我們需要做的 就是放下我們的驕傲── 暫時放下我們的想法, 放下我們名字後面的 一大堆頭銜, 放下我們的專家身份, 放下我們在大型 醫療機構裡的主管權力, 我們所應該知道的, 是如何滿足病患的需求。
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.
我們需要放下驕傲。 我們需要去拜訪幾間藥用大麻藥局。 我們需要搞清楚他們在做什麼。 我們需要搞清楚 為什麼很多像羅繽一樣的病人, 會放棄主流醫療院所, 轉向藥用大麻藥局。 我們需要搞清楚他們的秘訣, 他們使用的工具, 我們需要向他們學習。 如果我們這樣做了, 我認為我們可以, 並且我們必須做到的, 我們可以確保所有的患者 都能得到更好的體驗。
Thank you.
謝謝大家。
(Applause)
(掌聲)