早稲田国際教養2010 II

(1) Imagine watching a train go by. You are looking for one face in the window. Car after car passes. If you become distracted or inattentive, you risk missing the person. Or, if the train picks up too much speed, the faces begin to blur and you can't see the one you are seeking. "That's what primary care medicine is like," Victoria Rogers McEvoy told me. McEvoy is a tall, lean woman in her fifties with short- cropped blond hair and steady eyes. She practices general pediatrics1 in a town west of Boston. "It's much harder than finding the proverbial needle in a haystack, because the haystack is not moving. Each day there is a steady flow of children before your eyes. You are doing baby checks, examinations for school, making sure each child is up to date on his vaccinations. It can become routine and you stop observing closely. Then you have the endless number of kids who are irritable and have a fever, and it's almost always a virus or a throat infection. They can all blur. But then there's that one time it's a life-threatening disease."

(2) "The blessing of pediatrics, but also its curse, is that almost all of the children who come to the office turn out to be healthy or to have a minor problem," McEvoy continued. A blessing, of course, that the kids are fine, but a curse because the continual flow of minor problems can cause you to lose concentration. With that in mind, she asks herself one key question each time she sees a child, in essence the same question doctors who work in emergency rooms ask about each patient: Does he or she have a serious problem? "Every pediatrician2 should consider that as soon as the child comes into the room." And because many of the patients are infants and small children who cannot communicate what they are feeling, "your powers of observation have to be particularly acute."

(3) Essentially the doctor gets all the information from the parents, which means she has to consider both the parents' degree of familiarity with their child and their emotional reaction to the possibility that something is wrong. This reaction can be extreme: some parents deny the existence of a serious problem; others exaggerate what is normal because of their anxiety. Parents have reported that their child was lacking in energy and not eating, information that would trigger a high level of concern in the doctor; but with one glance she would see the child playing happily on the examining table and grinning. "The story was completely exaggerated, and you knew immediately that the kid was not seriously sick." Then there was the opposite, where a mother said that her baby felt a little warm but was otherwise okay. McEvoy was stunned to see the child breathing rapidly and lying weak in her mother's arms. The child had pneumonia. McEvoy, like all pediatricians, looks for certain key features. Does the child smile, play with toys, actively walk or crawl, or is she passive, not resisting when a medical instrument is placed on her chest?

(4) Pattern recognition in pediatrics begins with behavior. And the art of pediatrics is to further study the child while simultaneously interpreting what the parents report. This combining of data, McEvoy said, is not a skill that comes from a textbook, because it requires a level of awareness by the doctor about his own feelings towards the family. While first impressions are often right, you have to be careful and always doubt your initial response. "It's a foolish pediatrician who does not listen closely to the parents and take seriously what they are saying," McEvoy said. "But you need to filter what they say with the child's condition." I told her the story of my first child, Steven. My wife, Pam, and I had returned from living in California to the East Coast. It was the July Fourth weekend, and we stopped in Connecticut to visit her parents. Steven was then nine months old, and had been irritable and not feeling well during the cross-country flight. When we arrived at Pam's parent's house, he was restless in his crib. We took him to an older pediatrician in the town; the doctor glanced at Steve and quickly dismissed Pam's worries that he was seriously ill. "You're over-anxious, a first-time mother," the pediatrician told her. "Doctor parents are like this." By the time we arrived in Boston, Steve was grunting and drawing his legs up to his chest. We rushed him to the emergency room of the Boston Children's Hospital. He had an obstruction in his intestines and required an operation immediately. Pam and I could only conclude that despite his many years in practice, the pediatrician in Connecticut had made a hasty judgment ― that Pam was irrationally worried about her first-born child, not a reliable reporter of a meaningful change in her baby's behavior and condition.

(5) The pediatrician in Connecticut watched the train go by, hour after hour, day after day, year after year, for decades. I asked McEvoy, who had also been in practice for decades, "How do you keep your eyelids open?"

(6) "I prepare myself mentally before each session," she replied, just as she used to prepare herself mentally before a competitive tennis match. In 1968, when she was in college, McEvoy was ranked third in the nation in tennis, and played at Wimbledon. As an athlete, she learned to focus her mind, to anticipate the unexpected spin, and not to become overconfident despite her expertise. But beyond the skill from sports, "you simply have to control the volume," she said. "And the truth is that most pediatricians stay afloat by seeing large numbers of children each day."

(7) Before McEvoy took her current job, she worked in a busy group practice in another Boston suburb. At the time she had four children of her own at home. She spent each day tending to dozens of patients and their parents. "But it was the night calls that were killing me," she said. She was contacted every twenty or thirty minutes, and the calls continued until the next morning. If there was serious concern based on the telephone contact, then McEvoy returned to the office and saw the child, regardless of the hour. "After doing this for a few years, I was beginning to burn out. I just couldn't stand it." McEvoy found herself becoming irritable and bitter. "I was so exhausted from this hard schedule that at times I said things to parents that were rude and sharp, and later regretted saying them," she told me. "Pediatrics was no longer fun. Most worrisome, it affected my thinking. I would immediately assume that the parent was telephoning inappropriately. I was just so exhausted."

(8) McEvoy left that practice. In the course of a day, a full-time pediatrician may see two dozen or more children. Now she limits the number of patients she will see in any single session, despite the pressure to schedule brief visits and maintain a high volume. Many doctors who provide primary care do this because they feel they cannot function properly otherwise. Some suffer a fall in income. Others move into administrative roles, seeing fewer patients but sustaining their income. McEvoy chose this last path. Her group is associated with Partners Healthcare and the Massachusetts General Hospital. This association largely fixed the problem of relentless night calls; the Partner group hired experienced pediatric nurses who take the phone calls at night. These nurses offer advice to the parents, but if a family insists on speaking directly to the doctor, then the doctor will be paged. "This is the only way to maintain one's sanity," McEvoy said. "And the care is much better, because the doctors are not burned out."

[Adapted from Jerome Groopman, How Doctors Think, 2007]

(1) Choose the best way to complete the following sentences about paragraphs (1) to (8). Do not use the same answer twice.

1 Paragraph (1) describes

2 Paragraph (2) describes

3 Paragraph (3) describes

4 Paragraph (4) describes

5 Paragraph (5) describes

6 Paragraph (6) describes

7 Paragraph (7) describes

8 Paragraph (8) describes

A the boredom of working in a small country medical practice in America.

B the danger of making quick decisions about a parent's ability to judge the seriousness of his or her own child's condition.

C the difficulty of noticing children who are seriously ill among the large number who are only suffering from minor problems.

D the fact that a mother can always tell intuitively when her own child is dangerously ill.

E the importance of being continually on the look out for signs of a serious disease in the children who are brought to see you.

F the necessity of judging the nature of the parent's response to the child's illness when considering the information they provide.

G the need for doctors to remain physically fit and strong in order to cope with their demanding work.

H the negative consequences of overwork on a doctor's performance when seeing patients.

I the problem of how to remain alert even after years of seeing a huge number of children.

J the similarities between the skills required in competitive sports and in working as a doctor.

K the way that unreasonable and demanding parents drive many doctors to seek different work.

L the way to solve the problem of the large number of parents who want their children to see a doctor in the night time.

(2) Choose the FOUR statements that agree with what the passage says.

A Doctors need to be careful not to pay too little attention to what the parents of sick children tell them.

B Dr. McEvoy admits that as a young doctor she tended to be overconfident when seeing patients.

C Dr. McEvoy decided to quit her job when she found herself taking out her frustration on her own children.

D It is easy for busy doctors to miss symptoms of minor illnesses such as sore throats and colds.

E It is important for doctors to limit the number of patients that they see each day.

F Now Dr. McEvoy no longer has to deal with calls at night from anxious parents.

G One sign that a child is seriously ill is when he or she fails to respond to stimuli in their immediate environment.

H Some doctors choose to earn less money in order to be able to provide a better service to their patients.

I The anxiety that parents feel when their children are ill can lead them to take an aggressive attitude towards doctors.

J The author describes an episode when he and his wife over-reacted to their own son's illness.

①　列車が通り過ぎるのを見ていると想像しよう。あなたは窓の中にひとつの顔を探している。車両が次から次へと通り過ぎる。何かに気を取られたり，注意を怠ったりすると，その人物を見過ごす危険を冒す。あるいは，列車があまりにも速度を上げると，顔はぼやけ始め，探している顔を見ることはできなくなる。「それこそ，初期診療の現状ですよ」と，ヴィクトリア＝ロジャーズ＝マケヅオイは私に語った。マケヅオイは背の高いほっそりとした50代の女性で，短く刈り込んだ金髪と人をしっかり見すえる目をしている。彼女はボストンの西部にある叮で一般小児科を開業している。「ことわざに言う，干草の山から針を見つけるのよりもずっと難しいのです。干草の山は勣いていませんからね。毎日，目の前を子供たちがずっと流れていきます。乳児検診をし，学校の健康診断があり，どの子もちゃんと最新のワクチン接種をしたかどうか確認しているわけです。それは毎日のお決まりの仕事になってしまうおそれがあり，丹念に見るのをやめてしまうのです。それに，過敏で熱のある子供が数限りなくやってきますし，それはほとんどいつもウィルスか喉の感染症です。子供たちがみんなぼやけてくることもありえます。ですが，命にかかわる病気だという場合がそこにふっと入ってくるのです」

　②「小児科のありがたいところでもあり，また同時に災いでもあるのが，医院にやってくる子供のほとんどが，結果的には健康であるか，たいしたことのない問題を抱えているだけだとわかるということです」とマケヴォイは話を続けた。ありかたいことというのはもちろん，子供たちが問題がないということだが，災いというのは，たいしたことのない症状が次から次へとやってくることが，集中力を失わせる可能性があるからだ。それを念頭において，彼女は子供をひとり診察するたびに，自らに重要な問いかけをする。それは本質的には救急治療室で働く医師が，患者ごとに問う問いと同じである。つまり，この患者は重大な問題を抱えているだろうか，という問いだ。「小児科医はがれでも子供が診察室に入ってきたらすぐにそのことを考慮すべきです」そして，患者の多くは自分かどのように感じているかを伝えることができない赤ん坊や幼い子供なので，「観察力は特に鋭くなくてはならないのです」。

　③　つまるところ，医師は親からすべての情報を得ることになり，それは親が自分の子供のことをどれはどよくわかっているか，また何かまずいことが起きている可能性に対して親がどのような感情的反応を示すか，その両方を医師が考慮しなくてはならないということである。この感情的反応というのは，極端になることがある。深刻な問題があることを否定する親もいれば，不安のせいで正常なことを大げさに言う親もいる。親から，子供は元気がなく食事も取らないと聞いていると，それは医師には非常にぴりぴりする情報だが，ひと目見れば，子供は診察台の上で楽しそうに遊び，にこにこしているのがわかるということもある。「話が完全に誇張されていただけで，すぐにその子は重大な事態ではないことがわかりました」逆のケースもあった。母親は，赤ん坊の体温が少し高いが他は問題ないと言った。マケヅオイは，その子が母親の腕の中で，速い呼吸をし，ぐったりしているのを見て唖然とした。子供は肺炎だったのだ。マケヴォイは，小児科医がみんなそうであるように，カギになるなんらかの特徴を探す。子供はにっこりするか，おもちゃで遊ぶか，活発に歩いたりはいはいしたりするだろうか，それともなされるがままで，医療機器が胸に当てられても抵抗もしないだろうか。

　④　小児科におけるパターン認識は，振る舞いから始まる。そして，小児科の技術は，親の報告を解釈しながら同時に　さらに子供を調べることである。データをこのように組み合わせることは教科書から学べる技能ではない，というのも，医師自身がその家族に対して抱いている気持ちについての一定レベルの自覚が求められるからだ，とマケヴォイは言った。第一印象は正しいことが多い一方で，自分の最初の反応については，常に注意深く疑ってかからなくてはならない。「親の言うことにきちんと耳を傾けない，また親の言うことを真に受けるのは，愚かな小児科医です」とマケヅオイは言う。「そうではなく，親が言うことを，子供の状態と合わせてふるいにかける必要があるのです」私は彼女に，私の第一子であるスティーヅンの話をした。妻のパムと私は，カリフォルニア暮らしから東海岸に戻ってきていた。独立記念日の週末で，私たちは妻の両親を訪ねるのにコネチカットに立ち寄った。そのときスティーヅンは生後９ヵ月で，大陸を横断する空の旅の間中，ぐずって具合が悪かっか。パムの両親の家に着いたとき，スティーブンはベビーベッドの中で落ち着きがなかった。私たちは，町の年配の小児科医のところへ弘子を連れて行った。医者はスティーヅをちらっと見て，すぐに息子が重大な病気ではないかというパムの心配を否定した。「心配しすぎですよ。新人ママさん」と，彼は妻に言った。「医者である親というのはこうしたものです」私たちがボストンに着いたときには，スティーヅはうめき声を上げ，胸元に脚を抱え込んでいた。私たちは‥弘子を連れてボストン小児病院の救急治療室へ駆け込んだ。息子は腸閉塞を起こしており，すぐに手術が必要だった。パムと私は，コネチカットの小児科医は，何年も診察していても早計な判断をしてしまったと，そしてパムは初めての子供のことで冷静さを欠いた心配をし，赤ん坊の振る舞いや状態に見られる意味のある変化をきちんと伝えることができなかったと結論するしかなかった。

　⑤　コネチカットの小児科医は，列車が通り過ぎるのを，数十年にわたって，毎時間毎時間，来る日も来る日仏年年歳歳見ていたのだ。私は，やはり開業して数十年になるマケヅオイに尋ねた。「どうやって，まぶたをしっかり上げ続けているのですか」

　⑥「診察する前に毎回，気持ちの準備をします」かつて競技テニスの試合の前にメンタル面の準備をしたのとちょうど同しように　と彼女は答えた。1968年，彼女が大学生たったとき国内３位にランクされ，ウィンブルドンでもプレーした。スポーツ選手として，彼女は精神を集中し，予想外のスピンを考え，技能の高さがあるにもかかわらず自信過剰にならないようにすることを身につけていた。しかし，スポーツから学んだ技能以上に，「ただただ膨大な量をこなさなくてはならないのです」と彼女は言った。「そして，実は，たいていの小児科医は毎日，非常に多くの子供を診ているために，ふわふわ浮いた状態になったままなのです」

　⑦　今の仕事に就く前，マケヴォイはボストンの別の郊外で忙しくグループ診療にあたっていた。当時，彼女自身，家庭に４人の子供がいた。彼女は，毎日何十人もの患者とその親の応対をして過ごしていた。「ですが，私を参らせていたのは夜間にかかってくる電話でした」と彼女は言う。 20分か30分ごとに電話が鳴り，それが翌朝まで続いた。その電話連絡で非常に気にかかることがあれば，何時であろうとマケヴォイは診療所に戻り，子供の診察をした。「こんなことを続けて数年すると，私は疲れ果てかけていました。もう耐えられませんでした」マケヅオイは自分かいらいらし，人に厳しく当たっているのがわかった。「こういったきついスケジュールのせいで疲労困憊していて，時々親御さんに向かって乱暴で厳しいことを言ってしまいましたし，あとになってそんなことを言ったのを後悔しました」と彼女は私に語ってくれた。「小児科はもう楽しくありませんでした。いちばんやっかいだったのは，それが私の思考に影響したことでした。私は，親が必要もないのに電話してきているとすぐに思ったものです。それほど疲れ切っていました」

　⑧　マケヴォイはその診療所を辞めた。１日でひとりの常勤の小児科医が20人を超える子供を診ることもある。今では彼女は，１回の診察を短くし，数の多さをこなさなくてはならないというプレッシャーがあるにもかかわらず，どの診察時間帯でも１回に診る患者の数を制限している。初期診療を行う医者の多くはそうしているが，そうでなければきちんと診療できないと感じているからだ。収入が減って困っている医者もいる。行政機関の任務に移って，診る患者の数を少なくしながら収入を維持している医者もいる。マケヅオイはこの後者の道を選んだ。彼女の率いるグループは，パートナース・ヘルスケア，マサチューセッツ総合病院と提携している。この提携のおかげで，絶え間ない夜間の電話という問題は大幅に片付いた。パートナー・グループは，夜間の電話を受ける経験豊富な小児科看護師たちを雇ったのだ。この看護師たちが親に助言をするのだが，もしその家族が直接医師と話したいと主張すれば，その場合には医師が呼ばれるのである。「これが正気を保つ唯一の方法です」とマケヅオイは言う。「そうすれば診察もずっとよくなります。医師たちが疲れ切っていませんからね」

(1)1C 2E 3F 4B 5I 6J 7H 8L  (2)―A ･ E ･ G ･ H