原标题: 荥阳市激光去痘坑多少钱平安咨询

In 2012 when 17-year-old Malala Yousafzai was shot in the head on a school bus by the Taliban, she became the first Pakistani student to be actively targeted by the militants. Two years later, Yousafzai is tragically joined by hundreds more.2012年,17岁的马拉拉在一辆校车中遭塔利班击,头部中弹。她是第一个被武装恐怖主义分子追杀的巴基斯坦学生。两年后,悲剧再次发生在上百名巴基斯坦学生身上。On Tuesday, a Taliban attack on a school in Peshawar has left more than 100 schoolchildren killed. Shiza Shahid, the co-founder and CEO of the Malala Fund, an organization working to break the cycle of poverty and empower girls through education, has devoted much of her life to championing women around the world. In an exclusive interview with Fortune, Shahid — speaking as a Pakistani advocate — shared her initial reactions.上周,塔利班袭击了巴基斯坦北部城市白沙瓦的一间学校,100多名学生因此丧生。关注扶贫及女童教育问题的马拉拉基金(Malala Fund)联合创始人兼首席执行官希扎o沙希德接受《财富》(Fortune)的独家专访,以一名巴基斯坦持者的身份,与记者分享了她对这一事件的看法。Edited excerpts:以下是经编辑节选的采访内容:What was your reaction when you first heard about the attack?在最初听到这起校园袭击案时,你的第一反应是什么?It’s been incredibly heartbreaking as a Pakistani and as a human being. I have seen so many terrible things happening in Pakistan in recent years. Suicide attacks, sieges, Malala’s own shooting, but this really hits home in a way that is deeply painful. Malala was the first child to be deliberately target in Pakistan. Now they are targeting over 100 children dead.对巴基斯坦人和全世界其他人来说,这起事件都令人心碎。近年来我在巴基斯坦经历过如此多可怕的事情,包括自杀式袭击、围攻、马拉拉被击等,但是这次事件仍令我如被击中要害般痛彻心扉。马拉拉是第一个被塔利班蓄意袭击的巴基斯坦青少年,现在他们变本加厉,谋杀了100多名孩子。What is missing in Pakistan right now that these violent attacks are continuing?暴力袭击仍在继续,巴基斯坦目前最缺失的是什么?The roots of terrorism in Pakistan are deep and complicated and lawless and ungoverned. Various ideologies are all in the quest for the very same thing: Power. When territories are ungoverned, and people are disappointed and not given opportunities to strive for a better tomorrow, people fall prey to terrorist groups who have the means to intimidate and frighten.巴基斯坦国内的恐怖主义根深蒂固、错综复杂,而且缺少法律的约束和政府的管治。各个流派都在追逐同一个目标:权力。领土之内缺乏有力管治,人民对此深感失望,却又无力为争取更好的未来而抗争,只能活在恐怖分子的威胁和恐吓之下。Why do school children remain a target for the Taliban?为什么塔利班一再袭击在校学童?Significant progress has been made by the military to root out certain terrorist leaders and this was really an act of retaliation. This is a school that mostly has children of military officers and cadets and their wives were teachers. So really, this was retaliation to what was done by the military, and it shows how long this battle is going to be.巴基斯坦军方铲除了一部分恐怖分子头目,取得了反恐的重大进展,这次的袭击显然是报复行为。遭受袭击的是一间军人子弟学校,学校的老师大多数是军官和军事学员的家属。因此,这就是一次针对此前巴军方反恐行动的报复行为,表明了这场战争将会旷日持久地进行下去。Also, there is nothing more precious than our children. By going as far as attacking children, they are saying that nothing is off limits, so there is an utter lack of humanity. There have been instances where terrorists have bombed empty schools as a way to protect the teachings of western ideologies, but this act was clearly and deliberately meant to kill children, and it is as heinous as can be.没有什么比我们的孩子更加珍贵。恐怖分子袭击手无寸铁的儿童,表明他们毫无顾忌,没有底线。这种做法惨无人性。此前恐怖分子曾经轰炸无人的学校,以此拒绝西方的意识形态,但此次事件攻击的目标直接就是儿童,实在令人发指。Do you think this act of violence marks a tipping point in Pakistan?你认为这次暴力袭击会否成为巴基斯坦的一个转折点?We are at a point now were the country needs to stand up and stand up together. We need to grieve for who has been lost and take action for once and for all, and we need to say no more and say never again.在这个时刻,整个国家都应该团结起来,奋起抗争。我们既要哀悼逝者,又要采取行动彻底铲除恐怖分子,不再姑息并坚决杜绝此类事件重演。Are you fearful that this will deter children from going to school?这次事件是否会让孩子们害怕去学校上课?This has been happening for awhile. In the past, areas around schools have been targeted and school buses have been threatened and for a while now, military schools have been targeted as well. I live about a mile away from the Navy complex in Islamabad, and for awhile there has been heavy security. If children aren’t given an education there really isn’t anything left. So hopefully we will take the time to grieve, and hopefully the people will come together and do everything we can to protect children. For more children to lose their one chance to get an education will result in many more tragedies just like this.这种情况已经持续了一段时间。过去恐怖分子打击学校附件的地区,袭击校车,而现在他们袭击军事管理学校。我住在伊斯兰堡海军基地一英里以外的地方,当地暂时处于戒严状态。如果儿童无法接受教育,那这个国家就真的没有未来了。所以我希望人们为逝者哀悼,同时行动起来尽一切努力保护孩子们。如果越来越多的孩子失去受教育的机会,就会酿成更多这样的悲剧。What, if anything, has changed for the better in Pakistan since 2009 when you started a summer camp to empower young girls and their education?2009年时你组织了一个夏令营为女孩提供受教育机会,在那之后,巴基斯坦国内在此方面取得了怎样的进展?Where we have taken two steps forward, we have also taken two steps backward in various aspects. We have more girls going to school than before and we have more parents agreeing that sending their girls to school is a priority. We also have more women in medical school than men. On the other hand, you have terrorists targeting schools, and you still see female medical school graduates not going to work because they are worried about getting a husband. The terrorist threat is very real against women.我们有两点进步也有两点退步。上学读书的女孩子比以前多了,有更多家长认识到了送女儿上学的重要性。医学院的女学生也比男学生多。另一方面,出现了恐怖分子袭击学校的事件,还有医学院的女生毕业后为了结婚而不去就业的情况。恐怖主义对女性存在着切实的威胁。How can concerned people outside of Pakistan help?其他国家的那些关心你们的人如何能提供帮助?I am a big believer in finding local activists and advocates and supporting them. That is very much the model that I worked with at the Malala Fund. Now I am working on a social impact fund that will invest on the ground, and there are some great organizations that try and highlight local leaders and amplify their work.我强烈建议他们去找当地的活动家和倡导者,给这些人提供持。这就是我在马拉拉基金会的工作模式。现在我在为一个具有社会影响力的基金会工作,它能够在当地进行基础的投资,还有一些大型机构选择与当地领导人联手,扩大其影响力。We have heard Malala’s story, and it was a great example of the power of story telling. We have more stories to tell, and we need to bring those stories into the media and supporting their organizations is a great way for us to do it. You are seeing young girls in villages starting companies to sell handbags that employ local women. You see entrepreneurs and young people creating change and innovation. Those are the things we need to focus on, and those are certainly the things I focus on given how hard it is to get anything done through the government.我们都听说过马拉拉的故事,它充分显示了一个故事讲得好会具有怎样的力量。我们还有很多故事可讲,而且我们要在媒体上讲述这些故事,持相关的组织就是一个很好的方法。你可以看到年轻的乡村女性创建手包品牌并聘用当地的妇女,你还可以看到创业者和年轻人在变革和创新。这些就是我们需要关注的东西,也是我最为关注的方面,因为这些很难通过政府来实现。(财富中文网) /201412/350622

Aly beset by aftershocks, incessant rain and mudslides, relief efforts in China#39;s quake-stricken Yunnan province have run into another impediment: a flood of do-gooders champing at the bit to help.除余震、连绵细雨和泥石流之外,中国云南地震灾区的救援行动遇到了另一个障碍:大量志愿者迫不及待地想参与救灾。Authorities in northern Yunnan#39;s Ludian county temporarily closed down access to the quake zone Tuesday morning because traffic from volunteers pouring in had made the aly damaged access road all but impassable. Yuan Yao, an local official involved in directing the volunteer effort, said traffic was backed up for several kilometers.云南鲁甸县政府周二上午暂时关闭了通往灾区的道路,因为大量志愿者的涌入使本已受损的道路几乎无法通行。参与引导志愿行动的当地官员袁耀(音)表示,交通拥堵已达数公里。#39;It#39;s packed with people. They#39;re having a hard time trucking in relief supplies and trucking out the injured,#39; she said.她说,到处都是人,无论是用卡车把救灾物资运进去,还是把伤员转移出来,都很困难。The closing of the quake zone meant the county seat was crawling with clusters of volunteers desperate for something to do. Regular citizens from other parts of Yunnan, Beijing, the Sichuan province capital of Chengdu and other places -- many decked out in self-designed uniforms with the names of their volunteer groups emblazoned across the back -- sat crouched on sidewalks or milled around hotel lobbies, trading rumors about when the road would reopen and going over strategies for when it did.道路关闭使得鲁甸县政府所在地挤满了迫切想为灾区做些事情的志愿者。来自云南省其他地区、北京、四川省会成都以及其他地方的普通民众或蹲坐在路边,或聚集在宾馆大堂附近,交流著有关道路何时重开的传言,并讨论在道路重开后的行动方案。他们中的许多人穿着自己设计的统一装,衣的背后印有所在志愿组织的名字。One such group from northern China#39;s Hebei province was led by Wang Wenzhong, a wealthy entrepreneur and ex-soldier who has taken volunteer teams to six quake zones over the past six years. Mr. Wang, who says he was recently named one of the #39;Ten Great Moral Models#39; in his home county of Zaoqiang, organized and outfitted a team of 10 volunteers, spending around 30,000 yuan (,860) on rescue equipment and relief supplies.其中一个来自河北省的志愿者队伍由王文忠率领。王文忠是一位富有的企业家,也是一名退伍军人,在过去六年中,他曾经带领志愿者前往六个地震灾区。王文忠说他最近在自己的家乡枣强被评选为“十大道德模范”。他组织了一个由10名志愿者组成的小组,并花费约3万元(4,860美元)购置援救设备和救灾物资。#39;These days, a lot of people only worry about accumulating money and seeking personal benefits. They have more than they can spend, but they still don#39;t think to do something for society,#39; he said during a five-hour middle-of-the-night van ride to Ludian from the Kunming, Yunnan#39;s capital. #39;This is my way of thanking society and the government.#39;王文忠连夜从昆明开五个小时的货车赶往鲁甸,他说,现在很多人只顾着赚钱,实现个人利益,他们赚的钱自己已经花不完,但仍然不考虑为社会做些事情。他说这是他感谢社会和政府的方式。Mr. Wang was among the hordes of volunteers who descended on Sichuan province in 2008, when a 7.9 quake flattened the area around Wenchuan and killed some 87,000 people. The explosion of volunteerism was hailed as a watershed moment for civil society in China, a country where civic duty and social responsibility have long taken a back seat to personal achievement and the accumulation of wealth.2008年四川地震期间,王文忠也作为一名志愿者参加了救援。当时汶川附近发生了7.9级地震,导致87000人丧生。志愿精神的兴起被视为中国社会的一个分水岭,长期以来个人成就以及财富积累成了人们追逐的目标,而公民义务和社会责任没有得到应有的重视。But the 2008 effort was also criticized for being rash and disorganized and in some cases hurting relief efforts by gumming up roads and burdening food supplies.但2008年四川地震的志愿者也因为轻率和缺乏组织而受到批评,在一些情况下甚至因扰乱交通和加重食品供应负担而影响救灾活动。#39;Some people rush in and have no idea what the situation is. If you#39;re going to go you have to think first about what you can do,#39; Mr. Wang said. #39;That#39;s where my army experience comes in. Everyone on this team knows how to follow orders. And just like the People#39;s Liberation Army, we#39;re never a burden on the people. We don#39;t eat their food or drink their water.#39;王文忠说,一些人连情况都不了解就往里冲,如果你要冲进去的话,应该先想好自己进去能做什么。他说,我的从军经验此时就派上用场――我们队伍里的每个人都清楚如何从命令;而且,就像解放军战士们那样,我们从来不让自己成为别人的负担,不吃别人的东西、不喝别人的水。The Hebei group did indeed mimic the PLA. The entire group was outfitted with identical uniforms -- military fatigues, canvas shoes and red armbands -- and younger members described themselves as #39;new soldiers.#39; Appropriately, Mr. Wang runs the group like a battalion, collecting intelligence from contacts with state-run media and local government.王文忠的这队伍确实有着解放军的精神。整个小队着装统一,全体人员身着迷、穿帆布鞋、带红臂章。年轻一点的队员称自己是“新兵”。王文忠像军队营长一样带队,通过与官媒和地方政府接洽来收集信息。The Hebei team leader credits Wenchuan with teaching him the value of prior planning, but not all the volunteer groups in Ludian on Tuesday were so organized or professional. While Mr. Wang#39;s crew waited patiently for the go-ahead to enter the quake zone on Monday morning, another group of un-uniformed youth from various parts of Yunnan was loitering outside the county government offices trying to hitch a ride.王文忠说,汶川地震救援教会了他预先制定好计划的重要性。然而,周二在鲁甸灾区,并非所有的志愿者队伍都如此训练有素、如此专业。周一早晨,当王文忠的队伍耐心地等待进入灾区的放行信号时,一群着装各异、来自云南各地的年轻人却在县政府办公室外面逛荡,试图搭个便车。#39;They aren#39;t letting people in,#39; Li Wenwei, a volunteer from Kunming, said in a brief exchange with China Real Time. #39;Maybe we can go with you?#39;来自昆明的志愿者李文伟(音译)跟“中国实时报”栏目记者交涉道:他们(灾区官员)不让我们进去,我们能不能跟你们一起进去?It wasn#39;t immediately clear Monday morning how many volunteers had converged on Ludian with the hope of helping. #39;I don#39;t know. A lot. A lot,#39; said Ms. Yuan.袁耀说,周一早晨还无法立刻搞清楚有多少想帮忙的志愿者来到了鲁甸,我不清楚,只能说非常非常多。 /201408/319009

Baoding#39;s hub ambition保定拟打造京津冀中心Baoding should be made into a regional hub city as part of the Beijing-Tianjin-Hebei cluster as the framework of a regional hub city has been established after the recent administrative division adjustment in the city, according to Yan Liying, the deputy mayor of Baoding, Hebei.近日,河北保定市副市长闫立英指出,近期保定进行了城市区划调整,已经具备建设区域中心城市的基本框架,保定应该打造成京津冀核心城市群区域中心城市。Authorized by the State Council, Baoding made some changes to its administrative divisions, expanding them from 3 to 5.根据国务院近期批复,河北保定调整了部分行政区划,原市辖区范围由3个变成了5个。Accordingly, the urban area in Baoding has expanded to 2,531 sq km from 312 sq km.受此影响,保定市区面积由原来的312平方公里增加到2531平方公里。 /201505/377531

Out of the crooked timber of humanity, no straight thing was ever made. This famous remark of the German philosopher, Immanuel Kant, is particularly relevant to economists. “Homo economicus” is far-sighted, rational and self-interested. Real human beings are none of these things. We are bundles of emotions, not calculating machines. This matters.“人性这根曲木,绝然造不出任何笔直的东西。”经济学家尤其应该听听德国哲学家伊曼努尔#8226;康德(Immanuel Kant)的这句名言。“经济人”有远见、理性而且自私。真正的人跟经济人完全不一样。我们感情充沛,不是精于计算的机器。这非常关键。The World Bank’s latest World Development Report examines this territory. It notes that “behavioural economics” alters our view of human behaviour in three ways: first, most of our thinking is not deliberative, but automatic; second, it is socially conditioned; and, third, it is shaped by inaccurate mental models.世界(World Bank)在其发布的最新一期《世界发展报告》(World Development Report)中研究了该领域。它指出,“行为经济学”从3个方面改变了我们对人类行为的看法:首先,我们的大部分想法并非经过深思熟虑,而是自动产生的;其次,它受到社会的制约;第三,它脱胎于不精确的思维模式。The Nobel laureate, Daniel Kahneman, explored the idea that we think in two different ways in his 2011 bookThinking, Fast and Slow. The need for an automatic system is evident. Our ancestors did not have the time to work out answers to life’s challenges from first principles. They acquired automatic responses and a cultural predisposition towards rules of thumb. We inherited both these traits. Thus, we are influenced by how a problem is framed.诺贝尔奖得主丹尼尔#8226;卡内曼(Daniel Kahneman)在其2011年出版的《思维,快慢有别》(Thinking, Fast and Slow)一书中探讨了人类有两种不同思维方式的观点。拥有一种自动反应的思维体系显然是必要的。我们的祖先没时间从基本原则中寻找解决生活挑战的办法。他们获得了自动反应的本领,也形成了听从经验法则的文化倾向。这两种特质我们都继承了。因此,我们会受问题提出方式的影响。Another characteristic is “confirmation bias” — the tendency to interpret new information as support for pre-existing beliefs. We also suffer from loss aversion, fierce resistance to losing what one aly has. For our ancestors, on the margin of survival, that made sense.另一个特征是“确认偏误”(confirmation bias)——即将新信息解读为能够持已有观点的倾向。我们还有“厌恶损失”(loss aversion)的倾向,即强烈抗拒失去我们已经拥有的东西。对我们只能勉强维持生存的祖先来说,这种倾向非常明智。The fact that humans are intensely social is clear. Even the idea that we are autonomous is itself socially conditioned. We are also far from solely self-interested. A bad consequence of the power of norms is that societies may be stuck in destructive patterns of behaviour. Nepotism and corruption are examples. If they are entrenched, it may be difficult (or dangerous) for individuals not to participate. But social norms can also be valuable. Trust is a valuable norm. It rests on one of humanity’s strongest behaviours: conditional co-operation. People will punish free-riders even when it costs them to do so. This trait strengthens groups and so must raise members’ ability to survive.人类具有强烈的社会性,这是显而易见的。就连我们是独立的个体这个想法本身,也是受到社会制约的。我们也绝非完全自私。社会规范的强大威力带来的一个糟糕后果是,社会可能陷入消极的行为模式。裙带关系和腐败就是例。如果裙带关系或腐败根深蒂固,个人不参与其中或许就很困难(或危险)。但社会规范也可能是有用的。信任是一种有用的规范。它依赖于人类最擅长的行为之一:有条件的合作。人们将会惩罚搭便车者,即便惩罚他们要付出代价。这种特质增强了团队的凝聚力,从而肯定会提高团队成员的生存能力。Mental models are essential. Some seem to be inbuilt; and some can be damaging — as well as productive. Ideas about “us” and “them”, reinforced by social norms, may well lead to results that range from the merely unfair to the catastrophic. Equally important may be mental models that create self-fulfilling expectations of who will succeed and who will fail. There is evidence, notes the WDR, that mental models rooted in history may shape people’s view of the world for centuries: caste is an example. Such mental models survive because they are reproduced socially and become part of the automatic rather than the deliberative system. They influence not just our perceptions of others, but perceptions of ourselves.思维模式非常关键。有些似乎是人内在固有的,此外,有些模式可能同时具有创造性和破坏性。关于“我们”和“他们”的观念如果经过社会规范的强化,很可能导致各种各样的结果,从仅仅是不公平的,到酿成灾难的。有些思维模式能够产生有关谁将成功、谁将失败的预期(并且这种预期具有自我实现的能力),这些思维模式同样重要。《世界发展报告》指出,有据表明,有深厚历史根源的思维模式可能决定人们数百年的世界观:种姓制度就是一个例子。此类思维模式之所以经久不衰,是因为它们在社会上不断繁殖,成为了一种自动(而非经过深思熟虑)的反应。它们不仅影响我们对其他人的看法,还影响我们对自己的看法。To illustrate the relevance of these realities, the report analyses the policy challenges of poverty, early childhood development, household finance, productivity, health and climate change.为了表明这些研究与现实密切相关,该报告还分析了贫穷、幼儿期发展、家庭财务、生产率、健康和气候变化的政策挑战。On household finance, for example, the report notes that it makes a difference whether would-be borrowers are told explicitly how much more expensive is a payday loan than an equivalent loan on a credit card. Revealing the status of low-caste boys in a mixed-caste classroom depresses the performance of students from lower castes compared with what happens if caste is not revealed. The boys respond to how they are presented. Again, poverty is not just a lack of material resources:it undermines the ability to think deliberately.例如,在家庭财务方面,该报告指出,潜在借款者是否被明确告知发薪日贷款(payday loan,一种小额、短期的高利贷,用于贷款人下一次发薪之前临时急用——译者注)与等额信用卡贷款相比有多么昂贵,结果将大为不同。如果在一个种姓混杂的班级里让大家知道谁是低种姓学生,那么低种姓学生的表现就会不如其身份没有暴露时的表现。别人如何介绍自己,会影响这些男孩的表现。同样,贫穷不仅仅是物质资源的匮乏:它还削弱一个人审慎思考的能力。The way people think may also affect their productivity. An example is the benefits of contracts that penalise a worker for failing to meet the output targets she has chosen for herself. This is a way of closing the gap between good intentions and actual performance, such as when we agree to put money in the swearbox when we curse. We often disappoint ourselves. We may wish to bind ourselves to better behaviour, like Odysseus to his mast.人们的思考方式也可能影响他们的生产效率。一个例子是,签订这样的合同有不错的效果:约定工人如果未能完成自己选择的产量目标就会受到惩罚。要消除良好意愿与实际表现的差距,这是一种方法,比如我们同意只要我们骂人就要往罚款箱里投钱。我们常常让自己失望。我们可能希望约束自己、迫使自己表现得更好,就像奥德修斯(Odysseus)让人把自己捆在桅杆上(以抵挡海妖歌声的诱惑)那样。Health creates vital examples. One is the importance of mental models. An obvious one is the anti-vaccination hysteria. Another, illustrated by the WDR, is the tendency of poor women to believe that the right treatment for diarrhoea is to cut fluid intake, to stop their child “leaking”. Another is the tendency of people to be put off by even a very small charge for health products. The explanation for the reluctance to pay anything may, it suggests, be because free provision underpins the norm that everybody ought to take the medicine.健康领域产生了一些重要的例子,其中之一是思维模式的重要性。一种明显的思维模式是非理性地反对接种疫苗。《世界发展报告》举出的另一种思维模式是,贫穷的妇女往往认为,腹泻的正确治疗方法是减少液体的摄入,这样他们的孩子就不再“拉稀”。还有一种思维模式是,人们往往不愿购买收费的健康产品,哪怕金额极低。报告称,人们之所以一分钱都不愿花,可能是因为,免费提供才符合有难同当的社会规范。These then are intriguing examples of a more nuanced approach to policy. Another area where a narrow focus only on incentives is likely to be misleading is financial regulation. Many economists believe that dysfunctional behaviour in financial markets is due solely to distorted incentives: deposit insurance, the perception that institutions are “too big to fail” and a host of other explicit and implicit subsidies. Equally important, however, are behavioural norms, such as the view that the primary duty of bankers is to themselves not their customers; or inappropriate mental models, such as the widesp pre-crisis belief that house prices could not fall across the US. Regulation needs to be built on an understanding of such human frailties. It must focus on norms and groupthink, as well as on distorted incentives.因此这些有趣的例子表明了政策手段有必要更加细致。另一个关键领域是金融监管,在这一领域中,如果仅仅关注于激励就可能导致误解。许多经济学家相信,金融市场中的失灵行为完全是扭曲的动机造成的,比如:存款保险、机构“太大而不能倒闭”的观念,以及其他众多显性和隐性补贴。然而,同样重要的是社会行为规范,比如认为家主要应该对他们自己、而不是客户负责的观点;或者不适当的思维模式,比如危机前人们普遍认为,美国的房价不会普跌。监管需要建立在了解此类人性弱点的基础之上。它必须不仅关注于扭曲的动机,还关注于社会规范和群体迷思(groupthink)。How far should policy be based on these perceptions, particularly since those who make policy are, as the WDR admits, prone to all sorts of biases in their own decision-making? We are all made of Kant’s crooked timber: nobody has godlike wisdom and self-control.政策应该在多大程度上以这些观念为基础?尤其是正如《世界发展报告》承认的那样,那些制定政策的人士往往对他们自己的决策存在各种各样的偏见。我们全都由康德所说的“曲木”制成:没有人有上帝那样的智慧和自制力。Yet policy must be made. It is surely better to make well-informed and realistic policy than base it on a grossly simplistic view of our true capacities. Moreover, nudging people in the direction they aly want to go — by encouraging them to save, learn, behave healthily or bring up their children better — is hardly a gross violation of liberty. Yet encouragement should not slide too easily into coercion. Adults are not to be treated as children. That, too, is a social norm and quite a fundamental one.然而政策是必须制定的。充分了解相关信息、从现实出发制定政策,肯定要比基于对我们真实能力的过分简单化理解制定政策要好。此外,通过鼓励人们储蓄、学习、过健康生活或更好地抚育子女,推动人们朝他们本来就希望的方向前进,这不能说是严重侵犯自由。然而,鼓励不应轻易地演变为强制。不应把成年人当做小孩对待。那也是一种社会规范,而且还是相当根深蒂固的一种。 /201501/355489BETSY came to Dr. Martin for a second — or rather, a sixth — opinion. Over a year, she had seen five other physicians for a “rapid heartbeat” and “feeling stressed.” After extensive testing, she had finally been referred for psychological counseling for an anxiety disorder.贝蒂来找马丁医生是想问问第二个大夫的意见——实际上是第六个。在过去一年里,因为“心动过速”和“受迫感”的问题,她咨询过五位医生。在经过大量的检查后,医生最终建议她去做焦虑症方面的心理咨询。The careful history Dr. Martin took revealed that Betsy was taking an over-the-counter weight loss product that contained ephedrine. (I have changed their names for privacy’s sake.) When she stopped taking the remedy, her symptoms also stopped. Asked why she hadn’t mentioned this information before, she said she’d “never been asked.” Until then, her providers would sooner order tests than take the time to talk with her about the problem.马丁医生仔细地询问病史,终于得知贝蒂当时正在用一种减肥用的非处方药,其中含有麻黄碱。(为了保护隐私,文中用了化名。)停止用这种药物后,她的症状也就消失了。在被问到过去为什么没有提过这件事时,她说,“从来没人问过。”在那以前,她的医生都会很快让她去做检查,而不是花时间和她谈病情。Betsy’s case was fortunate; poor communication often has much worse consequences. A review of reports by the Joint Commission, a nonprofit that provides accreditation to health care organizations, found that communication failure (rather than a provider’s lack of technical skill) was at the root of over 70 percent of serious adverse health outcomes in hospitals.贝蒂的情况还算幸运,沟通不畅常常会导致更恶劣的后果。非营利组织“医疗机构认联合委员会”(Joint Commission)发布的一份报告指出,医院中发生的严重不良健康后果中,有逾70%的根源在于沟通不畅(而不是医护人员欠缺专业技能)。A doctor’s ability to explain, listen and empathize has a profound impact on a patient’s care. Yet, as one survey found, two out of every three patients are discharged from the hospital without even knowing their diagnosis. Another study discovered that in over 60 percent of cases, patients misunderstood directions after a visit to their doctor’s office. And on average, physicians wait just 18 seconds before interrupting patients’ narratives of their symptoms. Evidently, we have a long way to go.医生能否解释、倾听、与患者产生共鸣,对于病人的诊疗有着深远的影响。然而一项调查发现,有三分之二的病人在不知道诊断结果的情况下,就被要求出院了。另一项研究发现,在超过60%的病例中,患者在问诊后误解了医生的指示。医生平均只会等18秒,就会打断患者对症状的陈述。显然,我们有很长的路要走。Three years ago, my colleagues and I started a program in Harrisburg designed to improve doctors’ communication with their patients. This large urban hospital system serves a city with a population of about 50,000, together with the surrounding metropolitan area of more than 550,000 people.三年前,我和同事在宾夕法尼亚州哈里斯堡启动了一个旨在改善医患沟通的项目。这个规模庞大的城市医院系统,为本市大约5万人口提供务,同时也面向周边城市群共计超过55万的居民。The hospital faces particular challenges: The city has a high poverty rate (32 percent, compared with the state average of 13 percent), and the metro area has a high rate of childhood obesity. Over all, nearly a third of people around Harrisburg are uninsured, compared with about one in 10 for the rest of Pennsylvania.医院面临着一些特殊的挑战:这座城市贫困率极高(达32%,与之相对比,全州平均水平为13%),所在城区的儿童肥胖率也很高。总体而言,哈里斯堡及周边人口中,有近三分之一没有医疗保险,而宾夕法尼亚州其他地区的这一比例则约为十分之一。Our project started with a simple baseline assessment of how we as doctors communicated with our patients. Observation soon revealed that physicians introduced themselves on only about one in four occasions. And without an introduction, it’s no surprise that patients could correctly identify their physician only about a quarter of the time.项目开始时,我们对医生与患者的沟通状况做了一个简单的基准评估。通过观察,我们很快就发现,只有大约四分之一的情况,医生会向患者做自我介绍。既然没有做自我介绍,另一个现象也就不奇怪了:仅有大约四分之一的情况,患者能正确指出给自己诊断的医生是谁。Brief, rushed physician encounters were common, with limited opportunity for questions. A lack of empathy was often apparent: In one instance, after a tearful patient had related the recent death of a loved one, the physician’s next sentence was: “How is your abdominal pain?”与医生会面时简短、仓促的情况十分普遍,提问的机会也很有限。对患者缺乏理解的情况往往很明显:在一个案例中,患者痛哭流涕地倾诉,最近一位亲人去世了,但医生接下来问的却是,“你的腹痛是什么情况?”We developed a physician-training program, which involved mock patient interviews and assessment from the actor role-playing the patient. Over 250 physicians were trained using this technique. We also arranged for a “physician coach” to sit in on real patient interviews and provide feedback.我们推出了一项医生培训计划,其中包括由演员扮演的患者参与的模拟问诊和评估。有超过250名医生接受了运用这个技巧进行的培训。我们还安排了“医生辅导员”在实际接诊时坐在旁边,进而提供反馈。Over the next two years, patient satisfaction with doctors, as measured by a standard questionnaire, moved the hospital’s predicted score up in national rankings by a remarkable 40 percentile points. Several studies have found a correlation between higher patient satisfaction scores and better health outcomes. In one, published in The New England Journal of Medicine, Harvard health policy researchers reported that higher patient satisfaction was associated with improved outcomes for several diseases, including heart attacks, heart failure and pneumonia.在接下来的两年里,通过一项标准化问卷的衡量,患者对医生的满意度提高了,而这所医院的预期得分,在全美排名中也出现了40个百分点的可观提升。有若干项研究发现,患者满意度指标的提高,与治疗效果的改善存在正相关性。在一篇发表在《新英格兰医学杂志》(The New England Journal of Medicine)上的研究论文中,哈佛大学的医疗政策研究人员写道,患者满意度提高,与若干种疾病治疗效果的改善存在相关性,包括心肌梗死、心脏衰竭和肺炎。The need to train and test physicians in “interpersonal and communication skills” was formally recognized only relatively recently, in 1999, when the American Board of Medical Specialties made them one of physicians’ key competencies. Although medical schools and residency programs then began to train and test students on these skills, once physicians have completed training, they are seldom evaluated on them. And doctors trained before the mid-1990s have rarely, if ever, been evaluated at all.对医生在“人际关系和沟通技巧”方面进行培训和检验的需求,直到近年来才正式得到承认。在1999年,美国医疗专科委员会(American Board of Medical Specialties)将这些技巧列为医生的关键能力之一。尽管医学院和住院医项目从那时就开始对学生的这些技巧进行培训和测试,但是医生在完成学业后,极少还会受到这方面的评估。所有在上世纪90年代中期之前接受医学教育的医生,则极少甚至完全没有得到过评估。I realize that many colleagues may see methods like ours as too intrusive on their clinical practice and may say that they don’t have the time. But we need to move away from the perception that social skills and better communication are a kind of optional extra for doctors. A good bedside manner is simply good medicine.我明白很多同行可能会认为,我们这样的方法对临床实践的干扰太强,也可能会说他们没时间。不过,我们需要摒弃那种认为社交技巧和改善沟通对医生来说是一种可有可无的额外素质的念头,因为在临床实践中,良好的态度本身就是一剂良药。A passionate diabetes specialist told me how she sat down with a patient to understand why he was not using his diabetes medications regularly, despite numerous hospital admissions for complications.一位充满热情的糖尿病专科医师给我讲述了她与一名患者坐下来聊天的情形。尽管那名患者因为并发症而多次入院治疗,但是他还是不肯规律地摄入糖尿病药物,她想弄明白这是为什么。“I can’t continue to do this anymore,” he told her, on the verge of tears. “I’ve just given up.”“我不能再这样活了,”他强忍着泪水告诉她。“我干脆放弃了。”She placed a hand on his shoulder and just sat with him. After a pause, she said: “You have a heart that still beats, and legs you can still walk on — many of my patients don’t have that privilege.”她把手放在他的肩膀上,坐在了他身旁。停顿片刻后,她说:“你的心脏还能跳,腿也还能走。许多患者根本没有这样的运气。”Five years later, recalling this episode, her patient credits her with inspiring him to take better care of himself. The entire encounter took less than five minutes.五年之后,这位患者在回顾这一幕时称赞道,是医生的鼓舞让他更好地照顾自己。那次会面只花了不到五分钟。 /201501/352632

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