The Role, Principles and Competencies
of Family Medicine
家庭医学的作用、原则和能力
Chris Jenkins, MD 克里斯.金肯医学博士
Goals of Talk演讲的目的
Why is general practice an important specialty in
a medical system 为什么全科医学是医疗体
系里的一个重要专科
Discuss why post graduate GP training is
important
讨论为何毕业后的全科培训很重要
What are the benefits to the community and
individual patients
对社区和病人个体有什么益处
What do GPs do 全科医生做什么
2
A Little US Medical History
一点美国的医学史
Prior to 1969 a GP 早在1969年，全科医生：
– finished medical school
从医学院毕业
– finished a one year rotating internship
完成一年的实习医生轮转
– Began practicing开始行医
Up to early 1900’s most American doctors were GPs
在19世纪初之前大多数美国医生是全科医生
– Up to the 1930’s 80% were GPs and only 20%
specialists
到19世纪30年代，医生中80%是全科医生，20%是
专科医生
3
A Little US Medical History
一点美国的医学史
1940’s: an explosion of medical knowledge and
an increase in specialization
19世纪40年代：医学知识爆炸，专业化程度提高
– Medical students wanted security: know all
about one area of medicine
医学生想要安全感：掌握某个医学领域的全部
知识
– There was an increase of specialty
residencies and certification boards
专科医师培训项目和资格认证委员会增多
– Board certification was not seen as necessary
for general practice
专科资格认证并非全科医疗所必需的
4
Hard Times for GPs
全科医生的困难时期
1940 to 1952 specialty residencies grew from 5,200 to
22,000
1940到1952年，专科住院医生培训项目从5200增加
到22000
Health care was becoming unavailable to many
许多人无法得到卫生保健服务。
specialists stayed in cities near hospitals专科医生住在
医院附近城市
GPs became fewer in number全科医生数目越来越少
6
Hard Times for GPs
全科医生的困难时期
General practice was getting left behind
– 全科医疗被忽视
Began to fight back开始反击
– Established the American Academy of General
Practice in 1947
1947年建立美国全科医学学会
– Grew quickly快速发展
High standards高水准
CME requirement 150 hours every three
years (first specialty to do this)
要求每三年完成150小时的继续医学教育
（最先开始这样做的人群）
Still had no board certification仍然没有资格认证
7
GPs Struggle to Succeed
全科医生奋斗成功
In mid 1940’s AAGP requested specialty training
19世纪40年代中期，美国全科医学学会要求专科培
训
– Better training in diagnosing and treating disease
得到更好的诊断和治疗方面的训练
– Greater awareness of conditions requiring referral or
special tests or treatment
更清楚地知道哪些情况下需要转诊或特殊检查及治疗
Approached major medical schools进入重点医学院
“Good idea but do it somewhere else”
“很好的想法，但到别的地方进行”
8
GPs Struggle to Succeed
全科医生奋斗成功
All through 1950’s and most of the 1960’s
continued to work for improvement
整个19世纪50年代和19世纪60年代的多数
时间持续不断 地取得工作进步
9
American Medical System Suffered from Over Specialization
美国医疗体系曾遭遇过度专业化
US medical system in the 1960’s
19世纪60年代的美国医疗体系
– Increasingly specialized 越来越专业化
– Medical costs rising
医疗花费上升
– Patient care suffering
病人保健遭受到：
Patient care suffering
病人保健遭受到：
No one managing the overall care of the patient
没有人管理病人的总体保健
No one coordinating care among specialists
没有人综合协调专科医生的治疗
10
American Medical System Suffered from Over
Specialization
美国医疗体系曾遭遇过度专业化
– No one focused on preventive care没有人关
注预防保健
– No one who could treat most or all of common
diseases
没有人能够治疗大部分或是所有的常见病
Patients had to see many specialists to get routine
physical exams
病人不得不去看许多的专科医生以做常规体格检查
– Central Asia worse: 10-12 doctors needed to do
preschool physical
中亚情况更糟：做入学前体检需要看10到12个医生
– Increasing number of medical mistakes and
missed diagnosis
误诊和漏诊数目增加
11
Medical Community Finally Recognized
the Need for Well Trained Generalists
医学界终于意识到对受过良好训练全科医生的需求
The Folsom Report Folsom 报告
The Mills Commission Mills 委托代理
The Willard Committee Willard 委员会
12
Acceptance at Last 终于接受
Medical schools now began GP residencies
医学院校现在开始全科住院医生培训
– February 8, 1969 the first residencies started: “specialty
in breadth”
1969年2月8日第一个住院医生培训项目开始：
“范围宽的专业”
– 1970 the ABFP (American Board of Family Practice)
offered its first board exam
1970年美国家庭医学认证机构进行了第一次资格认证考试
13
Acceptance at Last 终于接受
– 1971 the name changed from GP to FP to signify the
change in training
1971年由GP更名为FP以象征在培训方面的变化
– Rapid growth快速发展
1970 250 residencies with 3,820 residents
1970年250个住院医师培训项目，包括3,820名住院医生
2007 463 residencies with 9,330 residents
2007年有463个住院医师培训项目，包括9,330名住院医生
Membership in the AAFP: 96,614 (includes residents,
etcetera)
AAFP的会员数目： 96,614 （包括住院医生，等等）
14
The Importance of
Post Graduate Training毕业后培训的重要性
Medical school alone is not enough仅医学院是不够的
– Medical information is increasing rapidly医学信息飞速增加
– GPs need to know how to diagnose and treat common diseases,
not just book knowledge
全科医生需要知道如何诊断和治疗常见病，不仅是知道书本的知识
Residency provides住院医生培训提供：
– Development of diagnostic and procedural skills
诊断和操作能力的发展
– Awareness of developments in other specialties
了解其它专业的发展
– Knowledge of how to use the entire medical system to benefit
their patients知道如何使用整个医疗体系以使病人受益
– Understanding of whole person care: bio-psycho-social-spiritual
model of health理解全人的照顾：健康的生物-心理-社会-精神模式
15
Primary Care Improves
Community Health
初级保健使社区健康得到改进
Better health outcomes
健康结局更好
Increased use of disease-focused preventive care (e.g.,
blood pressure screening, mammograms,
pap smears, etc)疾病为中心的预防保健增多（如血
压筛查，乳腺X片，宫颈防癌普查等）
Fewer patients admitted for preventable complications of
chronic disease
更少的病人因可预防的慢性病并发症而收入院
Lower all cause mortality全因死亡率降低
Fewer consultations with specialists专家会诊减少
Less use of emergency services
减少使用急救服务
16
Improved Community Health with Primary
Care 初级保健使社区保健得到改进
Less re-hospitalization减少再入院
Better detection of adverse effects of interventions
更好地发现干预措施的不良反应
Better understanding of psychological aspects of a
patient’s problem更好地理解病人问题的心理方面
Protection against overtreatment避免过度治疗
More efficient use of resources资源更有效地利用
Better compliance and lower hospitalization rate
依从性更高，入院率更低
Other benefits as well还有其它益处
All well documented 都被很好地记录
17
General Practice has a Unique and Important
Role in Health Systems
全科医学在健康系统中有独一无二的重要作用
Advocate for patients in medical system
在医疗体系中支持病人
Management of patient care病人保健的管理
Preventive health care and patient education
预防性的健康照顾和病人教育
Provision of comprehensive health care in a
single location在一个处所提供综合性的健康照顾
Care of entire families over time整个家庭的长期
照顾
– Not limited to gender, age, organ system
不局限性别、年龄、器官系统
18
General Practice has a Unique and Important
Role in Health Systems
全科医学在保健体系中有独一无二的重要作用
Benefits to communities and individuals
对社区和个人的益处
–
–
–
–
Doctor knows patient well 医生非常了解病人
Patients trust their doctor 病人信任医生
Increased patient satisfaction 病人满意度提高
Greater ease of access to medical care 医疗照顾更有
可及性
– Lower cost 更低的费用
– Fewer medical mistakes 更少的医疗错误
– Emphasis on prevention 强调预防
– Satisfying professional careers for GP doctors
19
全科医生对职业感到满意
What is Family Medicine? It Depends on Who
You Ask!
家庭医学是什么？不同的国家有不同的回答！
British 英国
Swedish 瑞典
Australia 澳大利亚
Hong Kong 香港
Canada 加拿大
America 美国
20
Family Medicine in China
中国的家庭医学
New in modern China是当代中国的新生物
Developing a new model
发展中
Principles of FM has similarities with some aspects of traditional
Chinese medicine
家庭医学的原则与传统中医的某些方面有相似之处
– Care for the whole family照顾整个家庭
Young and old 年轻者和年长者
Male and female 男性和女性
– All organ systems所有的器官系统
– Listen to patients 倾听患者
– Take time with the patients花时间与病人在一起
21
Family Medicine in China
中国的家庭医学
Some differences between GP and
traditional Chinese medicine:
– Understanding of causes of disease
– GPs emphasize family, social and
environmental influences
– GPs rely on science including evidence based
medicine
– History and physical exam are done more
thoroughly by GPs
22
Family Medicine in China
中国的家庭医学
The government and entire medical system
recognize need for general practice
大型医学中心认识到对全科的需要
The Ministry of Health has now provided a
model for general practice and training
– It is being implemented across China
大型医学中心在等待北京决定用何种模式及
何种培训项目
23
Where Do We Work?
我们在哪里工作？
Clinic
门诊
Hospital
医院
Emergency
Department
急诊室
Nursing Homes
养老院
Other
其他
27
Philosophical Focus of Family Medicine
家庭医学的理念
Continuity of care
照顾的持续性
Management of care
健康照顾管理
Treating patient in context of
family
在家庭背景下治疗病人
Preventive care
预防保健
Team approach
团队探讨
EBM
循证医学
28
Evidence Based Medicine
循证医学
Knowing the questions to ask
知道要问的问题
Identifying the best evidence to
answer the questions
找出回答问题的最好依据
Assessing the evidence for validity and
usefulness
评估证据的有效性和有用性
Applying the results to clinical/hospital
practice
将结论应用于门诊或住院医疗
Evaluating the results
评估结果
34
General Practice Competencies
全科医学的能力
There is a wide range of possible skills for GPs
全科医生可掌握的临床技巧很广泛
Different countries choose different skills to meet their
own needs
不同的国家根据本国的需要选择不同的临床技巧
The basic role of GP remains the same in each country
全科医生的基本任务在每个国家仍然是一致的
This next section will show you some of the skills we
train GPs to do in the USA
下一部分将向您介绍美国全科医生被训练的部分技能
35
Whom and what do we treat?
我们给谁治疗，治疗什么？
All ages and Both sexes
所有的年龄和性别
36
Obstetrics
产科学
(Will go into more detail on each area later if desired
如果愿意我们将在后面详细介绍每一方面的内容)
Ultra sound
超声
Dating
确定预产期
Fetal viability
胎儿变异度
Placenta position 胎位
Abnormalities
畸形
Vacuum extraction 胎头吸引
Episiotomies
侧切
External fetal heart
胎心监护
monitoring
Tocomonitor
宫缩监护
Placement of scalp
and IUPC 头皮电极放置及胎儿宫内检测
Leopold Maneuver
臀位分娩助产术
Reduction of shoulder dystocia
解除肩难产
Labor induction
引产
37
Pediatrics...
儿科学
38
Internal Medicine
内科学
But All Other Specialties as Well及所有其他专业
39
Diagnostic Modalities and Laboratory
Evaluations
诊断模式和实验室结果评估
Laboratory studies 实验室检查
CBC
血常规
Chemistries
生化检查
LFTs
肝功
Cultures
培炎
Lipids
血脂
TSH
促甲状腺素
Many others
很多其他的
Roentgen interpretation
Microscopy
显微镜检查
Wet prep
白带常规
Parasites
寄生虫
Other
其他
Rapid tests
快速检测
Strep
链球菌
Mono
单核细胞
Infulenza
流感
Hemoglobin and Hct 血红蛋白和血红蛋白压积
Blood sugar
血糖
H. Pylori
幽门螺旋杆菌
40
Others
其他
Procedures: Injections, Dermatological
procedures, and Fine needle aspirations
操作：注射，皮肤病方面的操作，和细针抽吸
Biopsies: 活检
Punch 剔除法
Shave 刮除法
Excision 切除法
Joint aspiration 关节液吸出
和腔内注射
and injection
Tendon injections 肌腱注射
Cryotherepy 冷冻
Hyfercation/cautery电切术
Cyst and lipoma removal囊
肿和脂肪瘤切除
Foreign body removal去除
异物
Eyes眼睛
Ears耳朵
Nose鼻子
Other其他
Suturing/laceration repair缝
合/裂伤修补
Casting simple fractures简
单骨折的固定术
Splinting 打夹板
41
42
Colposcopy, Exercise stress testing, Flexible
sigmoidoscopy, and many more!
阴道镜检查，运动负荷实验，纤维乙状结肠镜检查，
还有更多！
ECG心电图
Exercise Stress Test运动
负荷试验
Holter/event monitors动态
心电监护
Cardioversion with
defibrillator 除颤仪除颤
Colposcopy 阴道镜
Cryotherepy 冷冻
Thoracentesis 胸穿
Paracentesis 腹穿
Lumbar puncture 胸穿
Intubation 气管插管
Cardio-pulmonary resuscitation
心肺复苏
Endoscopy内镜
Vascectomy
输精管切除术
Circumscision
包皮环切术
43
Not only Treatment of Disease but also
Prevention
不但治疗疾病而且预防疾病
Cancer screening
癌症筛查
Vaccinations
预防接种
Lifestyle modification
生活方式的改变
44
Cooperation with other specialists - health care
professionals
与其他专科医生合作
45
Rural or Urban: 农村或城市
Do FP belong only in rural areas?
家庭医生只属于农村地区吗？
Needed in Rural areas: villages, towns, small cities
在村、镇、小城市等农村地区需要：
– Not enough specialists to supply all small towns
没有足够的专家可以为所有小镇提供医疗服务
– Not enough demand to support all the other
specialties
没有那样多的对所有专科的医疗需求
– FP/GP needs to be well trained to handle many
complex problems and procedures 家庭/全科医生需要
得到很好的培训以应付很多复杂的问题和操作
Needed in Urban/city areas 在城市也需要
– Specialization is one of the reasons FM is needed
需要家庭医生的一个理由是专科化
– Management of care is even more critical
l更为关键的是健康照顾管理
– Cost control费用控制
46
GP is New in Many Countries
全科医学在许多国家是新生事物
New Specialty新的专科
Challenge of deciding what it will be like
决定全科医学的模式是一个挑战
Integrating GP with existing medical system
将全科医学和现有的医疗系统一体化
Gaining acceptance with doctors and patients
得到医生和患者的接受
Becoming an attractive specialty to medical
students 成为对医学生有吸引力的专业
47
Knowledge Base
知识基础
FP’s know 20-30% of each of the other specialties
knowledge:
全科医生应该知道每一个专科知识的20-30%
Specialists see FP from their perspective
专科医生从他们的角度看待全科医生
– FP’s know less than the specialist in his area
在专科领域全科医生的知识不如专科医生
– FP’s know more than the specialist in other areas
在其他的领域全科医生的知识多于专科医生
53
Depth vs. Breadth of Knowledge Base
知识基础的深度与广度对比
100
90
80
70
60
50
40
30
20
10
0
Internist Pediatrics Ob-Gyn
儿科
内科
妇产科
Surgery
外科
54
Total Knowledge Content
总知识含量
100
90
80
70
60
50
40
30
20
10
0
FP全科
Internist内科
Peds儿科
Ob-gyn妇产科.
Surgery外科
55
How Many Years of Training to be a FP in
the USA?
在美国培训全科医生需要多少年？
Primary and Secondary School 12 years
小学和中学 12年
University
4 years
大学
4年
Medical School
4 years
医学院
4年
Post Graduate Residency
3 years
住院医生
3年
Total
总共
23 years
56
What are the requirements to be a Family
Medicine Doctor in the USA?
在美国成为全科医生的要求是什么？
Succesfully finishing medical school
成功地完成医学院校的学习
Passing the three step USMLE
通过三步美国行医执照考试
Completing approved residency program
完成住院医培训
Passing one day Family Practice Exam
通过一天的全科医生考试
Completing 150 hours of continuing medical education
every 3 years (The American Academy of Family Practice
was the first to require this
每三年完成150小时的继续医学教育（美国家庭医学会最先要
求这项内容）
Recertification required every 7 years
行医执照每7年重新认证一次
57
Our Clinic and Hospital
我们的诊所和医院
58
Why is GP the specialty of the 21st Century?
为什么全科医学会成为21世纪的专科？
Cost effective 符合成本效益原则
Satisfying for the patient 患者满意度高
Satisfying for the GP!
Emphasis on prevention 强调预防
Treating the patient in the context of the family
在病人的家庭背景下治疗
Whole person medicine
全人模式的医学
Systems based approach
以医疗体系为基础的方法
60