家庭医学是什么?

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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
March 2010 2010年3月
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
3
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
4
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
Effect of World War II二战的影响
World War II made the situation for GPs worse二战
让全科医生的境遇变差
– Government deferments for medical students going into
residencies. There was no residency for GP
政府让医学生延迟进入住院医生培训。当时没有全科住
院医生培训。
– Medical school graduates rushed into specialty
residencies
医学院毕业生匆匆进入专科住院医生培训。
– After WWII: government paid for medical school and
residency training but there were still no GP residency
programs
二战以后:政府给医学院和住院医生培训付费,但是仍
然没有全科住院医生培训项目。
6
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
7
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 group 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
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”
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’s19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:
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
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
10
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
11
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
–
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)
12
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
13
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
14
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
15
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
16
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
17
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
Australian澳大利亚
Hong Kong香港
Canada加拿大
America美国
18
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 – final model not yet decided
发展中-最终模式尚未确定
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
19
Family Medicine in China
中国的家庭医学
Major medical centers recognize need for
the specialty
大型医学中心认识到对全科的需要
Major medical centers waiting for Beijing
to decide what model and what training
program
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
What is Family Medicine in the USA?
美国的家庭医学是什么?
Medical specialty医 学 专 业
Recognized as specialty in the US since
1969自 从 1969 年 起 在 美 国 被 认 定
为一种医学专业
Over 80,000 family physicians in the US
在 美 国 有 超过80,000 多名 全 科 医 生
21
What is Family Medicine in the USA?
美国的家庭医学是什么?
Over 460 training programs(residencies) with
over 9,000 residents
超过460 个 住院医师培训项目 , 超过9,000名
住院医生
Can treat 85-90% of medical problems
能 够 治 疗 85-90%的医学问题
22
What is Family Practice in the United States?
在 美 国 家 庭 医 学 是 什 么 样 的?
12% of all US doctors are family practice
doctors
12% 的 美 国 医 生 是 家 庭 医 生
But 25% of all office visits in the US are to
family doctors!
但 是 美 国 25% 的 就 诊 都 是 看 全 科 医
生!
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
24
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
25
Continuity of Care
照顾的持续性
Seeing patients over an extended
period of time
长时间内照顾病人
Developing the doctor-patient
relationship
发展医患关系
Familiarity with patient health status
熟悉病患的健康状态
Developing trust
发展信任关系
26
Management of Care
保健管理
Evaluation of the Patient
病人病情的评估
Diagnostic tests
诊断检查
Involvement of specialists
专科医生参与
Treatment plans
诊疗计划
27
Patient Care in the Context of the Family
以家庭为背景的病人保健
Home environment
家庭环境
Family dynamics
家庭动力学
Family health beliefs and
practices
家庭的健康理念和实践
Social, work, and religious
settings
社会环境,工作环境和宗
教环境
28
Preventive Medicine
预防医学
Patient education
病人教育
Lifestyle modification
生活方式的调整
Age and gender specific
disease screening
根据年龄和性别而特异的疾病
筛查
Medical intervention 医疗干预
29
Team Approach to Health Care
健康照顾的团队合作
Involvement of other health care providers
其它医疗保健工作者的参与
Medical and surgical specialists
内外科专家
Behavioral medicine
行为医学
Physical, occupational, home therapists
物理治疗 , 职业理疗师 , 家庭治疗师
Dietitians
营养学家
30
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
31
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
32
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
33
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)
34
Pediatrics...
儿科学
35
Internal Medicine
内科学
But All Other Specialties as Well及所有其他专业
36
Diagnostic Modalities and Laboratory
Evaluations
诊断模式和实验室结果评估
37
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
38
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!
39
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
40
Cooperation with other specialists - health care
professionals
与其他专科医生合作
41
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 critica
l更为关键的是健康照顾管理
– Cost control费用控制
42
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
43
The Need for a Good Model
一个好的全科医学模式的需求
Meets patients primary health care needs
满足病人初级卫生保健的需要
Professionally satisfying 职业的满意度
High quality training 高质量的培训
Respect of Colleagues 同行的尊敬
Trust of Patients 病人的信任
Financially rewarding 薪酬上的回报
44
Major Lessons – Appropriate Model
重要的教训–合适的模式
model must be appropriate to the region模式必
须和地区相适应
– Transplanting models without modification doesn’t
work well 不做调整而直接移植模式不能有效运行
One Specialty, Many models一个专业,很多模式
– American Model
– 美国模式
– British Model
– 英国模式
– Knowledge base and technology/procedures
appropriate to the specialty and the region
知识基础、技术和操作要适合专业和地区
45
Consequences of an Inadequate Model
不适当模式的结果
No interest on the part of medical students
医学生没有兴趣
Inadequate training for the job assignment
对于分配的工作没有得到充分的培训
Feeling unprepared in those who do FP work
那些要做全科医疗工作的人感觉没有准备好
Lack of respect from colleagues
缺乏同事的尊重
Lack of trust from patients
缺乏病人的信任
Low salary
低薪酬
High drop out rate高的放弃率
46
Who is a FP/GP?
谁是家庭医生/全科医生?
Surgical personality!外科特性!
Internist personality!内科特性!
Family medicine personality!全科特性!
47
Knowledge Base – Important to Emphasize
知识基础-重中之重
Are three years of training enough?
三年的培训足够吗?
Know what is needed to be known!
知道所需要知道的知识
– 25-30% of knowledge cove 85-90% of the diseases
“Rapidly progressing glomerulonephritis” not high on the priority list
25-30%知识覆盖85-90%的疾病。
急进性肾小球肾炎不是最优先需要学习的
7/1,000,000 发病率
1/142,857 = 1/lifetime of FP…Maybe! 一个全科医生可能在一生中
就看一个这样的病例
– Debate over adding a 4th year 是否需要增加第四年的培训仍有争议
48
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
49
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
50
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
51
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
52
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
53
Our Clinic and Hospital
我们的诊所和医院
54
What is a typical week like for a family
medicine doctor?
(Statistics from 2008)
一个家庭医生典型的一周工作(2008年统计)
84.9 patients per week! (how many in China?) 每周84.9
个病人(中国多少?)
8.1 hospital patient visits per week 每周看8.1个住院病人
2.3 nursing home patients 每周2.3个养老院病人访视
0.6 home visits 每周0.6个家庭访视
7.5 Patients Supervised under home health care 7.5个家
庭照顾指导
9.6 Nursing home patients supervised 9.6个护理院病人指
导
2.1 Hospice patients supervised 2.1个临终关怀病人指导
9.5 patients with free or discounted care 9.5个减免费的病
人
51 hours a week
每周工作51 个小时
Approximately 2500 patients cared for (800 families) 大
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约需要照顾2500个病人(800个家庭)
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
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
56
Thank You!
谢谢!
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