基层全科医生在医联体内的角色定位研究
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摘要
全科医生是居民健康的"守门人",探讨全科医生在医联体内的角色定位、各角色间的联系、全科医生在医联体内发挥作用的条件等,有助于全科医生更好地认清自身的功能职责和医联体结构体系的完善。本文从基层首诊、健康管理、医疗信息的平衡、医疗资源的枢纽、教学科研方面探讨基层全科医生在医联体内的角色定位及各角色间的相互关系,分析了全科医生在医联体内发挥作用的条件和目前存在的问题。认为当前基层全科医生综合素质不高和积极性不强、患者参与度低、医联体结构建设不完整等问题将影响基层全科医生作用的有效发挥。建议重视基层全科医生的继续教育与奖励,对各项健康管理服务进行标价及制定奖惩措施,深化家庭医生签约制度的宣传内涵和细节,医联体按现代医学模式理念进行资源整合等。
General practitioners(GPs) are the "gatekeeper" for residents' health. Exploration of the roles of GPs working in primary healthcare settings of a regional medical consortium and the relationship between the roles,the conditions under which the GPs play a role in the medical consortium,etc. helps GPs better understand their roles and responsibilities,and promotes the improvement of the structural system of the medical consortium. We discussed the 5 roles [the initial care provider,health manager,conveyor of health information to patients(for reducing the asymmetry in information between them and patients),health service hub,teacher and researcher] of GPs who work in primary healthcare settings joining in a regional medical consortium,and the relationships of the roles. Moreover,we analyzed the problems that hinder GPs from playing their due roles,such as the unsatisfactory overall qualities and work enthusiasm of GPs working in primary healthcare settings,patients' inactive primary healthcare-seeking,and incomplete structure of the regional medical consortium. Furthermore,for addressing these problems,we proposed suggestions,such as attaching importance to the continuing education and incentives for GPs,pricing health management services,formulating positive and negative incentive measures for the performance of GPs,intensifying the publicity connotation and details of family doctor system,and integrating the resources owned by the members of a regional medical consortium with the concept of modern medical model.
General practitioners(GPs) are the "gatekeeper" for residents' health. Exploration of the roles of GPs working in primary healthcare settings of a regional medical consortium and the relationship between the roles,the conditions under which the GPs play a role in the medical consortium,etc. helps GPs better understand their roles and responsibilities,and promotes the improvement of the structural system of the medical consortium. We discussed the 5 roles [the initial care provider,health manager,conveyor of health information to patients(for reducing the asymmetry in information between them and patients),health service hub,teacher and researcher] of GPs who work in primary healthcare settings joining in a regional medical consortium,and the relationships of the roles. Moreover,we analyzed the problems that hinder GPs from playing their due roles,such as the unsatisfactory overall qualities and work enthusiasm of GPs working in primary healthcare settings,patients' inactive primary healthcare-seeking,and incomplete structure of the regional medical consortium. Furthermore,for addressing these problems,we proposed suggestions,such as attaching importance to the continuing education and incentives for GPs,pricing health management services,formulating positive and negative incentive measures for the performance of GPs,intensifying the publicity connotation and details of family doctor system,and integrating the resources owned by the members of a regional medical consortium with the concept of modern medical model.
引文
[1]国务院办公厅关于推进医疗联合体建设和发展的指导意见[Z].2017.
[2]王荣华,李云涛,葛瑶琪,等.医疗机构联合体建设的现状及思考[J].医学与哲学,2018,39(2):59-62.DOI:10.12014/j.issn.1002-0772.2018.02a.18.WANG R H,LI Y T,GE Y Q,et al.Present situstion and reflection of the construction of medical alliance[J].Med Phil,2018,39(2):59-62.DOI:10.12014/j.issn.1002-0772.2018.02a.18.
[3]FUNG C S,WONG C K,FONG D Y,et al.Having a family doctor was associated with lower utilization of hospital-based health services[J].BMC Health Services Research,2015,15(1):1-9.DOI:10.1186/s12913-015-0705-7.
[4]王芳,卢祖洵.英国卫生服务提供模式及卫生保健制度的主要特征[J].中国社会医学杂志,2005,22(4):145-149.DOI:10.3969/j.issn.1673-5625.2005.04.001.WANG F,LU Z X.Main features of the UK health service delivery model and health care system[J].Chinese Journal of Social Medicine,2005,22(4):145-149.DOI:10.3969/j.issn.1673-5625.2005.04.001.
[5]单海燕,祁慧萌,于晓松.英国的全科医学发展模式及其对我国的启示[J].中国全科医学,2017,20(7):763-767.DOI:10.3969/j.issn.1007-9572.2017.07.001.SHAN H Y,QI H M,YU X S.Developmental pattern of British general practice and its enlightenment to China[J].Chinese General Practice,2017,20(7):763-767.DOI:10.3969/j.issn.1007-9572.2017.07.001.
[6]国务院医改办.关于印发推进家庭医生签约服务指导意见的通知[Z].2017.
[7]GILL J M,MAINOUS A G,NSEREKO M.The effect of continuity of care on emergency department use[J].Arch Fam Med,2000,9(4):333-338.
[8]SAULTZ J W,LOCHNER J.Interpersonal continuity of care and care outcomes:a critical review[J].Annals of Family Medicine,2005,3(2):159-166.
[9]王荣华,李云涛,季国忠.中美英三国的协同医疗模式比较及启示[J].中国基层医药,2017,24(3):470-473.DOI:10.3760/cma.j.issn.1008-6706.2017.03.039.WANG R H,LI Y T,JI G Z.Comparison analysis of regional collaborative health care among China,America and Britain and the inspirations to China[J].Chin J Prim Med Pharm,2017,24(3):470-473.DOI:10.3760/cma.j.issn.1008-6706.2017.03.039.
[10]匡莉,LiLi.全科医疗特征功能视角下分级诊疗的定义及制度层次[J].中国卫生政策研究,2016,9(1):19-26.DOI:10.3969/j.issn.1674-2982.2016.01.003.KUANG L,LiLi.The definition of tiered health care systems and institutional levels from perspective of general practice attributes in China[J].Chinese Journal of Health Policy,2016,9(1):19-26.DOI:10.3969/j.issn.1674-2982.2016.01.003.
[11]STIGLITZ J.Economics of the public sector[M].2nd ed.New York:W.W.Nortion&Company,1988.
[12]ARROW K J.Uncertainty and the welfare economics of medical care:reply(the implications of transaction costs and adjustment lags)[J].American Economic Review,1965,55(1/2):154-158.
[13]宣颖超.论医生收入组成对患者效用的影响[J].商,2016,19(13):71.XUAN Y C.Influence of doctors'income composition on patients'utility[J].Business,2016,19(13):71.
[14]陶月玉,钱介荣,庄永忠,等.信息不对称对医患关系的影响及应对策略[J].中国医院,2004,8(1):50-52.DOI:10.3969/j.issn.1671-0592.2004.01.020.TAO Y Y,QIAN J R,ZHUANG Y Z,et al.The impact of asymmetrical information on the relations between medical service providers and patients and the strategy to respond it[J].Chinese Hospital,2004,8(1):50-52.DOI:10.3969/j.issn.1671-0592.2004.01.020.
[15]RUDY W.The university of europe(1100-1914)[M].London:Associated University Presses,1984:130.
[16]MILLER G E.The meaning of general education[M].New York:Teacher College Press,1988.
[17]武芳,伍祥林.重庆市全科医师培训学员社区工作行为转化效果研究[J].中国全科医学,2016,19(22):2696-2700.DOI:10.3969/j.issn.1007-9572.2016.22.017.WU F,WU X L.Behavioral transformation effect of community work of Chongqing general practitioners trainees[J].Chinese General Practice,2016,19(22):2696-2700.DOI:10.3969/j.issn.1007-9572.2016.22.017.
[18]陆媛,王朝昕,石建伟,等.全科医生开展科研工作的必要性及策略建议[J].中华全科医师杂志,2017,16(1):11-14.DOI:10.3760/cma.j.issn.1671-7368.2017.01.005.LU Y,WANG Z X,SHI J W,et al.Necessity and strategy of scientific research in general practice[J].Chinese Journal of General Practitioners,2017,16(1):11-14.DOI:10.3760/cma.j.issn.1671-7368.2017.01.005.
[19]梁世民,于晓飞,李晨,等.河南省居民对家庭医生式服务的签约意愿及影响因素研究[J].中国全科医学,2017,20(28):3488-3492.DOI:10.3969/j.issn.1007-9572.2017.28.008.LIANG S M,YU X F,LI C,et al.Intention and associated factors of signing a contract with a family doctor team in residents in Henan Province[J].Chinese General Practice,2017,20(28):3488-3492.DOI:10.3969/j.issn.1007-9572.2017.28.008.
[20]WINDHAM B G,BENNETT R G,GOTTLIEB S.Care management interventions for older patients with congestive heart failure[J].American Journal of Managed Care,2003,9(6):460-461.
[21]林丽萍,陈素斌.共情护理对急诊患者负面情绪及配合度的影响[J].基层医学论坛,2017,21(30):4195-4196.LIN L P,CHEN S B.Influence of empathy nursing on negative emotion and fit of emergency patients[J].The Medical Forum,2017,21(30):4195-4196.
[22]孟德昕,迟沫涵,岳凤莲,等.公立医院医患互动关系对医护人员工作投入影响研究[J].中国医院管理,2014,34(6):41-43.MENG D X,CHI M H,YUE F L,et al.Research on impact of quality of doctor-patient interaction relationship on medical staff's engagement in the public hospital[J].Chinese Hospital Management,2014,34(6):41-43.
[23]吴迪.循证医学协助全科医生高效诊疗[J].中华全科医师杂志,2012,11(7):483-484.DOI:10.3760/cma.j.issn.1671-7368.2012.07.005.WU D.Evidence-based medicine assists general practitioners in efficient treatment[J].Chinese Journal of General Practitioners,2012,11(7):483-484.DOI:10.3760/cma.j.issn.1671-7368.2012.07.005.
[24]DENTZER S.Rx for the"blockbuster drug"of patient engagement[J].Health Affairs,2013,32(2):202.
[25]OSBORN R,SQUIRES D.International perspectives on patient engagement:results from the 2011 Commonwealth Fund Survey[J].J Ambul Care Manage,2012,35(2):118-128.
[26]COULTER A.Patient engagement:what works?[J].J Ambul Care Manage,2012,35(2):80-89.
[27]武宁,程明羕,闫丽娜,等.中国全科医生培养发展报告(2018)[J].中国全科医学,2018,21(10):1135-1142.DOI:10.3969/j.issn.1007-9572.2018.10.001.WU N,CHENG M Y,YAN L N,et al.Training development report of GPs(2018)[J].Chinese General Practice,2018,21(10):1135-1142.DOI:10.3969/j.issn.1007-9572.2018.10.001.
[28]王良晨,葛敏,江萍,等.社区居民对家庭医生签约服务的认知与意愿研究[J].中国全科医学,2018,21(4):401-406.DOI:10.3969/j.issn.1007-9572.2018.04.006.WANG L C,GE M,JIANG P,et al.Community residents'awareness and willingness towards contractual services from family doctors[J].Chinese General Practice,2018,21(4):401-406.DOI:10.3969/j.issn.1007-9572.2018.04.006.
[2]王荣华,李云涛,葛瑶琪,等.医疗机构联合体建设的现状及思考[J].医学与哲学,2018,39(2):59-62.DOI:10.12014/j.issn.1002-0772.2018.02a.18.WANG R H,LI Y T,GE Y Q,et al.Present situstion and reflection of the construction of medical alliance[J].Med Phil,2018,39(2):59-62.DOI:10.12014/j.issn.1002-0772.2018.02a.18.
[3]FUNG C S,WONG C K,FONG D Y,et al.Having a family doctor was associated with lower utilization of hospital-based health services[J].BMC Health Services Research,2015,15(1):1-9.DOI:10.1186/s12913-015-0705-7.
[4]王芳,卢祖洵.英国卫生服务提供模式及卫生保健制度的主要特征[J].中国社会医学杂志,2005,22(4):145-149.DOI:10.3969/j.issn.1673-5625.2005.04.001.WANG F,LU Z X.Main features of the UK health service delivery model and health care system[J].Chinese Journal of Social Medicine,2005,22(4):145-149.DOI:10.3969/j.issn.1673-5625.2005.04.001.
[5]单海燕,祁慧萌,于晓松.英国的全科医学发展模式及其对我国的启示[J].中国全科医学,2017,20(7):763-767.DOI:10.3969/j.issn.1007-9572.2017.07.001.SHAN H Y,QI H M,YU X S.Developmental pattern of British general practice and its enlightenment to China[J].Chinese General Practice,2017,20(7):763-767.DOI:10.3969/j.issn.1007-9572.2017.07.001.
[6]国务院医改办.关于印发推进家庭医生签约服务指导意见的通知[Z].2017.
[7]GILL J M,MAINOUS A G,NSEREKO M.The effect of continuity of care on emergency department use[J].Arch Fam Med,2000,9(4):333-338.
[8]SAULTZ J W,LOCHNER J.Interpersonal continuity of care and care outcomes:a critical review[J].Annals of Family Medicine,2005,3(2):159-166.
[9]王荣华,李云涛,季国忠.中美英三国的协同医疗模式比较及启示[J].中国基层医药,2017,24(3):470-473.DOI:10.3760/cma.j.issn.1008-6706.2017.03.039.WANG R H,LI Y T,JI G Z.Comparison analysis of regional collaborative health care among China,America and Britain and the inspirations to China[J].Chin J Prim Med Pharm,2017,24(3):470-473.DOI:10.3760/cma.j.issn.1008-6706.2017.03.039.
[10]匡莉,LiLi.全科医疗特征功能视角下分级诊疗的定义及制度层次[J].中国卫生政策研究,2016,9(1):19-26.DOI:10.3969/j.issn.1674-2982.2016.01.003.KUANG L,LiLi.The definition of tiered health care systems and institutional levels from perspective of general practice attributes in China[J].Chinese Journal of Health Policy,2016,9(1):19-26.DOI:10.3969/j.issn.1674-2982.2016.01.003.
[11]STIGLITZ J.Economics of the public sector[M].2nd ed.New York:W.W.Nortion&Company,1988.
[12]ARROW K J.Uncertainty and the welfare economics of medical care:reply(the implications of transaction costs and adjustment lags)[J].American Economic Review,1965,55(1/2):154-158.
[13]宣颖超.论医生收入组成对患者效用的影响[J].商,2016,19(13):71.XUAN Y C.Influence of doctors'income composition on patients'utility[J].Business,2016,19(13):71.
[14]陶月玉,钱介荣,庄永忠,等.信息不对称对医患关系的影响及应对策略[J].中国医院,2004,8(1):50-52.DOI:10.3969/j.issn.1671-0592.2004.01.020.TAO Y Y,QIAN J R,ZHUANG Y Z,et al.The impact of asymmetrical information on the relations between medical service providers and patients and the strategy to respond it[J].Chinese Hospital,2004,8(1):50-52.DOI:10.3969/j.issn.1671-0592.2004.01.020.
[15]RUDY W.The university of europe(1100-1914)[M].London:Associated University Presses,1984:130.
[16]MILLER G E.The meaning of general education[M].New York:Teacher College Press,1988.
[17]武芳,伍祥林.重庆市全科医师培训学员社区工作行为转化效果研究[J].中国全科医学,2016,19(22):2696-2700.DOI:10.3969/j.issn.1007-9572.2016.22.017.WU F,WU X L.Behavioral transformation effect of community work of Chongqing general practitioners trainees[J].Chinese General Practice,2016,19(22):2696-2700.DOI:10.3969/j.issn.1007-9572.2016.22.017.
[18]陆媛,王朝昕,石建伟,等.全科医生开展科研工作的必要性及策略建议[J].中华全科医师杂志,2017,16(1):11-14.DOI:10.3760/cma.j.issn.1671-7368.2017.01.005.LU Y,WANG Z X,SHI J W,et al.Necessity and strategy of scientific research in general practice[J].Chinese Journal of General Practitioners,2017,16(1):11-14.DOI:10.3760/cma.j.issn.1671-7368.2017.01.005.
[19]梁世民,于晓飞,李晨,等.河南省居民对家庭医生式服务的签约意愿及影响因素研究[J].中国全科医学,2017,20(28):3488-3492.DOI:10.3969/j.issn.1007-9572.2017.28.008.LIANG S M,YU X F,LI C,et al.Intention and associated factors of signing a contract with a family doctor team in residents in Henan Province[J].Chinese General Practice,2017,20(28):3488-3492.DOI:10.3969/j.issn.1007-9572.2017.28.008.
[20]WINDHAM B G,BENNETT R G,GOTTLIEB S.Care management interventions for older patients with congestive heart failure[J].American Journal of Managed Care,2003,9(6):460-461.
[21]林丽萍,陈素斌.共情护理对急诊患者负面情绪及配合度的影响[J].基层医学论坛,2017,21(30):4195-4196.LIN L P,CHEN S B.Influence of empathy nursing on negative emotion and fit of emergency patients[J].The Medical Forum,2017,21(30):4195-4196.
[22]孟德昕,迟沫涵,岳凤莲,等.公立医院医患互动关系对医护人员工作投入影响研究[J].中国医院管理,2014,34(6):41-43.MENG D X,CHI M H,YUE F L,et al.Research on impact of quality of doctor-patient interaction relationship on medical staff's engagement in the public hospital[J].Chinese Hospital Management,2014,34(6):41-43.
[23]吴迪.循证医学协助全科医生高效诊疗[J].中华全科医师杂志,2012,11(7):483-484.DOI:10.3760/cma.j.issn.1671-7368.2012.07.005.WU D.Evidence-based medicine assists general practitioners in efficient treatment[J].Chinese Journal of General Practitioners,2012,11(7):483-484.DOI:10.3760/cma.j.issn.1671-7368.2012.07.005.
[24]DENTZER S.Rx for the"blockbuster drug"of patient engagement[J].Health Affairs,2013,32(2):202.
[25]OSBORN R,SQUIRES D.International perspectives on patient engagement:results from the 2011 Commonwealth Fund Survey[J].J Ambul Care Manage,2012,35(2):118-128.
[26]COULTER A.Patient engagement:what works?[J].J Ambul Care Manage,2012,35(2):80-89.
[27]武宁,程明羕,闫丽娜,等.中国全科医生培养发展报告(2018)[J].中国全科医学,2018,21(10):1135-1142.DOI:10.3969/j.issn.1007-9572.2018.10.001.WU N,CHENG M Y,YAN L N,et al.Training development report of GPs(2018)[J].Chinese General Practice,2018,21(10):1135-1142.DOI:10.3969/j.issn.1007-9572.2018.10.001.
[28]王良晨,葛敏,江萍,等.社区居民对家庭医生签约服务的认知与意愿研究[J].中国全科医学,2018,21(4):401-406.DOI:10.3969/j.issn.1007-9572.2018.04.006.WANG L C,GE M,JIANG P,et al.Community residents'awareness and willingness towards contractual services from family doctors[J].Chinese General Practice,2018,21(4):401-406.DOI:10.3969/j.issn.1007-9572.2018.04.006.