家庭医学的作用原则和能力

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April 2011 20011年4月,2,我 们 是 谁 ？ Who are we?,Cheung医生Dannemiller 医生Heffron医生 Jenkins医生 Leu医生 Rudd医生Zhou 周仲华医生,3,Gu Jian谷建医生Joseph金世红医生,我 们 是 谁 ？ Who are we?,Baer医生Chan医生Heffron医生 Jenkins医生 Leu医生 Schackow医生Zhou 周仲华医生Gujian谷建医生Longan医生,4,Gu Jian谷建医生Joseph金世红医生,我 们 是 谁 ？ Who are we?,Baer医生Heffron医生 Jenkins医生 Pang Yan医生Burgos医生,5,Gu Jian谷建医生Joseph金世红医生,Goals of Talk演讲的目的,Why general practice is 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What do GPs do 全科医生做什么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,6,What is Family Medicine? It Depends on Who You Ask!家庭医学是什么？看你问谁！,British 英国Swedish 瑞典Australia 澳大利亚Hong Kong 香港Canada 加拿大America 美国,7,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 发展一个新模式The government and entire medical system recognize need for general practice 政府和整个医学界认识到对全科的需要The Ministry of Health has now provided a model for general practice and trainingIt is being implemented across China 卫生部指出了全科医疗及其培训的模式 -全国都在实施,8,Family Medicine in China中国的家庭医学,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,9,Family Medicine in China中国的家庭医学,Some differences between GP and traditional Chinese medicine:全科医学和传统中医的区别Understanding of causes of disease对病因的理解GPs emphasize family, social and environmental influences全科强调家庭、社会和环境的影响GPs rely on science including evidence based medicine全科医学更依赖科学包括循证医学History and physical exam are done more thoroughly by GPs 全科医生采集病史和体格检查更全面彻底。,10,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,11,What is Family Medicine in the USA?美国的家庭医学是什么？,Over 420 training programs(residencies) with over 9,000 residents 超过420 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,12,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 ！,13,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,14,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,15,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,16,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,17,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,18,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,19,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,20,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,21,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,22,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,23,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),24,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 monitoringTocomonitor 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,Pediatrics.儿科学,25,Internal Medicine内科学,But All Other Specialties as Well及所有其他专业,26,Diagnostic Modalities and Laboratory Evaluations诊断模式和实验室结果评估,27,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 interpretationMicroscopy 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 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,28,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 injectionTendon 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,29,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！,30,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,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,31,Cooperation with other specialists - health care professionals与其他专科医生合作,32,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,33,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,34,Consider Changes in the Medical System医学界在考虑的变革,Need for adjustments in the practice of medicine医疗领域里需要调整之处More time per patient 每个病人更多的时间History taking 采集病史Accurate diagnosis and management of patient 准确的诊断和治疗Preventive care 预防性照顾Patient education病人教育，Etcetera等Need adjustments in how doctors are reimbursed 医生收入来源需要调整Complexity 复杂性Time 时间,35,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,36,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 doesnt 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,37,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,38,Knowledge Base知识基础,FPs 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FPs 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FPs 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,39,Depth vs. Breadth of Knowledge Base知识基础的深度与广度对比,40,Total Knowledge Content总知识含量,41,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 FPMaybe! 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,42,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,43,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 patients 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,44,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,45,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 全科医生对职业感到满意,46,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,47,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 1900s most American doctors were GPs 在20世纪初之前大多数美国医生是全科医生Up to the 1930s 80% were GPs and only 20% specialists 到20世纪30年代，医生中80%是全科医生，20%是专科医生,48,A Little US Medical History一点美国的医学史,1940s: an explosion of medical knowledge and an increase in specialization 20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,49,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。,50,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22000Health 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,51,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仍然没有专业资格认证,52,GPs Struggle to Succeed全科医生奋斗成功,In mid 1940s AAGP requested specialty training 20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”,53,GPs Struggle to Succeed全科医生奋斗成功,All through 1950s and most of the 1960s continued to work for improvement 整个20世纪50年代和20世纪60年代的多数时间持续不断 地取得工作进步,54,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 1960s20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,55,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,56,American Medical System Suffered from Over Specialization美国医疗体系曾遭遇过度专业化,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,57,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,58,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,59,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）,60,Who is a FP/GP?谁是家庭医生/全科