课件分级诊疗制度与tor-patient communication

1、 分级诊疗制度与Doctor- Patient Communication 2016.3.15微信群年级+专业+姓名通知课程与美国执医全科医生联盟1000人：规培+骨干师资每周讲座：常见健康问题诊疗动态美方将以雇主身份完成以下工作为甲方输送的学生在美国的安全及时与甲方沟通；负责落实中国学生在美学习的学校并与校方保持联系，保证学生取得医学硕士学位所需的学习条件；为有需要的学生提供学生贷款；辅导学生参加医师助理执照考试；负责为取得医师助理执照的学生提供美国相关医院的就业岗位；协助学生申办美国绿卡；辅导学生申请美国三年的住院医师培训，取得美国医师执照。作业 2016全科医学310分钟分级诊疗制度关于

2、推进分级诊疗制度建设的指导意见2017年：分级诊疗政策体系逐步完善，医疗卫生机构分工协作机制基本形成，优质医疗资源有序有效下沉，以全科医生为重点的基层医疗卫生人才队伍建设得到加强，医疗资源利用效率和整体效益进一步提高，基层医疗卫生机构诊疗量占总诊疗量比例明显提升，就医秩序更加合理规范。2020年：分级诊疗服务能力全面提升，保障机制逐步健全，布局合理、规模适当、层级优化、职责明晰、功能完善、富有效率的医疗服务体系基本构建，基层首诊、双向转诊、急慢分治、上下联动的分级诊疗模式逐步形成，基本建立符合国情的分级诊疗制度。完善分级诊疗服务体系明确城市二、三级医院、县级医院、基层医疗卫生机构以及慢性病医疗

3、机构等各级各类医疗机构功能定位加强基层医疗卫生人才队伍建设，实现城乡每万名居民有23名合格的全科医生，发挥全科医生的居民健康“守门人”作用。通过组建医疗联合体、对口支援、医师多点执业、鼓励开办个体诊所等多种形式，提升基层医疗卫生服务能力。全面提升县级公立医院综合能力，加强县级公立医院临床专科建设，县域内就诊率提高到90%左右，基本实现大病不出县。整合并开放二级以上医院检查检验等资源，推动区域资源共享。加快推进医疗卫生信息化建设，促进跨地域、跨机构就诊信息共享。分级诊疗保障机制完善医疗资源合理配置机制，制定不同级别、不同类别医疗机构服务能力标准，重点控制三级综合医院数量和规模。建立基层签约服务制

4、度，由二级以上医院医师与基层医疗卫生机构的医务人员组成团队，与居民或家庭自愿签约。推进医保支付制度改革，完善不同级别医疗机构的医保差异化支付政策。健全医疗服务价格形成机制，合理制定和调整医疗服务价格，对医疗机构落实功能定位、患者合理选择就医机构形成有效的激励引导。建立完善利益分配机制，引导二级以上医院向下转诊诊断明确、病情稳定的慢性病患者，基层医疗卫生机构绩效工资向签约服务的医务人员倾斜。以业务、技术、管理、资产等为纽带，建立医疗卫生机构分工协作机制。Hot discussionIn October 25, 2013, Zhejiang Wenling First Peoples Hospit

5、al occurred in intentional injury cases, 3 doctors in the outpatient when serving the patients were stabbed by a man. Among them, the deputy director of outpatient management department, director of the department of ENT Wang Yunjie, only 47 years old, was death after invalid rescue. Another 2 peopl

6、e were injured. At present, the suspected XXX has been under criminal detention, the case is still under investigation.In 2012, a nations total of 11 cases of malignant wound medicine, causing 35 casualties, which killed 7 people, injured 28 people (including patients and nursing staff 11, 16 medica

7、l staff, 1 security), involving Beijing, Heilongjiang and other 8 provinces and cities. Which have attracted a great social extensive concern, and exposed many prominent problems and weak links in hospital security work. A patient stabbed a doctor to death, and 3 to injured in Harbin Medical Univers

8、ity2012年3月23日，哈尔滨医科大学附属第一医院发生一起恶性伤害案件，致1人死亡、3人受伤。据介绍，犯罪嫌疑人李梦南为男性，18岁，汉族，户籍所在地为内蒙古自治区，患强直性脊柱炎，23日9时许到哈医大一院住院处治疗。因其同时患有肺结核，治疗强直性脊柱炎会对肺部造成影响，医生建议他先治好肺结核后再治疗强直性脊柱炎。李梦南对此心生不满，于案发当日16时许，购买一把水果刀，来到医生办公室将王浩、郑一宁、王宇、于惠铭4名医务人员捅伤。Minister of Health to respond to Harbin kill Medical Records to punish the murdere

9、rsAccording to the Ministry of Health website reported March 26, for The First Affiliated Hospital of Harbin Medical University, doctors were killing event, the Minister of Health Chen Zhu requirements of the General Office of the Ministry of Health to the Health Department of Heilongjiang Province

10、to understand the situation and demanded stern punishment for the murderer to crack down on crime, harm the medical staff and Heilongjiang Provincial Health Department on behalf express deep condolences and sympathy to the family members of killed and injured staffThinking about the doctor-patient r

11、elationshipWhat have changed in the doctor-patient relationship?What have changed in the influence factors of doctor-patient relationship?Objective: ResourcesSubjective: System, policy, doctors, patients, management, intermediary agency?Different “doctors” and “patients”in times of changing-Bad rela

12、tionship comes from the comparative gapsDoctorsInfluencesPatientsService：System：Body： e：Policy：Require：Occupation：Management：Result：Position：Intermediary：Psychology：Coordination：Consciousness：Others：Lightness depends on electricity Better result should value my pay新农合 8.4亿居民医保 1.9亿职工医保 2.2亿管理保健求医：距离

13、远了关系疏了成本高了卫生体制（公平、经济、有效）Doctorpatient relationshipThe doctor-patient relationship is central to the practice of healthcare and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. The doctor-patient relationship forms one of the foundations of contempo

14、rary medical ethics. Errors in medical practiceMany of the errors in medical practice have their origins in a failure of communication. The doctor either fails to understand the patients meaning or fails to convey his or her own meaning. These misunderstandings cause frustration for doctors and pati

15、ents, with all that follows in lowered morale, patients dissatisfaction, ineffective medicine, conflict, and litigation. Effective communication is fundamental If we have not understood the patients problem as the very first step, everything that follows in investigation and treatment may be wrong.

16、Even when diagnosis and therapy are technically correct, the way they are communicated to patients has important implications for their response. Moreover, communication is the essence of a therapeutic relationship.Features of Communication in FMMost of these can be summed up in one word: context. C

17、ommunication usually takes place between a doctor and patient who know each other, who have shared previous experiences, and have other relationships in common, for example with other family members. It takes place, very often, over extended periods of time, and in the different environments of offi

18、ce, home, and hospital. It is important, therefore, for us to understand how context influences and enhances communication.Understanding of the patients symptomsMost consultations begin with the patients account of his or her symptoms. A very high proportion of patients have symptoms without physica

19、l signs or abnormal investigations.Even when signs and abnormal tests are found, the correct diagnosis is more likely to depend on the history than on the examination and investigation. This is particularly so in general practice. An understanding of the patients symptoms is, therefore, fundamental.

20、What are symptoms?Symptoms are the patients description of what he or she perceives to be abnormal sensations. By definition, they are subjective and not open to verification by empirical methods. There is no objective test by which we can verify that a patient is actually feeling a pain. This is no

21、t to say, however, that we cannot apply rigorous methods to understanding the meaning of a patients symptoms. The methods are those of attentive listening, clarification of meaning through dialogue, and avoidance of selection bias.Symptoms are communication and informationSymptoms are a form of comm

22、unicationa patient conveys feelings of illness, distress, or fort. Symptoms are the information on which we base our understanding of the patients problem. The starting point is the information received by the patient in the form of messages transmitted from his or her nervous system. SignalsUnder u

23、sual circumstances, we are unaware of these messages. Nor are we normally aware of bodily functionsThe signals that lead to an adjustment in heart rate, blood pressure, or posture are, received and acted on below the level of consciousness, like digestion and respiration. In unusual circumstances, s

24、ignals reach consciousness and have to be interpreted or decoded. How the signals are decoded depends on a number of factors, including the persons past experience and culture. These all form the context within which the messages are transmitted and interpreted.Interpretation is both cognitive and a

25、ffectiveLet us suppose that the constancy of the background feeling is broken by a sensation of chest pain on waking one morning. At first there is a moment of anxiety; then a fall the day before, when a blow was received on that part of the chest, is remembered. This explanation is panied by a feel

26、ing of relief. On the other hand, no such explanation may be available. Perhaps the memory instead is of a colleague who had a severe heart attack panied by chest pain. The anxiety results in a visit to the doctor. The presenting complaint is probably the pain, not the anxiety. But things can be eve

27、n more complicated. Even though the anxiety is not expressed in words, it may be expressed in bodily waysfacial expression, gestures, heart rate and so on. An observant physician may recognize the emotion from these signs.To complicate things even morethe original change in body state may itself be

28、the bodily expression of an emotion., the patient suddenly became short of breath after her fathers funeral (P283). This distress signal was interpreted as the approach of death . The extreme fear would probably generate more bodily changes: tachycardia, sweating, and pallor, thus adding to her anxi

29、ety. A doctors explanation of her symptoms as an expression of grief would have been processed both cognitively and emotionally, with increased understanding and lessening of fear. As it happened, she encountered a physician who was dismissive and provoked an angry reaction that was anti-therapeutic

30、.Information level of a signal is directly related to its capacityThe information level of a signal is directly related to its capacity to surprise the receiver. A person who usually coughs up some mucoid sputum in the morning gets no information by looking at his sputum. If one morning it is bloods

31、tained, he does get information. Information depend on the context The information conveyed by the bloodstained sputum will depend on the context within which the message is received. A person who believes that blood in the sputum always means cancer will decode the message differently from the pers

32、on who does not connect the blood with cancer. A person who coughs up blood for the first time will decode it differently from a person who has coughed up blood before.Information is a daily occurrenceWe know that information arising from differences in our inner state is a daily occurrence. We all

33、experience minor aches, pains and forts of various kinds: headaches, muscle pains, dyspepsia, fatigue, itching, insomnia, irregularity of bowels or menses, and so on. The fact that a person consults a physician means that he has interpreted the information as a departure from his usual pattern, or a

34、s a signal that is outside his frame of reference. Interpretation varies enormously from one person to anotherThere is no clear relationship between the severity of the symptoms and the decision to consult. A common defense against e information is denial. People have a great capacity for self-decep

35、tion. On the other hand, there are those whose tolerance is low and who consult for very minor ailments. There may, of course, be a very good reason for consulting, as with the person who comes with vague chest pain after a friend has died of a myocardial infarction.How information be treated?Initia

36、l decoding of information the first gate: the gate where information from bodily feelings is interpreted and acted on in illness behavior. Symptoms admitted through this gate may be acted on in different ways. For some, self-care will be triedat least for a time; for others, advice from family, frie

37、nds, or members of the persons lay referral system. The decision to consult a physician may be an individual one or may be made with the assistance of family and friends.Decision - the second gateHaving decided to see a doctor, the person must then decide how to code his or her symptoms for transmis

38、sion to the physician, including what language to use and which symptom or problem to mention first. The decision is influenced by many factors. Very seldom is there a single symptom or problem; more usually there are many. Often there are also emotions related to the symptoms: anxieties, fantasies,

39、 fears. Complexities and difficulties of communication at second gate How can the patient convey how he or she feels? At this gate we encounter the complexities and difficulties of doctor-patient communication. First the patient has to code the information in verbal form. How well he or she can do t

40、his depends on the availability of a language and his or her own familiarity with it. For some symptoms a well-understood language is quite readily available. The message is coded in words that have a direct causal relationship with the sensation the patient is trying to communicate. There may also

41、be a clear and direct relationship between the symptom and a diseased state, such as the one between anginal pain and ischemic heart disease. Other sensations and feelings are much more difficult to put into words: vague illness and distress, changes of mood, unhappiness, anxiety, grief, self-doubt,

42、 guilt, remorse. These difficulties are so great that some very sick people do not consult physicians. In his population survey in Glasgow, Hannay (1979) found severely depressed people who had never consulted a doctor. It seems that disorders that threaten the integrity of the personality are parti

43、cularly difficult to find expression for.Burack and Carpenter (1983) studied the relationship between the presenting complaint and the principal problem identified during new patient visits. The problems were classified as somatic, psychosocial, or health maintenance. The presenting complaint correc

44、tly identified the category in 76 percent of somatic problems, but only 6 percent of psychosocial problems. If, however, the presenting complaint was psychosocial, the principal problem was psychosocial in all cases. If the presenting complaint was somatic, only 53 percent of the identified problems

45、 were somatic.How patient e these difficulties of expressionTo e these difficulties of expression, patients find other ways of coding their message. This means using an indirect, rather than a direct, form of communication. When patients express personal distress through bodily symptoms, they are no

46、t inventing the symptoms, or imagining the sensations. They are simply selecting the aspect of the illness experience which they can most easily put into words. Patient may express the problem in terms of a familiar symptomA patient who cannot find words for his or her feeling of despair may express

47、 the problem in terms of a familiar symptom like headaches, which may be an effect of the problem but are not the core of it. It is much easier to talk about headaches than about despair. Patient may express the problem by using metaphors or nonverbal formsIn indirect communication, the patient may

48、express meaning by using metaphors or nonverbal forms. Metaphors, according to Jeremy Campbell (1982), “place the familiar in the context of the strange” or, one might add, the strange in the context of the familiar. The message is in the context. A patient with a chronic disease, who is also in per

49、sonal distress, may communicate this distress in the form of a visit for the disease.Case 7.1A patient with multiple sclerosis came with the usual symptoms of her disease. The distress she was trying to communicate was caused by her husbands refusal to countenance birth control. This problem was rel

50、ated to the disease, in that she felt unfit to manage another child, but only indirectly.Indirect communication is common in family practiceIt is a universal experience that words are inadequate to express feeling: “words, like nature half reveal and half conceal the soul within,” wrote Tennyson in

51、In Memoriam. In all cultures, the deepest feelings are expressed in dance, drama, poetry, and other forms of symbolism. Many patients who come to see us are in the grip of powerful emotions, so it is not surprising that indirect communication is common in family practice.SomatizationThis is defined

52、as the process by which emotions are transduced to bodily symptoms, for which medical aid is sought. The symptoms of conversion were therefore forms of communication rather than the experience of physiological disturbances. The concept has now been expanded to embrace any bodily manifestation of dis

53、tress. Context“All communication necessitates context. without context there is no meaning,” One of the most difficult things for a physician is knowing what context to use in decoding the patients message.If the physician decodes the message using the context of physical pathology, the result may b

54、e a spurious diagnosis and all its consequences. If the patient is also misreading the context, as is sometimes the case, the possibilities of misdiagnosis are even greater.Difficult RelationshipsWeston defines a difficult patient as one with whom the physician has trouble forming an effective worki

55、ng relationship. The long-term relationships with patients in general practice make this a particular problem for family physicians. Because therapeutic success depends so much on the relationship between doctor and patient, the inability to form a therapeutic relationship is usually a source of muc

56、h frustration for the doctor. InterviewingInterviewing is a process by which one person, usually a professional, reaches an understanding of another, usually a patient or client. Medical interviewing provides the context for history takingthe collection of information about the patients problem. Int

57、erviewing is a process of communication, both verbal and nonverbal. It is much more than asking questions and receiving answers. ListeningThe greatest single fault in interviewing is probably the failure to let the patient tell his or her story. So often the talk is dried up by questions that divert

58、 the flow of conversation, by changes of subject, or by behavior in the physician that expresses lack of interest (thumbing through the records or glancing at a wristwatch). At the beginning of an interview, the physician should try, by every means possible, to encourage patients to tell their own s

59、tory in their own way.EmpathyEmpathy is the capacity to enter into another persons experience. For the physician it is the capacity to sense what it is like to be the patient: to experience illness, disability, depression, and so on. On other occasions it may be the capacity to sense what it is like

60、 to be the person caring for the patient. This may seem like an impossible task. Some experiences are so different from the common run that nothing can prepare one for them. Many people have described bereavement in these terms.Key QuestionsEven after listening attentively and responding to all the