家庭醫(yī)學(xué)的用原則與能力FamilyMedicinePrinciplesand課件

1、The Role, Principles and Competencies of Family Medicine 家庭醫(yī)學(xué)的作用、原則和能力Chris Jenkins, MD克里斯.金肯醫(yī)學(xué)博士March 2010 2010年3月 我 們 是 誰 ？ Who are we?Chan醫(yī)生Demena醫(yī)生Dannemiller醫(yī)生 Gu Jian谷建醫(yī)生 Kim Potters醫(yī)生Logan醫(yī)生 Jenkins醫(yī)生 Place醫(yī)生 Tim Potter醫(yī)生Watters醫(yī)生Zhau 周仲華醫(yī)生2Goals of Talk演講的目的Why is general practice an importa

2、nt specialty in a medical system為什么全科醫(yī)學(xué)是醫(yī)療體系里的一個重要?？艱iscuss why post graduate GP training is important 討論為何畢業(yè)后的全科培訓(xùn)很重要What are the benefits to the community and individual patients 對社區(qū)和病人個體有什么益處What do GPs do全科醫(yī)生做什么3A Little US Medical History一點(diǎn)美國的醫(yī)學(xué)史Prior to 1969 a GP 早在1969年，全科醫(yī)生：finished medical

3、school從醫(yī)學(xué)院畢業(yè)finished a one year rotating internship完成一年的實(shí)習(xí)醫(yī)生輪轉(zhuǎn)Began practicing開始行醫(yī)Up to early 1900s most American doctors were GPs 在19世紀(jì)初之前大多數(shù)美國醫(yī)生是全科醫(yī)生Up to the 1930s 80% were GPs and only 20% specialists 到19世紀(jì)30年代，醫(yī)生中80%是全科醫(yī)生，20%是?？漆t(yī)生4A Little US Medical History一點(diǎn)美國的醫(yī)學(xué)史1940s: an explosion of medica

4、l knowledge and an increase in specialization 19世紀(jì)40年代：醫(yī)學(xué)知識爆炸，專業(yè)化程度提高M(jìn)edical students wanted security: know all about one area of medicine 醫(yī)學(xué)生想要安全感：掌握某個醫(yī)學(xué)領(lǐng)域的全部知識There was an increase of specialty residencies and certification boards ?？漆t(yī)師培訓(xùn)項(xiàng)目和資格認(rèn)證委員會增多Board certification was not seen as necessary for

5、 general practice ?？瀑Y格認(rèn)證并非全科醫(yī)療所必需的Effect of World War II二戰(zhàn)的影響World War II made the situation for GPs worse二戰(zhàn)讓全科醫(yī)生的境遇變差Government deferments for medical students going into residencies. There was no residency for GP 政府讓醫(yī)學(xué)生延遲進(jìn)入住院醫(yī)生培訓(xùn)。當(dāng)時沒有全科住院醫(yī)生培訓(xùn)。Medical school graduates rushed into specialty residenc

6、ies 醫(yī)學(xué)院畢業(yè)生匆匆進(jìn)入?？谱≡横t(yī)生培訓(xùn)。After WWII: government paid for medical school and residency training but there were still no GP residency programs 二戰(zhàn)以后：政府給醫(yī)學(xué)院和住院醫(yī)生培訓(xùn)付費(fèi)，但是仍然沒有全科住院醫(yī)生培訓(xùn)項(xiàng)目。6Hard Times for GPs全科醫(yī)生的困難時期1940 to 1952 specialty residencies grew from 5,200 to 22,000. 1940到1952年，?？谱≡横t(yī)生培訓(xùn)項(xiàng)目從5200增加到2200

7、0Health care was becoming unavailable to many 許多人無法得到衛(wèi)生保健服務(wù)。specialists stayed in cities near hospitals專科醫(yī)生住在醫(yī)院附近城市GPs became fewer in number全科醫(yī)生數(shù)目越來越少7Hard Times for GPs全科醫(yī)生的困難時期General practice was getting left behind全科醫(yī)療被忽視Began to fight back開始反擊Established the American Academy of General Practic

8、e in 1947 1947年建立美國全科醫(yī)學(xué)學(xué)會Grew quickly快速發(fā)展High standards高水準(zhǔn)CME requirement 150 hours every three years (first group to do this)要求每三年完成150小時的繼續(xù)醫(yī)學(xué)教育（最先開始這樣做的人群）Still had no board certification仍然沒有資格認(rèn)證GPs Struggle to Succeed全科醫(yī)生奮斗成功In mid 1940s AAGP requested specialty training 19世紀(jì)40年代中期，美國全科醫(yī)學(xué)學(xué)會要求?？婆嘤?xùn)

9、Better training in diagnosing and treating disease 得到更好的診斷和治療方面的訓(xùn)練Greater awareness of conditions requiring referral or special tests or treatment 更清楚地知道哪些情況下需要轉(zhuǎn)診或特殊檢查及治療Approached major medical schools進(jìn)入重點(diǎn)醫(yī)學(xué)院“Good idea but do it somewhere else”“很好的想法，但到別的地方進(jìn)行”All through 1950s and most of the 1960s

10、 continued to work for improvement 整個19世紀(jì)50年代和19世紀(jì)60年代的多數(shù)時間持續(xù)不斷地取得工作進(jìn)步9American Medical System Suffered from Over Specialization美國醫(yī)療體系曾遭遇過度專業(yè)化US medical system in the 1960s19世紀(jì)60年代的美國醫(yī)療體系Increasingly specialized 越來越專業(yè)化Medical costs rising 醫(yī)療花費(fèi)上升Patient care suffering 病人保健遭受到：No one managing the over

11、all care of the patient 沒有人管理病人的總體保健No one coordinating care among specialists 沒有人綜合協(xié)調(diào)?？漆t(yī)生的治療 No one focused on preventive care沒有人關(guān)注預(yù)防保健No one who could treat most or all of common diseases 沒有人能夠治療大部分或是所有的常見病Patients had to see many specialists to get routine physical exams 病人不得不去看許多的?？漆t(yī)生以做常規(guī)體格檢查Cen

12、tral Asia worse: 10-12 doctors needed to do preschool physical 中亞情況更糟：做入學(xué)前體檢需要看10到12個醫(yī)生Increasing number of medical mistakes and missed diagnosis 誤診和漏診數(shù)目增加10Medical Community Finally Recognized the Need for Well Trained Generalists醫(yī)學(xué)界終于意識到對受過良好訓(xùn)練全科醫(yī)生的需求The Folsom Report Folsom報告The Mills Commission

13、Mills委托代理The Willard Committee Willard委員會11Acceptance at Last終于接受Medical schools now began GP residencies 醫(yī)學(xué)院?，F(xiàn)在開始全科住院醫(yī)生培訓(xùn)February 8, 1969 the first residencies started: “specialty in breadth” 1969年2月8日第一個住院醫(yī)生培訓(xùn)項(xiàng)目開始： “范圍寬的專業(yè)”1970 the ABFP (American Board of Family Practice) offered its first board e

14、xam 1970年美國家庭醫(yī)學(xué)認(rèn)證機(jī)構(gòu)進(jìn)行了第一次資格認(rèn)證考試1971 the name changed from GP to FP to signify the change in training 1971年由GP更名為FP以象征在培訓(xùn)方面的變化Rapid growth快速發(fā)展1970 250 residencies with 3,820 residents 1970年250個住院醫(yī)師培訓(xùn)項(xiàng)目，包括3,820名住院醫(yī)生2007 463 residencies with 9,330 residents 2007年有463個住院醫(yī)師培訓(xùn)項(xiàng)目，包括9,330名住院醫(yī)生Membership in

15、the AAFP: 96,614 (includes residents, etcetera) AAFP的會員數(shù)目： 96,614 （包括住院醫(yī)生，等等）12The Importance of Post Graduate Training畢業(yè)后培訓(xùn)的重要性Medical school alone is not enough僅醫(yī)學(xué)院是不夠的Medical information is increasing rapidly醫(yī)學(xué)信息飛速增加GPs need to know how to diagnose and treat common diseases, not just book knowled

16、ge 全科醫(yī)生需要知道如何診斷和治療常見病，不僅是知道書本的知識Residency provides住院醫(yī)生培訓(xùn)提供：Development of diagnostic and procedural skills 診斷和操作能力的發(fā)展Awareness of developments in other specialties 了解其它專業(yè)的發(fā)展Knowledge of how to use the entire medical system to benefit their patients知道如何使用整個醫(yī)療體系以使病人受益Understanding of whole person care

17、: bio-psycho-social-spiritual model of health理解全人的照顧：健康的生物-心理-社會-精神模式13Primary Care Improves Community Health初級保健使社區(qū)健康得到改進(jìn)Better health outcomes健康結(jié)局更好Increased use of disease-focused preventive care (e.g., blood pressure screening, mammograms, pap smears, etc)疾病為中心的預(yù)防保健增多（如血壓篩查，乳腺X片，宮頸防癌普查等）Fewer pa

18、tients admitted for preventable complications of chronic disease 更少的病人因可預(yù)防的慢性病并發(fā)癥而收入院Lower all cause mortality全因死亡率降低Fewer consultations with specialists專家會診減少Less use of emergency services 減少使用急救服務(wù)14Improved Community Health with Primary Care初級保健使社區(qū)保健得到改進(jìn)Less re-hospitalization減少再入院Better detection

19、 of adverse effects of interventions 更好地發(fā)現(xiàn)干預(yù)措施的不良反應(yīng)Better understanding of psychological aspects of a patients problem更好地理解病人問題的心理方面Protection against overtreatment避免過度治療More efficient use of resources資源更有效地利用Better compliance and lower hospitalization rate 依從性更高，入院率更低Other benefits as well還有其它益處All

20、 well documented 都被很好地記錄15General Practice has a Unique and Important Role in Health Systems全科醫(yī)學(xué)在健康系統(tǒng)中有獨(dú)一無二的重要作用Advocate for patients in medical system 在醫(yī)療體系中支持病人Management of patient care病人保健的管理Preventive health care and patient education 預(yù)防性的健康照顧和病人教育Provision of comprehensive health care in a sin

21、gle location在一個處所提供綜合性的健康照顧C(jī)are of entire families over time整個家庭的長期照顧Not limited to gender, age, organ system 不局限性別、年齡、器官系統(tǒng)16General Practice has a Unique and Important Role in Health Systems全科醫(yī)學(xué)在保健體系中有獨(dú)一無二的重要作用Benefits to communities and individuals 對社區(qū)和個人的益處Doctor knows patient well醫(yī)生非常了解病人Patient

22、s trust their doctor病人信任醫(yī)生Increased patient satisfaction病人滿意度提高Greater ease of access to medical care醫(yī)療照顧更有可及性Lower cost更低的費(fèi)用Fewer medical mistakes更少的醫(yī)療錯誤Emphasis on prevention強(qiáng)調(diào)預(yù)防Satisfying professional careers for GP doctors 全科醫(yī)生對職業(yè)感到滿意17What is Family Medicine? It Depends on Who You Ask!家庭醫(yī)學(xué)是什么？不

23、同的國家有不同的回答！British英國Swedish瑞典Australian澳大利亞Hong Kong香港Canada加拿大America美國18Family Medicine in China中國的家庭醫(yī)學(xué)New in modern China是當(dāng)代中國的新生物Developing final model not yet decided 發(fā)展中最終模式尚未確定Principles of FM has similarities with some aspects of traditional Chinese medicine 家庭醫(yī)學(xué)的原則與傳統(tǒng)中醫(yī)的某些方面有相似之處Care for th

24、e whole family照顧整個家庭Young and old 年輕者和年長者M(jìn)ale and female 男性和女性All organ systems所有的器官系統(tǒng)Listen to patients 傾聽患者Take time with the patients花時間與病人在一起19Family Medicine in China中國的家庭醫(yī)學(xué)Major medical centers recognize need for the specialty 大型醫(yī)學(xué)中心認(rèn)識到對全科的需要Major medical centers waiting for Beijing to decide

25、what model and what training program 大型醫(yī)學(xué)中心在等待北京決定用何種模式及何種培訓(xùn)項(xiàng)目What is Family Medicine in the USA?美國的家庭醫(yī)學(xué)是什么？Medical specialty醫(yī) 學(xué) 專 業(yè) Recognized as specialty in the US since 1969自 從 1969 年 起 在 美 國 被 認(rèn) 定 為 一 種 醫(yī) 學(xué) 專 業(yè) Over 80,000 family physicians in the US在 美 國 有 超過80,000 多名 全 科 醫(yī) 生 21What is Family

26、Medicine in the USA?美國的家庭醫(yī)學(xué)是什么？Over 460 training programs(residencies) with over 9,000 residents 超過460 個 住院醫(yī)師培訓(xùn)項(xiàng)目 , 超過9,000名住 院 醫(yī) 生Can treat 85-90% of medical problems 能 夠 治 療 85-90%的醫(yī)學(xué)問題22What is Family Practice in the United States?在 美 國 家 庭 醫(yī) 學(xué) 是 什 么 樣 的? 12% of all US doctors are family practice

27、 doctors 12% 的 美 國 醫(yī) 生 是 家 庭 醫(yī) 生 But 25% of all office visits in the US are to family doctors! 但 是 美 國 25% 的 就 診 都 是 看 全 科 醫(yī) 生 ！ 23Where Do We Work?我們在哪里工作？Clinic 門診Hospital 醫(yī)院Emergency Department 急診室Nursing Homes 養(yǎng)老院Other 其他24Philosophical Focus of Family Medicine家庭醫(yī)學(xué)的理念Continuity of care 照顧的持續(xù)性Man

28、agement of care 健康照顧管理Treating patient in context of family 在家庭背景下治療病人Preventive care 預(yù)防保健Team approach 團(tuán)隊探討EBM 循證醫(yī)學(xué)25Continuity of Care照顧的持續(xù)性Seeing patients over an extended period of time 長時間內(nèi)照顧病人Developing the doctor-patient relationship 發(fā)展醫(yī)患關(guān)系Familiarity with patient health status 熟悉病患的健康狀態(tài)Devel

29、oping trust 發(fā)展信任關(guān)系26Management of Care保健管理Evaluation of the Patient 病人病情的評估Diagnostic tests 診斷檢查Involvement of specialists ?？漆t(yī)生參與Treatment plans 診療計劃27Patient Care in the Context of the Family以家庭為背景的病人保健Home environment 家庭環(huán)境Family dynamics 家庭動力學(xué)Family health beliefs and practices 家庭的健康理念和實(shí)踐Social, w

30、ork, and religious settings 社會環(huán)境，工作環(huán)境和宗教環(huán)境28Preventive Medicine預(yù)防醫(yī)學(xué)Patient education 病人教育Lifestyle modification 生活方式的調(diào)整Age and gender specific disease screening 根據(jù)年齡和性別而特異的疾病篩查Medical intervention 醫(yī)療干預(yù)29Team Approach to Health Care健康照顧的團(tuán)隊合作 Involvement of other health care providers 其它醫(yī)療保健工作者的參與 Med

31、ical and surgical specialists內(nèi)外科專家 Behavioral medicine行為醫(yī)學(xué) Physical, occupational, home therapists物理治療 ， 職業(yè)理療師 ， 家庭治療師Dietitians營養(yǎng)學(xué)家 30Evidence Based Medicine循證醫(yī)學(xué)Knowing the questions to ask 知道要問的問題Identifying the best evidence to answer the questions 找出回答問題的最好依據(jù)Assessing the evidence for validity a

32、nd usefulness 評估證據(jù)的有效性和有用性Applying the results to clinical/hospital practice 將結(jié)論應(yīng)用于門診或住院醫(yī)療Evaluating the results 評估結(jié)果31General Practice Competencies全科醫(yī)學(xué)的能力There is a wide range of possible skills for GPs 全科醫(yī)生可掌握的臨床技巧很廣泛Different countries choose different skills to meet their own needs 不同的國家根據(jù)本國的需要選

33、擇不同的臨床技巧The basic role of GP remains the same in each country全科醫(yī)生的基本任務(wù)在每個國家仍然是一致的This next section will show you some of the skills we train GPs to do in the USA 下一部分將向您介紹美國全科醫(yī)生被訓(xùn)練的部分技能32Whom and what do we treat?我們給誰治療，治療什么？ All ages and Both sexes所有的年齡和性別33Obstetrics產(chǎn)科學(xué) (Will go into more detail o

34、n each area later if desired如果愿意我們將在后面詳細(xì)介紹每一方面的內(nèi)容)34Pediatrics.兒科學(xué)35Internal Medicine內(nèi)科學(xué)But All Other Specialties as Well及所有其他專業(yè)36Diagnostic Modalities and Laboratory Evaluations診斷模式和實(shí)驗(yàn)室結(jié)果評估37Procedures: Injections, Dermatological procedures, and Fine needle aspirations操作：注射，皮膚病方面的操作，和細(xì)針抽吸38Colposco

35、py, Exercise stress testing, Flexible sigmoidoscopy, and many more!陰道鏡檢查，運(yùn)動負(fù)荷實(shí)驗(yàn)，纖維乙狀結(jié)腸鏡檢查，還有更多！39Not only Treatment of Disease but also Prevention不但治療疾病而且預(yù)防疾病Cancer screening 癌癥篩查Vaccinations 預(yù)防接種Lifestyle modification 生活方式的改變40Cooperation with other specialists - health care professionals與其他?？漆t(yī)生合作4

36、1Rural or Urban:農(nóng)村或城市Do FP belong only in rural areas?家庭醫(yī)生只屬于農(nóng)村地區(qū)嗎？Needed in Rural areas: villages, towns, small cities在村、鎮(zhèn)、小城市等農(nóng)村地區(qū)需要：Not enough specialists to supply all small towns 沒有足夠的專家可以為所有小鎮(zhèn)提供醫(yī)療服務(wù)Not enough demand to support all the other specialties 沒有那樣多的對所有專科的醫(yī)療需求FP/GP needs to be well tr

37、ained to handle many complex problems and procedures家庭/全科醫(yī)生需要得到很好的培訓(xùn)以應(yīng)付很多復(fù)雜的問題和操作Needed in Urban/city areas在城市也需要Specialization is one of the reasons FM is needed 需要家庭醫(yī)生的一個理由是?？苹疢anagement of care is even more critica l更為關(guān)鍵的是健康照顧管理Cost control費(fèi)用控制42GP is New in Many Countries全科醫(yī)學(xué)在許多國家是新生事物New Specia

38、lty新的?？艭hallenge of deciding what it will be like 決定全科醫(yī)學(xué)的模式是一個挑戰(zhàn)Integrating GP with existing medical system 將全科醫(yī)學(xué)和現(xiàn)有的醫(yī)療系統(tǒng)一體化Gaining acceptance with doctors and patients 得到醫(yī)生和患者的接受Becoming an attractive specialty to medical students 成為對醫(yī)學(xué)生有吸引力的專業(yè)43The Need for a Good Model一個好的全科醫(yī)學(xué)模式的需求Meets patients

39、primary health care needs 滿足病人初級衛(wèi)生保健的需要Professionally satisfying 職業(yè)的滿意度High quality training 高質(zhì)量的培訓(xùn)Respect of Colleagues 同行的尊敬Trust of Patients 病人的信任Financially rewarding 薪酬上的回報44Major Lessons Appropriate Model重要的教訓(xùn)合適的模式model must be appropriate to the region模式必須和地區(qū)相適應(yīng)Transplanting models without mo

40、dification doesnt work well 不做調(diào)整而直接移植模式不能有效運(yùn)行One Specialty, Many models一個專業(yè)，很多模式American Model美國模式British Model英國模式Knowledge base and technology/procedures appropriate to the specialty and the region 知識基礎(chǔ)、技術(shù)和操作要適合專業(yè)和地區(qū)45Consequences of an Inadequate Model不適當(dāng)模式的結(jié)果No interest on the part of medical st

41、udents醫(yī)學(xué)生沒有興趣Inadequate training for the job assignment對于分配的工作沒有得到充分的培訓(xùn)Feeling unprepared in those who do FP work那些要做全科醫(yī)療工作的人感覺沒有準(zhǔn)備好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高的放棄率46Who is a FP/GP?誰是家庭醫(yī)生/全科醫(yī)生？Surgical personality!外科特性！Inter

42、nist personality!內(nèi)科特性！Family medicine personality!全科特性！47Knowledge Base Important to Emphasize知識基礎(chǔ)-重中之重Are three years of training enough?三年的培訓(xùn)足夠嗎？Know what is needed to be known!知道所需要知道的知識25-30% of knowledge cove 85-90% of the diseases “Rapidly progressing glomerulonephritis” not high on the priori

43、ty list 25-30%知識覆蓋85-90%的疾病。 急進(jìn)性腎小球腎炎不是最優(yōu)先需要學(xué)習(xí)的7/1,000,000 發(fā)病率1/142,857 = 1/lifetime of FPMaybe! 一個全科醫(yī)生可能在一生中就看一個這樣的病例Debate over adding a 4th year 是否需要增加第四年的培訓(xùn)仍有爭議48Knowledge Base知識基礎(chǔ)FPs know 20-30% of each of the other specialties knowledge:全科醫(yī)生應(yīng)該知道每一個?？浦R的20-30%Specialists see FP from their persp

44、ective ?？漆t(yī)生從他們的角度看待全科醫(yī)生FPs know less than the specialist in his area 在專科領(lǐng)域全科醫(yī)生的知識不如?？漆t(yī)生FPs know more than the specialist in other areas 在其他的領(lǐng)域全科醫(yī)生的知識多于專科醫(yī)生49Depth vs. Breadth of Knowledge Base知識基礎(chǔ)的深度與廣度對比0102030405060708090100Internist內(nèi)科Pediatrics兒科Ob-Gyn婦產(chǎn)科Surgery外科500102030405060708090100FP全科Internist內(nèi)科Peds兒科Ob-gyn婦產(chǎn)科.Surgery外科Total Knowledge Content總知識含量51How Many Years of Training to be a FP in the USA?在美國培訓(xùn)全科醫(yī)生需要多少年？Primary and Secondary School 12 years 小學(xué)和中學(xué) 12年University