全科醫(yī)學(xué) 第1講 FM概論學(xué)習(xí)課件

Introduction

toFamilyMedicine杜亞uyp@2014.2.24

《全科醫(yī)學(xué)》不僅是一門(mén)課程，它是社會(huì)和醫(yī)學(xué)發(fā)展密切相關(guān)的重要組成部分主要問(wèn)題現(xiàn)狀未來(lái)（20年后）還存在？經(jīng)濟(jì)增長(zhǎng)GDP7.7%不可能房?jī)r(jià)人均35方，“鬼城”現(xiàn)象顯現(xiàn)1人2房失業(yè)5%8%教育小班化由低到高蔓延總量控制結(jié)合調(diào)整通脹低于GDP增長(zhǎng)，約3%維持現(xiàn)狀養(yǎng)老老年化14%更趨嚴(yán)重至25%醫(yī)療衛(wèi)生費(fèi)用占GDP5%看病難看病貴過(guò)去30年和未來(lái)20年不變引入新制度化解矛盾哪些民生問(wèn)題20年后還存在？TextbooksIanRMcWhinney:ATextbookofFamilyMedicineOxfordUniversityPress余海主編：全科醫(yī)學(xué)導(dǎo)論四川科技出版社Terminology全科(家庭)醫(yī)學(xué)General/FamilyMedicine全科(家庭)醫(yī)療General/FamilyPractice全科(家庭)醫(yī)生FamilyPhysician/Doctor通科醫(yī)生GeneralPractitionerTheOriginsofFMEnglishPartIChapter1(pp1-12)《導(dǎo)論》第一章第一、二節(jié)（1-5頁(yè)）Background-MedicineMedicinehasbeenchangingconstantly,medicinechangesinresponsetomanyinfluences:ScientificprogressTechnicalrenovationSocialdevelopmentBackground-NewdisciplineNewdisciplinesariseinanumberofways:Fromancientcraftskills(surgery,obstetrics)Basedonnewtechnology(otolaryngology,anesthesiology)Basedonneeds(childhealth)FamilymedicinedevelopedunderallofaboveinfluencesNewdisciplinesbegininthreeways:TransformationfromanolderdisciplineDenovoFragmentationfromanlargerdisciplineFamilymedicinehasevolvedfromolderbranchofmedicine-generalpracticeBackground-ChangesinmortalityandmorbiditySuccessfulcontrolofmajorinfectiousdisease-emergenceofnewpatternsofdiseases:chronicdiseases,developmentdisorders,behavioraldisorders,accidentsanddifferentrangeofinfectiousdiseases;Thereducedmortality-increasedpopulationofelderlypeopleinsociety.

Changesinmortalityandmorbidity1900：pneumonia,tuberculosis,diarrhea1990；heartdiseases,cancer,stroke20世紀(jì)：新生兒死亡率的下降和平均期望壽命的增加Apersonafflictedwithmortalinfection-diedorrecoveredinashortperiodoftime(lifeordeath);afflictedwithchronicdisorders-toadaptchangedenvironment.Roleofpractitioners-tohelppatientstoachieveanewequilibriumwiththeirenvironmentinthefaceofchronicdiseasesordisability;Themodernmedicalprofessionhasnotexisteduntilthe19thcentury,beforethattimeinEurope:Physicians,smallandelitegroup(精英集團(tuán)）oflearnedmenpracticedintownsamongtherichandinfluential.Mostwerehealers:craftsmen（匠人）(surgeon)andtradesmen(apothecaries藥劑師)servedthepoorerandruralpeople.Surgeonstrainedbyapprenticeship（學(xué)徒）,apothecarieswhooriginallydispensedandsolddrugs,inresponsetoneed,graduallytookontheroleofmedicalpractitioner.TheGrowthofSpecializationTheearlycolonieswereservedbyavarietyofpractitioners,butonlyoneinninepractitionershadbeentrainedasaphysician.18thcenturyinNorthAmerica,becauseofheavydemandforhealthserviceandbreakdownofsocialbarriers,allpractitionerswerepracticingasgeneralpractitioner

InBritainby19thcenturysurgicaltrainingimproved(apprenticeship+hospitaltraining)andtheexaminationintheRoyalCollegeofSurgeons(M.R.C.S)wasrequired;1815ApothecariesAct:legalrecognitiontotherightofapothecariestogivemedicaladviceandcompulsorytoundergo5-yapprenticeshipandcoursesByaslowprocesssurgeonsandapothecariesweregraduallyintegratedwithphysicianstoformthemodernmedicalprofessionThetermgeneralpractitionerwasfirstusedintheLancertearlyinthe19thcentury.Thegeneralpractitionerbornin18th-centuryAmericaandnamedin19th-centuryBritain.TheAgeoftheGeneralPractitionerInEuropeandNorthAmericathe19thcenturywastheageofthegeneralpractitioner,mostmembersoftheprofessionweregeneralpractitioners,includingfacultiesofmedicalschools;Bytheendofthe19thcentury(1892)pediatricsbecameaseparatediscipline

Generalpractitioner-FamilydoctorTheageofgeneralpractitionerTheAgeoftheGeneralPractitionerProgressofthesciencesgaveanimpactonmedicine,butmedicaleducationwasdivorcedfromthescientificfoundationsofmedicineandinverypoorquality1889thefoundingofJohnsHopkinsthelandmarkinthedevelopmentofmedicineTheAgeoftheGeneralPractitioner1910AbrahamFlexner’sreportonmedicaleducation(“incompetentphysiciansaremanufacturedbywholesaleinthiscountry”)1910-1930FlexnerreformpavedtheageofspecializationTheAgeofSpecializationThefirsthalfof20thcentury:theemergenceofthemajorspecialtiesofmedicinewithitsdefinedtrainingprogramandqualifyingexamination.MedicaleducationemphasizedlaboratoryscienceandtechnologyPrestigeofspecialistsandvaluationoftechnicalandresearchskilloverpersonalcaremadegeneralpracticeunpopularasacareer.TheAgeofSpecializationTheAgeofSpecializationThefragmentationoftheprofessionandtheemphasisoftechnologyleadstoseriouseffect:deteriorationofthedoctor-patientrelationshipTheneglectofthecaringandpersonalaspectsofmedicinehavenegativeconsequences:increaseinmalpracticesuitsReturnofGeneralPracticeTheneedforanewkindofgeneralists,whohaveawell-differentiatedroleandadefinedsetofskills-differentfromtheoldgeneralpractitionersTheformationofcollegesandacademiesofgeneralpracticeinthe1950sand1960s.Andfamilymedicineintroducedintotheundergraduatecurriculum1972theWorldOrganizationofNationalCollegeandAcademiesofGeneralPractice/FamilyMedicine(WONCA)wasformed

GeneralPracticeorFamilyPracticeChangeofnamefromgeneralpracticetofamilypracticeorfamilymedicineandfromgeneralpractitionerstofamilyphysiciansAcademyofGeneralPracticetoAcademyofFamilyPractice;theCollegeofGeneralPractitionerstotheCollegeofFamilyPhysiciansGeneralPracticeorFamilyPracticeThereasonsforthechange-mixedGeneralpracticeassociatedwithanobsoletetypeofmedicineEmphasisdifferentconceptoffamilypracticefromgeneralpracticeTonameanewbodyofknowledgeonwhichtheclinicaldisciplineisbasedTrainingrequirementTheChangingRoleoftheHospitalSince1960s,threelevelsofhealthcarePrimarylevel:generalpractitionerprovidecontinuingpersonalandcomprehensivecareSecondarylevel:specialistsprovideserviceforspecialfieldsTertiarylevel:highlyspecializedservicesRoleofFamilyDoctorFamilydoctorbecomeakeyfigureintheorganizationofhealthcareIntegrationofservicebecomeessentialtoconserveresourcesandeliminatewaste(familydoctor-”Gatekeeper”).Horizontalintegration-workingasteammemberswithotherhealthprofessionalsVerticalintegration-collaborationbetweenthethreelevelsofcareNewDevelopmentintheBehavioralScienceRecentdevelopmentinbehavioralandsocialsciencesareimportanttomedicineasawholeparticularlytofamilym