河南省医师执业环境现况调查与发展对策研究

目的 了解河南省医师执业环境现状,探讨其存在的问题,为改善医师执业环境提出建议。方法河南省医师协会组织多个专科分会,采用集中填答法进行问卷调查。结果 医师每周平均工作时间是54小时,80.1%的医师认为执业环境差;工作压力来源排前三位的是患者的期望值高、医疗纠纷多、患者和公众对医生不信任;患者暴力频度和家属暴力频度很频繁或较频繁的数据都高于10%;62.2%的医师认为社会地位低于4年前水平,子女报考医学院校的意愿选择不愿意的占66.8%。结论 应加快基层医疗机构的建设,缓解医生工作压力;重视医德医风建设;正确发挥媒体导向作用;加强法制建设,改善医师执业环境。     

临床医师对电子病历相关知识认知的调查研究

目的:了解临床医师对电子病历书写的态度和行为现状以及电子病历管理和对医疗质量的认知等情况,为制定科学的电子病历管理方案提供借鉴。方法:选取两所2所三级甲等和2所三级乙等医院临床医师共计450名进行调查,采用问卷调查医师对电子病例相关知识(如临床医师对电子病例相关法规认知、电子病例监控对电子病历影响及电子病历优点等)的认知和需求。结果:临床医师电子病历总体书写现状调查显示,对于书写电子病历中相似的部分,48.7%(219例)的医师直接复制粘贴再修改;复制粘贴使用比率≥40%占76.7%(345例);电子病历书写出错原因主要为认为责任心不强(38.2%)和病历系统掌握不到位(29.6%);促进临床医师按要求写好病历的主要动力为法律证据(32.9%)和培养临床思维(49.1%);54.9%(247例)医师能对自己的病历进行经常检查;科室负责人对电子病历经常检查的占33.1%(149例);50%左右人员对电子病历系统操作掌握情况一般;79.33%的临床医师认为电子病历的使用有助于提高医疗质量;临床医师认为电子病历对医疗质量的影响主要是提高病历书写速率、病历完成及时性、管理系统性、病历安全性和患者满意度。结论:临床医师在电子病历书写中复制粘贴比例较高,且对相关的法律法规认识一般,对医院电子病历系统掌握不熟悉,应加大相关内容的培训,更有利于医院电子病历的管理。     

实施医师定期考核制度的政策环境分析

从宏观、微观两个层面分析了医师定期考核制度实施所遇到的政策环境,着重探讨了各种阻力的现状及其影响。认为在宏观层面的阻力主要包括医师协会的法律地位和作用尚未确立、部分执业规则对于医师执业行为产生束缚、医疗事故责任界定与医师考核结果之间衔接有待理顺,在微观层面的阻力主要包括医师准入标准各地尚未统一、职业道德评价机制尚不完善、制度运行经费出处并未明确。     

医师多点执业与公立医疗机构运行机制关系评价

医师多点执业从理论上通过调动医疗人力资源最大限度地满足基层社区患者医疗服务需求,调动医师主动参与基层卫生服务,合理使用医疗资源,并在医疗联合体基础上,逐步实现分级诊疗。但是公立医疗机构现行体制和运行机制不支持医师多点执业。本文对医师多点执业与公立医疗机构现行体制和运行机制关系予以讨论。     

从医疗损害赔偿责任层面破解我国医师多点执业困境

推行医师多点自由执业从理论上讲可以打破优质医疗资源集中在大城市、大医院这种不均衡分布的局面。由于医师异地执业出现医疗损害的赔偿责任究竟是执业医师本人承担、接受或输出医疗机构承担并不明确,一旦发生医患纠纷或医疗损害可能会出现“三方都不想管、三方都要负责”的局面。从试点地区的情况来看,结果并不满意,多数属于“叫好不叫座”。尝试从医疗损害赔偿责任层面解读我国医师多点执业面临的困境后得出：必须完善医疗损害鉴定机制,构建执业医师自由人制度,医师本人需购买异地执业医疗损害赔偿责任强制性保险,在此基础上才有可能逐步推行真正意义上的医师多点执业。     

医师执业行为质量安全评价体系的构建与应用

为推进落实全市改善医疗服务行动计划,进一步加强医师依法执业,落实16项医疗核心制度,规范诊疗行为,持续改进医疗服务质量,保证临床医疗科学、合理、有效,确保医疗质量安全,市卫生计生委结合实际,构建了医师执业行为质量安全评价体系。体系由4个部分组成：一是病历书写,二是医疗核心制度,三是依法执业,四是临床用血。通过病历对这4个方面进行考评,确保荆门市医疗质量得到控制并持续性改进,增强医务人员规范化的病历书写意识,促进医疗质量的全面提高。     

加拿大医师能力框架对我国制定执业医师能力标准的启示

CanMEDS是加拿大皇家内科和外科医师学会提出的能力框架,指出医师应该扮演7种不同角色,基本满足了医学模式的转变和医疗实践的挑战对医师能力提出的新要求。CanMEDS与英美专业医学管理机构制定的医师能力标准相比更加全面和直观,与我国现有医师能力基本要求相比更加详细而系统。CanMEDS启发我国有关机构提高对执业医师能力标准制定工作的重视,加强调研,使得最终制定的有中国特色的执业医师标准能够更好地指导医学教育、规范医疗实践。     

互联网医疗与我国医事立法的断裂与弥合

我国医疗卫生资源分布不均衡与服务区域不相称,呼吁互联网医疗的介入并深度发展,这对于均衡资源配置和促进分级诊疗制度的形成均大有裨益。为此,国家出台了多项政策措施给予有力支持,进一步巩固医药卫生改革的成果。但是由于我国《执业医师法》、《医疗机构管理条例》等医事法律的立法理念和立法内容比较滞后,导致互联网医疗在医师执业注册、医师多点执业等方面与其形成断裂,亟需通过立法加以弥合,为互联网医疗的健康发展保驾护航。

     

从公立医院角度探讨注册医师多点执业

阐述公立医院在实施医师多点执业过程中应注意的3对基本矛盾,同时探讨医师多点执业可能给公立医院带来的影响,并提出合理化建议：理清利益相关集团,建立风险分担机制;建立全方位的绩效考核体系,创造人才成长氛围;探索医疗集团化的多点执业,实现多赢局面;完善双向转诊机制,确保医疗安全。     

我国实施医师多点执业的政策分析与思考

医师多点执业试点工作正在各地逐步推开。文章依据国家新医改政策,以医师多点执业为基点,对医师多点执业现状和对医疗卫生系统的运行管理可能带来的影响进行综合分析,结合医疗单位的实际,提出意见建议。     

Health Data and the Physician

California Health Data Corporation was formed to create better health data resources under the direction of hospitals and medicine. Highest priority is being given to developing information systems that will serve physicians, as well as those who are usually considered health data users. This is illustrated in CHD''s first major activity, sponsorship of a medical record information system for California hospitals. This system is designed first of all to provide better information for medical staff committees, and as a byproduct to provide data flow into a CHD data bank. For the practicing physician, the significance of CHD is that the organization will attempt to develop information systems that will help the medical profession maintain its central role in guiding the present and future patterns of health care.     

Effects of Clinical Preceptorship on Career and Practice Site Choices

To evaluate the effects of primary care preceptorships on the choices of career site and specialization, graduates of the University of Utah School of Medicine, 1972 through 1975, were questioned. Most practicing physicians who elected preceptorship training rated the experiences as valuable, but not important enough to be required. Physicians based their decisions for an urban practice on medical factors; rural areas were chosen more for personal reasons. In addition, data showed that the size of the respondents'' hometowns was not associated with their choice in the size of their practice site nor their specialty. Respondents also reported that their medical school training was deficient in preparing them for the economic and psychosocial aspects of medical practice. Many Utah graduates are participating as clinical faculty or as preceptors for medical institutions and indicated that for their particular communities family physicians, obstetricians-gynecologists and pediatricians are still needed.     

Topics to ponder: Part-time practice and pay parity

Background: The medical profession has undergone a significant demographic change, with a dramatic increase in the number of women applying to medical school and practicing medicine.Objectives: In recognition of the changing demographics in the medical profession, the American Medical Association's Women Physicians Congress (AMA-WPC) conducted a members' survey to identify the issues affecting women physicians and to ascertain certain practice characteristics.Methods: In 2008, an e-mail survey link was sent to a randomly selected nationwide sample of 4992 WPC members, and a second, identical survey was sent to 596 female AMA members, utilizing the Epocrates database (Epocrates, Inc., San Mateo, California). Two e-mail reminders were sent for the first survey, which had a 15% response rate. A quota of 148 physicians was received within 4 days and was utilized to interpret results from the second survey.Results: Achieving work-life balance was a significant concern for 91% of the respondents (n = 884). Half of the respondents believed that pay is gender neutral, and 28% indicated that they were “somewhat or very concerned about sexual harassment”. When queried regarding practice patterns, 29% of respondents indicated that they had worked part-time at some point during their careers.Conclusions: In this survey, women physicians indicated that gender pay disparity and sexual harassment remain important issues in the medical profession. Less than a third of respondents had ever worked part-time, which should be a consideration for physician workforce studies. Barriers to part-time practice may exist.     

Alberta euthanasia survey: 2. Physicians' opinions about the acceptance of active euthanasia as a medical act and the reporting of such practice.

OBJECTIVE: To ascertain the opinions of Alberta physicians about the acceptance of active euthanasia as a medical act (the "medicalization" of active euthanasia) and the reporting of colleagues practising active euthanasia, as well as the sociodemographic correlates. DESIGN: Cross-sectional survey of a random sample of Alberta physicians, grouped by site and type of practice. SETTING: Alberta. PARTICIPANTS: A total of 2002 (46%) of the licensed physicians in Alberta were mailed a 38-item questionnaire in May through July 1991; usable responses were returned by 1391 (69%). RESULTS: Although only 44% of the respondents considered active euthanasia morally "right" at least 70% opted to medicalize the practice if it were legal by restricting it to be performed by physicians and to be taught at medical sites. Even though active euthanasia is criminal homicide in Canada, 33% of the physicians stated that they would not report a colleague participating in the act of anyone, and 40% and 60% stated that they would not report a colleague to medical or legal authorities respectively. Acceptance or rejection of active euthanasia as a medical act was strongly related to religious affiliation and activity (p < 0.01). CONCLUSIONS: This survey about active euthanasia revealed profound incongruities in the opinions of the sample of Alberta physicians concerning their ethical and social duties in the practice of medicine. These data highlight the need for relevant modifications of health education policies concerning biomedical ethics and physicians'' obligations to society.     

Smoking and Health

Although cigarette smoking is the number one public health problem in the United States, physicians have failed to take the lead either in convincing youngsters not to begin smoking or in aiding adults to quit smoking. To be most effective and convincing in combating the smoking epidemic, practicing physicians must have the same basic fund of knowledge about the short- and long-term consequences of smoking as they do about other commonly encountered medical problems. By acting on such knowledge and adopting a definite set of attitudes and activities in their offices and with patients, physicians can make a significant contribution to their patients and to the entire community in which they practice.     

Tort reform and the obstetric access crisis. The case of the WAMI states.

The states of Washington, Alaska, Montana, and Idaho (WAMI) have all had declines in the proportion of physicians offering obstetric services during the past few years, a decline precipitated by rising medical malpractice premiums. One response to the problem of rising liability premiums has been the passage of extensive tort reform legislation. We present the results of recent studies of physicians'' obstetric practices in the WAMI states and summarize the major changes in tort legislation and regulation that have occurred in these states. Most general and family physicians in the WAMI region no longer provide obstetric care; by contrast, more than 80% of the obstetrician-gynecologists in the WAMI states are still practicing obstetrics. Despite the fact that only a minority of family physicians are still active in obstetrics, most rural family physicians in all four states still deliver babies. Most physicians in all four states limit the amount of care they provide to those covered by Medicaid, which suggests that significant barriers to care exist for medically indigent persons. All four states have adopted significant tort reforms. Despite these changes in the legal environment, the cost of malpractice premiums and concerns over the likelihood of being sued continue to limit the number of physicians willing to provide obstetric care. Although it cannot be inferred from these data that tort reform has decreased the rate at which physicians give up obstetric practice, the evidence is compatible with such a conclusion.     

A Physician's Perspective on the Incorporation of Pictograms as a Supplement to Medical Instructions in Chile: A Pilot Study

Introduction and objectivesCurrent models of health care are progressively migrating to more participatory models, where for treatment to achieve results that last over time, there must be effective communication between the patient, his or her caregivers, and health professionals. Although the use of pictograms in the context of medical instructions has been widely studied, in our country, there are no studies about their usefulness, or which set of symbols should be used by the systems. This work aims to present the first step towards the development of platforms that automatically suggest pictograms to supplement medical instructions for primary care settings in Chile.Materials and methodsIn this pilot study, we collected and analyzed the physicians' opinions on the selection of medical instructions that later will automatically be supplemented by the software that is under construction. We designed an expert validation survey using a set of 66 medical instructions with pictograms. This survey provided three rating options for each medical instruction: Not necessary (supplementing the instruction with a pictogram does not carry any value), Useful (supplementing the instruction with a pictogram may help patients to understand and remember the instruction), and Essential (supplementing the instruction with a pictogram is essential). Seventy-one physicians responded to the survey.Results22 out of 66 medical instructions were considered “essential” by >=51% of the experts, and 12 of the 66 were considered to be “useful but not essential” by >=51% of the experts.ConclusionResults of our survey validate the potential use of pictograms as a complement to better comprehension of medical instructions in our country.     

Women in medicine: practice patterns and attitudes.

Increasing numbers of women are entering medicine in Canada. In 1959 women accounted for 6% of the medical school graduates, but by 1989 they accounted for 44%. Although there has been little systematic investigation of the impact of this increase on Canada''s health care system, there are grounds for believing that female physicians bring with them distinctive values and interests, which may be reflected in the way they conduct their professional practices. We used data from a recent national survey of 2398 Canadian physicians to examine differences between women and men in their practices and their attitudes toward health care issues. Significant differences were found in the organization and management of the practices. Women preferred group over solo practice and were overrepresented in community health centres, health service organizations and centres locaux de services communautaires in Quebec. One-third of the women, as compared with half of the men, were in specialties. Even after adjusting for differences in workloads the incomes of the women were significantly lower than those of the men. Only minor differences were observed in the assessment of the health care system and alternative modes of organizing health care services. We believe that the differences were due to the double workload of women as professionals and family caregivers and the powerful socialization effects of medical education. As women overcome their minority status in the medical profession, differences between the sexes may become more apparent. Thus, the extent and effects of the progressive increase in the number of women in Canadian medicine should be assessed on an ongoing basis.     

Documenting wife abuse: a guide for physicians

An estimated 12% to 30% of women are assaulted by their male partners at least once during the relationship. Therefore, in their everyday practice, physicians are likely to encounter women who have suffered domestic abuse. The authors define wife abuse, outline epidemiologic aspects and discuss common signs and symptoms. In cases of suspected or confirmed abuse, it is very important for physicians to document the details of the injuries, the patient visit, any treatment and follow-up as well as to screen for associated conditions and ensure that any samples taken are not tampered with. When asked to disclose information by police or courts, physicians need to know when they are obliged to submit copies of their patients'' medical records, when patient consent is required, what information should be divulged and how to defend this information in court. The authors present information about the necessary, relevant and appropriate evidence to be collected and documented for both medical and legal purposes. They also discuss the criminal justice system and the role of physicians in legal proceedings concerning wife abuse.