网络成瘾的生物学机制研究与展望

网络成瘾是指由于过度使用网络而导致社会及心理损害的现象,危害极大,故受到广泛关注。网络成瘾主要受生物学机制的调控。在脑神经机制方面,通过对成瘾者的自发脑电、事件相关电位以及成瘾者静息态BOLD-f MRI的分析,发现成瘾者脑功能区出现异常。同时,网络成瘾也受到自主神经功能的影响。另外,脑内奖赏系统和成瘾记忆模型也可能成为引发网络成瘾的脑神经机制。体内化学物质的失衡也能引发网络成瘾。鉴于此,一些治疗方法如药物干预、行为干预、认知干预以及综合干预疗法使得根治网络成瘾成为可能。本文拟从网络成瘾的概念、表现特点、不良影响及其发生的生物学机制等方面的研究进展进行阐述,以期为相关研究提供一些有价值的参考依据。     

Poem: the prophet in his own country

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians'' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians'' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians'' financial and nonfinancial concerns about providing care for poor patients.     

Resource allocation and physician liability

Lawyer Karen Capen says funding cutbacks that have affected the services physicians can provide may cause legal problems for Canada''s doctors. If cutbacks affect the care that is being provided, they should be discussed with the patient and noted on the chart. She says physicians have "good reason to be concerned" about increasing pressures that create an imbalance between health care resources and the demand and need for services. For some doctors, these have resulted in court cases.     

Physician communication skills and malpractice claims. A complex relationship.

We assessed the relationship between patients'' opinions about their physicians'' communication skills and the physician''s history of medical malpractice claims. The sample consisted of 107 physicians and 2,030 of their patients who had had an operation or a delivery. Although patients tended to give their physicians favorable ratings, they were least satisfied with the amount of explanations they received. Patients gave higher ratings to general surgeons and obstetrician-gynecologists and poorer ratings to orthopedists and anesthesiologists. Women and better-educated patients gave higher ratings on explanations and communication to physicians with fewer claims. Men and patients with less education, however, gave higher ratings on these dimensions to physicians with more claims. These findings suggest the need for physicians to tailor their communications to a patient''s individual needs. Improved communication between physicians and patients may result in fewer nonmeritorious malpractice claims while leading to less costly resolution of meritorious claims.     

Pheo or not a pheo,that is the question.

The current fault-based tort system assumes that claims made against physicians are inversely related to the quality of care they provide. In this study we identified physician characteristics associated with elements of medical care that make physicians vulnerable to malpractice claims. A sample of physicians (n = 248) thought to be at high or low risk for claims was surveyed on various personal and professional characteristics. Statistical analysis showed that 9 characteristics predicted risk group. High risk was associated with increased age, surgical specialty, emergency department coverage, increased days away from practice, and the feeling that the litigation climate was "unfair." Low risk was associated with scheduling enough time to talk with patients, answering patients'' telephone calls directly, feeling "satisfied" with practice arrangements, and acknowledging greater emotional distress. Prediction was more accurate for physicians in practice 15 years or less. We conclude that a relationship exists between a history of malpractice claims and selected physician characteristics.     

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.     

Primary care physicians' refusal to care for patients infected with the human immunodeficiency virus.

We conducted a telephone survey of a random sample of office-based primary care physicians in Los Angeles County to determine their practice experiences with patients infected with the human immunodeficiency virus (HIV). Telephone interviews included questions related to the physicians'' experiences evaluating patients for HIV infection during the past 6 months and the presence of HIV-infected patients in their practices. Those without HIV-infected patients were asked if this was because they had not encountered such patients, because those patients had died, or because the physicians had chosen to refer these patients elsewhere or the patients had gone elsewhere for care. Of physicians who participated in the survey, 78% had evaluated a patient for HIV infection in the past 6 months; 34% were currently providing primary care for infected patients; and 36% had elected to refer HIV-infected patients elsewhere, or their patients had elected to find other physicians. In all, 48% of physicians in the sample had elected not to care for, or said they would not provide care for, patients with HIV infection. Among Los Angeles County primary care physicians, 36% have refused to provide continuing care for HIV-infected patients and another 12% indicated their unwillingness to do so should such patients present themselves for care. As of 1991, the reservoir of primary care physicians in Los Angeles not yet involved with but willing to care for HIV-infected patients is relatively small (15%).     

Are MDs more intent on maintaining their elite status than in promoting public good?

The message that philosopher John Ralston Saul delivered during a recent CMA policy conference may have been unpopular with many physicians, but it wasn''t intended to win their support. Instead, organizers wanted him to provide food for thought. Charlotte Gray reports that he did just that.     

Bus rounds for palliative care education in the community

Increasingly, patients with cancer are dying at home and in continuing care facilities. The purpose of bus rounds is to provide continuing education to physicians and nurse palliative care consultants, to familiarize family physicians with the delivery of care in these settings and to educate family medicine and specialty residents as well as medical students. A total of 18 4-hour bus rounds took place during 1996. A mean of 13 (range 9 to 17) participants attended, to discuss a mean of 3.5 (range 2 to 4) patients and 4.5 (range 3 to 8) journal articles. A questionnaire was filled out anonymously by 18 first-time medical and 24 first-time nursing participants. On a scale from 1 (worst) to 5 (best), they gave the rounds an overall rating of 5 (range 4 to 5). The mean cost per round was $245.40. The authors conclude that bus rounds provide an opportunity for intensive exposure to community-based learning for physicians, nurses and students and are highly satisfactory from the participants'' perspective.     

What factors influence primary care physicians' charges for their services? An exploratory study using standardized patients

OBJECTIVE: To determine the extent of variation in physicians'' charges for health care encounters with unannounced standardized patients and factors associated with the variation. DESIGN: Cross-sectional study. SETTING: Family practices open to new patients within 1 hour''s drive of Hamilton, Ont. PARTICIPANTS: A stratified random sample of 125 physicians who had responded to an earlier survey regarding preventive care were invited to participate. Of the 125, 44 (35.2%) declined to participate, and an additional 19 (15.2%) initially consented but later withdrew because they closed their practices to new patients. Sixty-two physicians thus participated in the study. INTERVENTION: Unannounced standardized patients posing as new patients to the practice visited study physicians'' practices between September 1994 and August 1995, portraying 4 scenarios: 28-year-old woman, 52-year-old woman, 48-year-old man and 70-year-old man. OUTCOME MEASURES: Physician characteristics, encounter characteristics and charges made for services. RESULTS: The 62 physicians had 246 encounters with the standardized patients. Charges were made to the health insurance plan for services by 59 physicians for up to 4 encounters (215 encounters in all). Charges varied considerably both within and across patient scenarios. Time spent with the patient was an important factor predicting charges made (p < 0.01), although the effect of time spent on charges varied across scenarios (p < 0.01). Fee-for-service physicians charged more for their services than physicians who usually had alternative billing arrangements (p < 0.01). Female physicians charged more for their services than their male colleagues (p = 0.03). No relation was found between quality of preventive care and charges made (p = 0.15). CONCLUSIONS: Physician-related factors are better able to account for the variability in charges for their services than patient-related factors. Physicians seeing comparable patients may earn much more or less than their colleagues because of differences in the services they provide and the way they apply the fee schedule. Quality-assurance techniques are likely needed to reduce the variability in charges seen and increase value for money spent in health care.     

Bioethics for clinicians: 9. Involving children in medical decisions

Medical decisions involving children raise particular ethical issues for physicians and other members of the health care team. Although parents and physicians have traditionally made most medical decisions on behalf of children, the developing autonomy of children is increasingly being recognized in medical decision-making. This poses a challenge for physicians, who must work with the child''s family and with other health care practitioners to determine the child''s role in decision-making. A family-centred approach respects the complex nature of parent-child relationships, the dependence and vulnerability of the child and the child''s developing capacity for decision-making.     

Taking care of patients--does it matter whether the physician is a woman?

Researchers have recently begun to compare male and female physicians'' attitudes toward patients, medical knowledge, and practice styles. Although women start medical school with more "humanistic views," the conservative effect of medical socialization on both male and female students attenuates these differences. While some studies suggested that men are more scientifically knowledgeable, recent studies showed no significant differences in physicians'' medical knowledge. Male and female physicians also had comparable diagnostic and therapeutic behavior. In the intimate world of physicians and patients, however, there were notable differences. Women physicians seemed better able to communicate sensitivity and caring to patients, which may account for the common perception that women are more caring and empathic physicians. Medical educators may wish to study more closely female physicians'' communication styles to identify these behaviors and inculcate them into all physicians.     

Attitudes of Washington State physicians toward health care reform.

Attitudes of Washington State physicians about health care reform and about specific elements of managed competition and single-payer proposals were evaluated. Opinions about President Clinton''s reform plan were also assessed. Washington physicians (n = 1,000) were surveyed from October to November 1993, and responses were collected through January 1994; responses were anonymous. The response rate was 80%. Practice characteristics of respondents did not differ from other physicians in the state. Of physicians responding, 80% favored substantial change in the current system, 43% favored managed competition, and 40% preferred a single-payer system. Of physicians responding, 64% thought President Clinton''s proposal would not adequately address current problems. Reduced administrative burden, a central element of single-payer plans, was identified by 89% of respondents as likely to improve the current system. Other elements of reform plans enjoyed less support. More procedure-oriented specialists than primary care physicians favored leaving the current system unchanged (28% versus 8%, P < .001). While physicians favor health care reform, there is no consensus on any single plan. It seems unlikely that physicians will be able to speak with a single voice during the current debates on health care reform.     

Understanding physicians' response to AIDS.

Attempts to comprehend physicians'' extreme reaction to AIDS (acquired immune deficiency syndrome) have met with great difficulty since the disease brings into question traditional norms and assumptions. As the medical profession struggles to develop guidelines and policies to help it deal with this disease, it can draw on very little systematic research on the effect of AIDS on physicians'' attitudes and practices. We suggest a framework developed from the literature on physicians'' and society''s response to other disorders that would provide a basis for organizing the ever-increasing amount of information on physicians and AIDS and would guide systematic research aimed at understanding and predicting physicians'' participation in the prevention and management of AIDS. Within this framework we consider how characteristics of the disease, elements of the health care system and physicians'' attitudes interact to influence clinical and personal practices. AIDS had led to new delineations of physicians'' responsibility, modification of prevailing beliefs about physician autonomy and thus a redefinition of the role of the physician in North America.     

CMA membership survey: opinions on issues facing the medical profession

A sample survey of Canadian Medical Association (CMA) members, conducted in early summer 1985 and designed to provide information to help guide the association''s activities and policies, shows that most Canadian physicians support involvement in political activities both by CMA and by indivudual physicians. A majority wishes to maintain the concept of extra/balance billing, to pursue the position that the health care system is underfunded and favours medicare premiums and hospital user fees as the preferred methods for increasing revenue.Most respondents believe that the number of doctors in Canada is about right but would prefer any reduction to be achieved by cutting medical school admissions or reducing postgraduate training positions open to graduates of foreign medical schools.Most of those members who know of CMA policies on a number of health care issues agree with them and also find them useful, but a significant proportion are not aware of their content.There is support for compulsory payment of dues by all licensed physicians to both their provincial medical association and CMA. A majority would like more information on pharmaceutical products and additional membership surveys.     

Chronological Changes in Japanese Physicians' Attitude and Behavior Concerning Relationships with Pharmaceutical Representatives: A Qualitative Study

Background

Recent qualitative studies indicated that physicians interact with pharmaceutical representatives depending on the relative weight of the benefits to the risks and are also influenced by a variety of experiences and circumstances. However, these studies do not provide enough information about if, when, how and why their attitudes and behaviors change over time.

Methods and Findings

A qualitative study using semi-structured face-to-face individual interviews was conducted on 9 Japanese physicians who attended a symposium on conflicts of interest held in Tokyo. Interviews were designed to explore chronological changes in individual physicians'' attitude and behavior concerning relationships with pharmaceutical representatives and factors affecting such changes. Their early interaction with pharmaceutical representatives was passive as physicians were not explicitly aware of the meaning of such interaction. They began to think on their own about how to interact with pharmaceutical representatives as they progressed in their careers. Their attitude toward pharmaceutical representatives changed over time. Factors affecting attitudinal change included work environment (local regulations and job position), role models, views of patients and the public, acquisition of skills in information seeking and evidence-based medicine, and learning about the concepts of professionalism and conflict of interest. However, the change in attitude was not necessarily followed by behavioral change, apparently due to rationalization and conformity to social norms.

Conclusions

Physicians'' attitudes toward relationships with pharmaceutical representatives changed over time and factors affecting such changes were various. Paying attention to these factors and creating new social norms may be both necessary to produce change in behavior consistent with change in attitude.     

Future role of neurologists.

Clinical neurologists in the health care system of the future should have a multifaceted role. Advances in the basic understanding of the nervous system and therapeutics of neurologic disease have created, for the first time in human history, an ethical imperative to correctly diagnose neurologic disease. In many situations, the neurologists may function as a consultant and principal physician for patients with primary nervous system disorders including Parkinson''s disease, multiple sclerosis, Alzheimer''s disease, epilepsy, migraine, cerebrovascular disease, movement disorders, and neuromuscular disease. Other important roles for neurologists include the training of future physicians, both neurologists and primary care physicians, the application of cost-effective approaches to care, and the support of health care delivery research and academic programs that link basic research efforts to the development of new therapy. To be successful, future residency training programs should include joint certification opportunities in both neurology and general medicine, and training programs for clinical investigators should be expanded. Despite its threats to specialists, managed care should also provide opportunities for new alliances among neurologists, other specialists, and primary care physicians that will both improve patient care and increase efficiency and cost-effectiveness.     

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。

     

"Take some action,take some risk," conference on rural recruiting told

Physicians attending a recent conference on the retention of physicians in rural areas proposed more than 40 recommendations for dealing with recruitment and retention issues. The conference was organized by Ontario''s residents, who have been feeling the impact of attempts to encourage physicians to move to rural and underserviced areas.     

Physicians must cast off grief over change if they're to move forward,anthropologist advises

It''s time for physicians to stop grieving over the massive changes occurring in health care and instead create a new vision that will lead them forward into the future, a cultural anthropologist told the CMA''s 8th annual Leadership Conference in March. About 175 physicians attended the 2-day conference on regaining the perspective on values in times of change.