关于开展医学信息学教育的思考和建议

当前，医疗卫生专业人员对现代数据处理、信息处理和知识处理技术及其在医疗决策中的作用还普遍缺乏深入了解。为有效利用信息资源，提高医疗水平，要求他们应用信息技术，但知识有限。有鉴于此，迫切需要大量训练有素的医学信息学专业人才。欲达此目的，只有通过改进医学教育，使更多的医疗卫生专业人员接受医学信息学培训。     

Social ties and mental health

It is generally agreed that social ties play a beneficial role in the maintenance of psychological well-being. In this targeted review, we highlight four sets of insights that emerge from the literature on social ties and mental health outcomes (defined as stress reactions, psychological well-being, and psychological distress, including depressive symptoms and anxiety). First, the pathways by which social networks and social supports influence mental health can be described by two alternative (although not mutually exclusive) causal models—the main effect model and the stress-buffering model. Second, the protective effects of social ties on mental health are not uniform across groups in society. Gender differences in support derived from social network participation may partly account for the higher prevalence of psychological distress among women compared to men. Social connections may paradoxically increase levels of mental illness symptoms among women with low resources, especially if such connections entail role strain associated with obligations to provide social support to others. Third, egocentric networks are nested within a broader structure of social relationships. The notion of social capital embraces the embeddedness of individual social ties within the broader social structure. Fourth, despite some successes reported in social support interventions to enhance mental health, further work is needed to deepen our understanding of the design, timing, and dose of interventions that work, as well as the characteristics of individuals who benefit the most.     

The postgraduate education of physicians in preventive medicine

The Graduate Medical Education National Advisory Committee report projected a serious shortage of preventive medicine specialists in 1990, and the recommendations of a recent report from the Association of American Medical Colleges called for increased training of medical students in health promotion and disease prevention and in adapting to changes in health and health care. To help meet the need for physician manpower in preventive medicine a new residency was established at the State University of New York at Stony Brook in July 1983. The program features a structured approach to the practicum year, incorporating an organized core curriculum and opportunities for a varied field experience. In addition to the School of Medicine and University Hospital, major training sites include two large county health departments on Long Island, three community hospital departments of community medicine, a health maintenance organization as well as several neighborhood health centers, and community-based programs operated by these hospitals and health departments. The curriculum includes both longitudinal experiences at the medical school involving teaching, research, and didactic conferences, and block field rotations within the above affiliated agencies, providing practice experience in preventive medicine and public health. The diversity in the organization and type of preventive medicine institutions used for training enriches the residency experience and is complemented by core educational activities.     

我国专科医师培养模式与基地认证评审的研究

专科医师培养作为中观层次的系统管理教育模式研究,在相关教育过程、教育结构和教育方法的规划设计中,应以继续职业发展的国际标准确立的培养目标、培养内容为导向．研究适合中国国情的专科医师培养策略、管理程序和效果评价,并制定包括认证评审、对象和内容、依据和原则、组织领导和工作程序在内的专科医师培训基地的全国医师行业协会认证评审实施方案。     

Do medical schools still train doctors?

In practice, medical finals are not final and a supplementary training is necessary before medicine may be practised independently. Social factors and an ongoing evolution of medical science prompt reconsideration of the structure, content and duration of the training of doctors and specialists. This was the subject of a meeting of this Journal. One possibility of differentiation in the basic training is an early subdivision into care physicians, clinical specialists and health physicians. In the training of social medical officers one of the factors to be taken into account is the influence of principals. For GP's, postgraduate training is increasingly important because of social and other developments. The training of non-surgical specialists can be made shorter since a significant proportion of the time in the present training is devoted to areas requiring special attention. The training of surgical specialists could be shortened by introducing a training programme that is independent of the procedure. Responsibility for the total care of the patient will be borne by the specialists jointly.     

Trans-local ties, local ties and psychological well-being among rural-to-urban migrants in Shanghai

During the past three decades, an estimated 200 million rural residents have moved to urban centers in China. They are "sojourners" in the cities and maintain close ties with their home communities, which we term trans-local ties. This paper examines the relationship between migrants' social ties and their mental health, and contrasts the trans-local ties with migrants' ties in the receiving communities, which are termed local ties. We expect that for the migrants, trans-local ties foster better mental health not only through providing emotional support but also through generating favorable social comparisons; whereas local ties may furnish important social support, but may also produce negative social comparisons. We use data collected in Shanghai to test our expectations. We compare the migrants to a sample of Shanghai natives to assess patterns of relationship between social ties and mental health that are unique to the migrants. We find that for the migrants, more numerous trans-local ties are associated with better mental health, whereas the number of local ties is not a significant predictor. This pattern is not observed among the Shanghai natives. Moreover, for migrants, trans-local ties foster a favorable evaluation of their status in Shanghai and buffer their perception of discrimination; in contrast, more numerous local ties tend to be associated with a more negative perception of social status. The findings highlight an often-overlooked pathway between social ties and health outcomes, namely, through influencing social comparison and perceived social status. This study also suggests that in addition to reducing institutional and personal discrimination, facilitating close bonds between the migrants and their home communities may be a productive way to foster their well-being, in the context of contemporary urban China.     

The effectiveness of a computer-assisted instruction programme on communication skills of medical specialists in oncology

BACKGROUND: Although doctor--patient communication is important in health care, medical specialists are generally not well trained in communication skills. Conventional training programmes are generally time consuming and hard to fit into busy working schedules of medical specialists. A computer-assisted instruction (CAI) programme was developed -- 'Interact-Cancer' -- which is a time-efficient learning method and easily accessible at the workplace. OBJECTIVE: To investigate the effect of the CAI training, 'Interact-Cancer', on the communication behaviour of medical specialists, and on satisfaction of patients about their physician interaction. DESIGN: Consultations of medical specialists with cancer outpatients were videotaped at 4 specific stages, 2 before and 2 after Interact-Cancer, with intervals of 4 weeks. PATIENTS/PARTICIPANTS: Participants were 21 medical specialists, mainly internists, working in 7 hospitals, and 385 cancer outpatients. METHODS: Communication behaviour was assessed on 23 observation categories derived from the course content. Frequencies were rated as well as judgements about the quality of the performance of each target skill. Satisfaction was measured by the Medical Interview Satisfaction Scale. Data were analyzed by means of multilevel statistical methods. RESULTS: The behavioural assessment showed course effects on ratings of the physicians' quality of performance. No course effects were found on the frequencies of physicians' behaviours and on the patient satisfaction ratings. CONCLUSIONS: CAI is a promising method to supply medical specialists with postgraduate training of communication skills. The application of judgement ratings of communication behaviour proved to be valuable to evaluate course effects in real-life patient encounters.     

卫生信息管理岗位能力及未来培训需求调查

采用分层整群随机抽样的方法，对浙江省卫生机构中从事卫生信息管理的人员进行调查，分析其专业素质及能力需求，结果显示：最适合卫生信息管理岗位的专业是卫生信息管理，相关高校在教学中要设置计算机网络及硬件维护、常用软件的安装使用和维护、医学信息检索、疾病分类、病案管理、统计等内容，并把相应教学内容与在职工作人员的培训需求及相关专业IT认证内容相衔接，以适应卫生信息管理工作需求。     

Ritual coordination of medical pluralism in highland Nepal: implications for policy

In highland Nepal, just as in many other regions of South Asia, multiple indigenous healing traditions and a variety of traditional curing specialists co-exist in a pluralistic cultural environment. It is argued that the interaction of diverse medical traditions is a particular aspect of the more general tendency toward the accretion and super-imposition of cultural traits which has been a common feature of Hindu-influenced social systems. Allopathic medicine and its practitioners, therefore, are less likely to displace traditional curing practices than to become integrated into a network characterized by continued pluralism. To insure that allopathy is properly understood and utilized within the pluralistic context, the identification and training of coordinating personnel who may specialize in diagnosis or referral demonstrates promise. The traditional curing network of the Thakali people of Northwest Nepal is described, with particular attention to the mu tu ceremony of divination, as an example of an indigenous agency of medical referral. It is suggested that referral specialists such as the Buddhist monks who perform mu tu are particularly appropriate targets for health education initiatives aimed at familiarizing village populations with the role and proper usage of modern medicine.     

What would happen if large firms offered MSAs?

This paper reports the results of a survey of more than 500 health benefit specialists about the advice they would give to medium-size and large employers on offering a tax-advantaged medical savings account (MSA). About 42 percent of respondents would recommend an MSA combined with a catastrophic health plan, while a third would advise against such a plan. When presented with a specific example of an MSA package that would be attractive to a large fraction of workers, the percentage of benefit specialists favoring adding an MSA option rose to 74 percent. However, respondents generally did not believe that most workers would choose the MSA, especially if the alternative were a health maintenance organization (HMO).     

卫勤优化决策模拟训练系统研发

目的：通过卫勤优化决策模拟训练系统的研发，提高战役卫勤机关人员的作业技能和决策能力，使其能够胜任现职岗位并满足未来任职的需要，为卫勤模拟训练提供工具支持和方法借鉴。方法：以现代卫勤理论和决策支持理论为基础，应用软件开发技术，在“卫勤优化决策支持系统”的基础上，融入训练、考试的相关功能模块，研发“卫勤优化决策模拟训练系统”，并以之作为开展卫勤模拟训练的工具，在实际教学中进行应用。结果：研发了卫勤优化决策模拟训练系统，为信息化条件下开展卫勤模拟训练提供了工具上的支持。结论：卫勤优化决策模拟训练系统的研发，为传统的卫勤训练引入了信息化工具，改革了训练方式与考核方法，实现了考训结合。     

Specialist training

Specialist training must be reshaped to meet the challenges of new systems for the delivery of health care and rapid expansion in biomedical knowledge. An adequate and affordable supply of trained specialists and generalists able to deal with the health problems of populations served, is the responsibility of governments and policymakers that fund and those who deliver graduate education. Clearly defined objectives for specialist training are needed, linked to planning for the medical workforce size. A balance between numbers of specialists and generalists is essential, although flexibility in programmes should allow individuals to change. Curricula for all specialties should be published. Strategies and methods for delivery of graduate education and training must be coherent with those of medical schools. Training should be planned and sequenced to meet the identified needs of individuals. Those who teach should themselves learn how to train and assess trainees. The location for training should reflect present and future clinical practice if disfunction between medical education and the health of populations served and their need is to be avoided. Specialist training should form the basis for continuing education by encouraging lifelong, evidence-based learning. Any reshaping of specialist training must be consistent with the continuum of medical education. Instruments for assessment of specialists in training have to be refined, based on action research. Ensuring mastery in the competencies of each component of the curriculum is essential. Those competencies will change in consequence of altered societal needs plus advances in technology and biomedical knowledge.     

A Multilevel Analysis of Social Ties and Social Cohesion among Latinos and Their Neighborhoods: Results from Chicago

Research suggests that, among Latinos, there are health benefits associated with living in a neighborhood populated with coethnics. While social networks and social cohesion are the proposed explanation for the salubrious effect and are assumed to be characteristics of Latino immigrant enclaves, evidence for this is limited. We used multilevel regression to test the relative contribution of individual race/ethnicity and neighborhood concentration of Mexican Americans as predictors of social networks and social cohesion. After accounting for personal characteristics, we found a negative association between neighborhood concentration of Mexican Americans and social cohesion. Among Latinos, living in a neighborhood with increased coethnics was associated with increased social ties. Compared to non-Latino whites, Mexican Americans reported more social ties but lower social cohesion. Contrary to the assumption that Mexican immigrant enclaves beget social cohesion, we did not find this to be true in Chicago neighborhoods.     

荷兰以人为本整合型卫生服务的实践与启示*

从服务提供、治理机制、组织管理和筹资支付四个维度,分析荷兰实现以人为本的整合型卫生服务的关键要素,包括以全科医生服务团队为核心的网络化医疗卫生服务体系、良性市场竞争机制和广泛的社会参与及多部门合作的治理网络,促进整合的医保支付制度,成熟的全科医生培养体系和互联互通的信息系统,并结合中国实际,提出我国现阶段应将基层医疗卫生服务体系作为建设重点和优先领域,以家庭医生签约服务为抓手,加强医保对服务提供者的激励和约束,破除市场竞争、人才培养和信息共享等方面的体制机制障碍,构建以家庭医生服务团队为核心的网络化服务体系。     

Technical assistance offered to community health programs through a resource model.

A multidisciplinary unit in the Department of Community Medicine, Mount Sinai School of Medicine, consists of a core group of specialists who plan, develop, and evaluate community health care programs. The primary tools used by the staff of the Services Coordination Unit, epidemiology and behavioral and management sciences, result in improved organization and coordination of health services and community resources. The small unit of specialists functions as a resource group, helping community groups address the complex problems of planning, organization, delivery, and financing of health services. By offering technical assistance rather than day-to-day health care services, the unit has established an education and training program in New York''s East Harlem, which surrounds the medical school. Over the last 10 years, that approach has enhanced the administrative and financial viability of existing health programs in East Harlem. Since the unit''s establishment, it has collaborated with a broad variety of community groups. More than 20 programs have resulted. The income generated by the unit completely covers the expenses and has done so since 1976; "seed money" was used for startup and the first 3 years of operation. The unit is paid for long-term services and for most consultations.     

Social capital and core network ties: a validation study of individual-level social capital measures and their association with extra- and intra-neighborhood ties, and self-rated health

Research on social capital and health has assumed that measures of trust, participation, and perceived cohesion capture aspects of people's neighborhood social connections. This study uses data on the personal networks of 2707 Montreal adults in 300 different neighborhoods to examine the association of socio-demographic and social capital variables with the likelihood of having core ties, core neighborhood ties, and high self-rated health (SRH). Persons with higher household income were more likely to have core ties, but less likely to have core neighborhood ties. Persons with greater diversity in extra-neighborhood network capital were more likely to have core ties, and persons with greater diversity in intra-neighborhood network capital were more likely to have core neighborhood ties. Generalized trust, perceived neighborhood cohesion, and extra-neighborhood network diversity were shown associated with high SRH. Conventional measures of social capital may not capture network mechanisms. Findings suggest a critical appraisal of the mechanisms linking social capital and health, and the further delineation of network and psychosocial mechanisms in understanding these links.     

Cost-control and medical specialist payment: the Dutch alternative

The fee-for-service system is a growing problem for insurers and governments. The main reason for this is the open-ended character of this system which makes cost-control a very difficult task. The pressures on the fee-for-service system are becoming more pronounced, especially in countries such as Canada, Germany and the Netherlands which use budget restrictions on national health care expenditure (macro caps). In these countries policy makers are searching for an alternative payment system and an appropriate definition of a corresponding status for doctors. The alternative, however, does not have to lead automatically to a salaried status of doctors in the hospital organization. The Dutch experience of the change of the payment system for medical specialists illustrates the transition to a new 'negotiated order'. The introduction of the 'lump sum' and the sub-contractor relationship with the insurance companies leaves the organizational autonomy of medical specialists intact. In exchange the medical specialists cooperate with the insurers in trying to control the costs of health care. In this process of strategic change, two factors are very significant, i.e. the new leadership of the local medical specialists and the governmental 'circumvention' of the powerful associations of doctors and insurers.     

坚持四个统筹 推进新形势下专科医师制度的实施

“人才强卫”是医疗改革新形势下做好卫生工作的重要指导思想,加快卫生事业改革发展必须依靠人才。实施专科医师制度,重点是要统筹专科医师与全科医师、专科医师与医学专家、专科医师培训与住院医师规范化培训、专科医师制度与学校医学教育等四大关系。     

Physicians for the 21st century. Challenges facing medical education in the United States

Since the 1980s, the American medical educational system has come under attack for its failure to train and prepare physicians for the challenges created by the changing health care market. The medical schools have been criticized for producing too many specialists and for not providing sufficient training in ethics and moral reasoning, care of the terminally ill, health care economics, alternative medicine, and the role of spiritual and religious values in healing. This study attempts to ascertain the extent to which medical schools have responded to these criticisms by changing their curriculum. The study is based on a survey of deans of medical schools in the United States. The study finds that medical schools have indeed responded to some of the criticisms by incorporating training in ethics, communication, primary and preventive care, and care of the terminally ill in their curriculum. However, the study concludes that more changes are needed to train physicians for the 21st century.