我的中国疼痛学发展之梦——再谈疼痛科医师的培养

2007年卫生部《医疗机构诊疗科目名录》中增加“疼痛科”诊疗科目的通知下发后，随着各医疗单位尤其是二级医院疼痛科的建立，人才培养的问题凸显。当时我以个人亲身经历在本刊撰文“疼痛科医师素质培养浅谈”，提出素质培养是完成麻醉科医师向疼痛科医师角色转换的关键。时隔5年，卫生部启动疼痛科国家临床重点专科建设项目工作，激起了更多单位尤其是三级医院建立和完善疼痛科建设的热情。依个人拙见，     

关于疼痛科建设与发展若干问题的探讨

2007年7月16日,卫生部下发了“关于在《医疗机构诊疗科目名录》中增加‘疼痛科’为一级诊疗项目的通知”。其中规定,我国二级以上医院可开展“疼痛科”的诊疗服务,并且执业范围明确界定为“慢性疼痛的诊疗”,同时文件对疼痛科从业人员的来源也做了相应的界定。然而,从中国疼痛医学发展的历史和现状来看,尽管疼痛科领到了“准生证”,但它的发展绝不会是一帆风顺的,在其建设与发展的道路上必定会遭遇许多问题和挑战。因此,对一些大家较为关心和困惑的问题进行探讨甚为必要。1如何处理麻醉医师的困惑众所周知,麻醉最初就是出于为手术提供“无痛”这一简单目的。可以说,从麻醉发展史来看,麻醉与镇痛本来就是一对孪生儿,任何简单把这两者的关系割裂开来似乎都是不妥的。因此,卫生部关于确立疼痛科的文件一出台,立即引发了巨大的争议,其中最大的争议恰恰来自于麻醉科。有报道显示,文件下发之前,全国各地已有几千家医院在开展疼痛治疗的业务,已有的模式以门诊为主,并且94%的疼痛门诊系由麻醉科建立。之前我国卫生部也曾经出台过相应文件,指出:麻醉科的业务范围包括临床麻醉、重症监护治疗与疼痛诊疗。就此来看,疼痛诊疗业务理应归属于麻醉科掌管,疼痛诊疗应当是作为麻醉科的...     

桂林全国疼痛会议简介

由中华麻醉学杂志编委会举办的全国疼痛学术会议于2002年11月9日至11月11日于广西桂林召开,中华麻醉学杂志编委会也同时举行。中华麻醉学杂志的全体编委、中华医学会麻醉学会的全体委员和来自全国各地的麻醉学科医师和疼痛科医师,以及其他学科的医师约400余人参加了会议。会议邀请全国疼痛诊疗学专家进行了专题讲演,与会代表进行了热烈的讨论。会议由中华麻醉学会疼痛学组组长、北京友谊医院麻醉科主任李树人教授主持,中华麻醉学会主任委员、北京协和医院麻醉科罗爱伦教授致开幕词。她在开幕词中指出疼痛诊疗是麻醉学科的重要任务之一,麻醉科医师是疼痛诊疗的主力和最合适的人选。因此,麻醉学科应当积极开展疼痛诊疗工作,麻醉科医师更应当     

应加强提高疼痛诊疗人员的诊断水平

随着疼痛治疗的开展,我国疼痛诊疗发展之迅速是前所未有的。全国无论大中小城市、大中小医院纷纷开设了疼痛诊治门诊。从全国开展疼痛治疗门诊和从近几年疼痛学杂志刊登的稿件分析,我们应当加强和提高疼痛诊疗人员的诊断水平,减少误诊率,捉高治愈率。疼痛科医师主要来源于麻醉科医师,麻醉科医师主要任务是在手术室作临床麻醉工作,对疼痛治疗的神经阻滞技术是他们的特长。但是在疼痛疾病的诊断     

编后记

“疼痛学发展之梦”仍是本期第一篇文章,特请深圳市第六人民医院蒋劲教授撰写。本刊特约创建我国疼痛学科的一代专家写“梦”有特殊意义。他们白手起家,从麻醉科和其他不同专业聚集在疼痛科旗下,将我国疼痛科一步一步地发展起来,功不可没。今后如何发展下去？若干年后疼痛科应该发展到什么模样？疼痛科的业务范围、技术特点、科室建制、医师资质该如何界定,和其他从事疼痛诊治的科室如何合作？又如何形成自己的特色？对此,我们现在都应该有个“梦”,也就是要有个详细计划。蒋劲教授的寻梦之路值得我们深思。三叉神经痛的射频热凝治疗依然是本期报道的热点,常州市中医院麻醉科商建飞与徐州医学院疼痛科申文等采用此法治疗,随访达到了两年,治愈率76％,复发率5．9％,对这种顽固性疼痛疾病可认为效果不错。以山东大学齐鲁医院神经外科吴承远教授为通信作者报道的侧入法行半月神经节穿刺治疗三叉神经痛,在前入路穿刺遇到困难或失败时,采用侧入路是一种较好的选择。     

卫生部关于在《医疗机构诊疗科目名录》中增加"疼痛科"诊疗科目的通知

卫医发[2007]227号各省、自治区、直辖市卫生厅局，新疆生产建设兵团卫生局，部直属有关单位：随着我国临床医学的发展和患者对医疗服务需求的增加，根据中华医学会和有关专家建议，经研究决定：一、在《医疗机构诊疗科目名录》(卫医发[1994]第27号文附件1)中增加一级诊疗科目“疼痛科”，代码：“27”。“疼痛科”的主要业务范围为：慢性疼痛的诊断治疗。二、开展“疼痛科”诊疗科目诊疗服务的医疗机构应有具备麻醉科、骨科、神经内科、神经外科、风湿免疫科、肿瘤科或康复医学科等专业知识之一和临床疼痛诊疗工作经历及技能的执业医师。三…     

转型成为疼痛科医师：我的心路历程

2007年卫生部第227号公文承认疼痛科为一医学专科并鼓励二级以上的医院开展疼痛科工作。这两年在全国各地疼痛科之建立如雨后春笋,欣欣向荣。基于过去科室的特色,目前国内的疼痛科医师多来自麻醉科,但亦有不少的同仁对此转型感到困惑和惶恐。     

建设一个强大的中国疼痛专科

弹指一挥间,从1978年开始担任麻醉科医师,1996年参加疼痛门诊,2004年全职负责疼痛病区业务,我已从事疼痛科业务19年了。我的中国疼痛学发展之梦,即我愿景中的10年后中国疼痛医学中,有一支很专业诊疗慢性疼痛的骨干队伍,建成一个强大的疼痛专科,保护着人体感觉神经系统。2007年,中国卫生部宣布成立一级临床科目“疼痛专科”,指定专科诊疗范围是“慢性疼痛”。     

刘小立介绍

刘小立,河北医科大学第四医院疼痛科与康复科主任,主任医师,教授,瑞典医学博士。现任河北省医学会疼痛学分会主任委员,中华医学会疼痛学分会常委,河北省医学会麻醉学分会副主任委员,中国医师协会麻醉科医师分会委员,     

疼痛科应是麻醉科三个分支之一

卫生部(89)第12号文件指出麻醉科除临床麻醉外,应由原来的手术室逐步扩大到病房,应承担急救、复苏、重症监测治疗(ICU)与疼痛诊治任务。利用麻醉学的理论与方法,对疾病进行诊断与治疗,概括了整个麻醉科医师的工作,即临床麻醉、疼痛诊疗     

“医药分开”政策对于临床医师服务行为的影响研究简

目的：了解“医药分开”政策对临床医师服务行为的影响。方法：以北京市试行“医药分开”政策的部分医院为研究现场,随机抽取800名临床医师进行问卷调查,分析该政策对临床医师服务行为的影响。结果：临床医师对“医药分开”政策的知晓率为99.5%;92.1%的临床医师更加重视规范诊疗;85.0%的临床医师提高了服务意识,服务更周到;86.8%的临床医师更加重视患者满意度。结论：试点医院临床医师对政策的知晓和掌握情况良好。大多数临床医师优化了服务行为,并对政策的进一步完善提出有益建议,如应加强宣传,正确舆论导向;提高医疗服务收费标准;提高医务人员待遇,建立完善激励机制和考核机制;提高医师积极性等。     

武汉市高等医科院校附属医院临床医师队伍建设现状分析

通过文献研究、问卷调查和关键知情人深度访谈,分析武汉市4所高等医科院校附属医院临床医师队伍建设现状,发现临床医师队伍总体结构不尽合理;“近亲繁殖”现象较严重;“医师博士化”造成高职低就,组织中的上升空间受限;各职称临床医师的工作满意度之间差异较大等问题。提出了完善人才引进机制,有效发挥团队的作用,建立有效的人才激励机制等建议。     

利用信息化手段搭建临床医生院感上报平台

根据卫计委《医院感染监测规范》要求,医院必须长期、系统、连续地收集、分析医院感染在一定人群中的发生、分布及其影响因素,并将监测结果报送和反馈给有关部门和科室,为医院感染的预防、控制和管理提供科学依据。为了做好这…工作,医院长期依赖临床医生的手工上报获得院感疑似病历,但实际效果较差,漏报率非常高。基于这一情况,结合医院信息化系统,针对性地提出搭建“自动化临床医生院感上报平台”（上报平台）的观点,并阐述了上报平台设计和实现的基本理念,达到根本优化临床医生上报模式,极大提高临床医生上报效率和准确性的目的。     

Beware! Preimplantation genetic diagnosis may solve some old problems but it also raises new ones

Preimplantation genetic diagnosis (PIGD) goes some way to meeting the clinical, psychological and ethical problems of antenatal testing. We should guard, however, against the assumption that PIGD is the answer to all our problems. It also presents some new problems and leaves some old problems untouched. This paper will provide an overview of how PIGD meets some of the old problems but will concentrate on two new challenges for ethics (and, indeed, law). First we look at whether we should always suppose that it is wrong for a clinician to implant a genetically abnormal zygote. The second concern is particularly important in the UK. The Human Fertilisation and Embryology Act (1990) gives clinicians a statutory obligation to consider the interests of the future children they help to create using in vitro fertilisation (IVF) techniques. Does this mean that because PIGD is based on IVF techniques the balance of power for determining the best interests of the future child shifts from the mother to the clinician?     

Bioethics for clinicians: 25. Teaching bioethics in the clinical setting

BIOETHICS IS NOW TAUGHT IN EVERY CANADIAN MEDICAL SCHOOL. Canada needs a cadre of teachers who can help clinicians learn bioethics. Our purpose is to encourage clinician teachers to accept this important responsibility and to provide practical advice about teaching bioethics to clinicians as an integral part of good clinical medicine. We use 5 questions to focus the discussion: Why should I teach? What should I teach? How should I teach? How should I evaluate? How should I learn?     

Reliability and validity of clinically assessing first-ray mobility of the foot

The objective of the present study was to determine the amount of agreement among three clinicians in the clinical assessment of dorsal mobility of the foot's first ray and the agreement between their assessments and that of a mechanical device designed to quantify first-ray mobility. Sixty feet from 30 individuals evaluated clinically by three health-care professionals were classified as having a hypomobile, normal, or hypermobile first ray. The amount of first-ray dorsal mobility of each participant's foot was then measured using a device specifically constructed for that purpose. The results of this study show generally poor agreement among the three clinicians on whether a foot should be classified as having hypomobility, hypermobility, or normal mobility of the first ray. The amount of agreement with the quantitative device was poor for two of the clinicians and moderate for the third clinician.     

北京市“医药分开”背景下临床医师对患者用药意愿的影响研究

目的 探讨北京市“医药分开”改革背景下临床医师对患者用药意愿的影响.方法 以北京市试行“医药分开”的部分医院为研究现场,于2013年6月随机抽取800名临床医师进行问卷调查,分析改革后临床医师对患者用药意愿的影响.结果 被调查的临床医师中,95.9％在日常诊疗过程中遇到患者用药意愿与“医药分开”政策相悖的情况,89.3％会主动向患者宣传“医药分开”政策,86.4％认为其宣传对患者用药意愿的影响有效.结论 临床医师向患者宣传“医药分开”政策和合理用药有较高的主动性,并取得了比较明显的效果.     

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions

Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention—the starting point for delivery of “All the right care, but only the right care,” an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.     

A clinician's experiences on the Internet.

Dr. John Doyle, a Toronto anesthetist, shares some recent experiences on the Internet. He explains how he became involved and how electronic mail and computer resources help in his daily clinical practice. He also explains how he and other clinicians share opinions, expertise and advice through an Internet-based discussion group devoted to his specialty.     

The office laboratory director's guide

More than 90% of primary care physicians have access to an office laboratory. These physicians serve as the director of their laboratory services and are legally responsible for test results. This responsibility has become a greater challenge as more sophisticated laboratory testing is available for office use. Yet clinicians find few reliable sources to help them face these changes. This article is intended to serve as a guide for the clinician facing the new responsibilities as laboratory director.