就医行为选择与分级诊疗体系：一个经济学理论框架

通过研究轻症患者和重症患者就医行为选择和分级诊疗体系之间的理论机制,发现异质性病患在自由就诊选择模式下,轻症病诊疗服务市场和重症病诊疗服务市场存在结构性需求不平衡,具体包括:在重症病医疗服务市场上,轻症病患者会挤占重症病患者的医疗资源;在分级诊疗模式下,轻症病医疗服务市场和重症病医疗服务市场都达到了均衡,不存在轻症病患者挤占重症病患者医疗资源的情况;在分级诊疗服务体系下,最优的分级医疗机构空间布局是一个综合性专业位于市中心,而基础性诊疗机构位于社区中心。建议加强基层诊疗机构服务质量;明确各级医院诊疗服务功能定位;简化医疗转诊程序,提升转诊效率。     

A theoretical framework for human and veterinary medical ethics education

In their practice, physicians and veterinarians need to resort to an array of ethical competences. As a teaching topic, however, there is no accepted gold standard for human medical ethics, and veterinary medical ethics is not yet well established. This paper provides a reflection on the underlying aims of human and veterinary medical ethics education. Drawing from published literature on ethics education in the health professions a theoretical framework common to the teaching of human and veterinary medical ethics is proposed, based on three concepts: professional rules, moral virtues and ethical skills. The rules approach relies on the transmission of professional and social values by means of regulatory documents and depends intimately on the knowledge that students have of those documents. The virtues approach involves the inculcation of moral values and virtues that will stimulate students to develop desirable behaviours. The main focus of this approach to ethics is to develop students’ attitudinal competences. Finally, the skills approach is focused on equipping the students with the necessary moral reasoning abilities to recognise and respect the plurality of ethical views that make part of contemporary society. This framework can inform future curriculum development in human and veterinary medical ethics as well as in other health care professions.     

Telemedicine and doctor-patient communication: a theoretical framework for evaluation

The literature on doctor-patient communication demonstrates that patient, provider and contextual characteristics influence behaviour within medical encounters, which in turn is an important determinant of health outcomes. This paper introduces a conceptual model which posits that telemedicine affects health outcomes through changes in the way doctors and patients communicate with one another. It also proposes that this process depends on the medium through which the consultation takes place, whether in person, over the telephone, via fax or email, or through two-way interactive video. Since participants in two-way interactive video-consultations rarely meet in person, it is particularly important that the effect of substituting video for face-to-face consultations be delineated.     

Contribution of medical students to admission interviews

Objective  Medical students were included in 3-person interview panels selecting applicants for a 4-year medical programme for graduates and health professionals. We analysed student contributions to the interview panels.
Methods  A total of 188 semi-structured interviews were carried out over 2 years. The scores of 17 student interviewers were compared with those of the other 2 members of the panels.
Results  Students were positive about the interview process and their involvement. Overall interview scores did not differ between students and other interviewers. However, students gave lower scores overall and in a number of individual areas to those who had the highest consensus scores and were offered places on the programme. Students were more likely than other interviewers to be indecisive between 2 scores (25.2% versus 17.5%; P  <   0.01).
Conclusions  Students can be integrated effectively into the interview process. However, they tend to be more reluctant to give high scores and less decisive about committing to a single score than more experienced interviewers. Students value the experience of participating in the selection process, especially when combined with an exploration of the literature related to selection procedures.     

Setting performance standards for medical practice: a theoretical framework

BACKGROUND: The assessment of performance in the real world of medical practice is now widely accepted as the goal of assessment at the postgraduate level. This is largely a validity issue, as it is recognised that tests of knowledge and in clinical simulations cannot on their own really measure how medical practitioners function in the broader health care system. However, the development of standards for performance-based assessment is not as well understood as in competency assessment, where simulations can more readily reflect narrower issues of knowledge and skills. This paper proposes a theoretical framework for the development of standards that reflect the more complex world in which experienced medical practitioners work. METHODS: The paper reflects the combined experiences of a group of education researchers and the results of literature searches that included identifying current health system data sources that might contribute information to the measurement of standards. CONCLUSION: Standards that reflect the complexity of medical practice may best be developed through an "expert systems" analysis of clinical conditions for which desired health care outcomes reflect the contribution of several health professionals within a complex, three-dimensional, contextual model. Examples of the model are provided, but further work is needed to test validity and measurability.     

供给侧视角下的过度医疗与分级诊疗的理论机制研究

目的:探讨我国医疗市场供给侧行为主体的行为决策理论机制以及分级诊疗制度抑制过度医疗行为的机制。方法:建立供给侧视角下的医生医疗行为选择模型和分级诊疗制度下的医生医疗行为选择模型。结果与结论:在不完全信息和医疗需求刚性患者假设的供给侧视角医生医疗行为选择模型下,患者接受医生全部的医疗供给,一般医疗市场和高级医疗市场存在结构不平衡,一般医疗市场的需求为零而高级医疗市场需求过剩,存在过度医疗;在分级诊疗制度下医生医疗行为选择模型中,通过政策引导进行基层首诊,一般医疗市场和高级医疗市场都达到均衡,提高社会资源配置的效率,改善患者的福利状况。     

A theoretical framework for environmental noise annoyance

Noise annoyance is a phenomenon of 'mind and mood'. It is only partly determined by acoustic factors: typical noise metrics (LAeq and the like) allow only the prediction of aggregated annoyance scores (community levels) with moderate degree of precision. Many non-acoustic factors have been identified with varying degrees of association with annoyance. However, the proper identification and understanding of the role of non-acoustical factors can only be achieved on the basis of sound theories about rise and reduction of noise annoyance. This article discusses first the few systematic theories to understand the relative role of acoustic and non-acoustic factors. Then, it presents a theoretical perspective that places a major non-acoustic factor in the center: perceived control. It views noise annoyance as a form of psychological stress: disturbances may tax persons resources, and different people may use different ways of coping to deal with annoyance. The focus on perceived control also highlights that for residents exposed to environmental noise 'noise management at the source' often will be an equally important external stimulus to respond to as 'noise at the source'.     

Physicians' use of medical knowledge resources: preliminary theoretical framework and findings

The recurring decision of selecting among potential knowledge resources was modeled as a cost-benefit tradeoff, with associated observable features. Internal medicine and community family practice physicians (n = 228) completed a self-administered questionnaire designed to elicit reported use and cost-benefit features of nine knowledge resources. The subjects reported most frequent use of clinical colleagues, intermediate use of textbooks and journals, and least use of indexing systems. Resources' benefit-related qualities (extensiveness and credibility) were not related to reported use. In contrast, the model's access cost variables (availability, searchability, understandability, and clinical applicability) were significantly related to use. Results were generally favorable to the model's framework of knowledge resource selection. Multiple linear regression analysis suggested that physicians' use of clinical knowledge resources could be described by the physician's level of training, availability, applicability, and the resource medium (colleague, index, or text/journal).     

A theoretical framework for TTO valuations of health

This paper proposes a theoretical framework, drawing on Hicks utility theory, for the Time Trade-off (TTO) method conventionally used to value health states. We briefly describe that theory and posit four distinctive TTO valuation approaches suggested by it: each of compensating variation and equivalent variation for both gains and losses in health, with valuation of health states in each case derived from trade-offs between health and length of life. Recent developments and research on TTO valuation are placed in the context of this framework.     

Introducing medical students to family therapy using simulated family interviews

Small groups of medical students are introduced to the subject of family therapy using a technique involving the simulation of family interviews. The students are called upon to enact a situation in which family members visit their general practitioner with a problem relating to one of the children, and the diffusion of this problem within the family is traced during the course of the simulation. Discussion is focused on the feelings evoked by the simulation, the psychodynamics of the simulated family and the quality of the relationship between the general practitioner and the family as it arises out of the interview. An effort is made to help the students to get in touch with some of their feelings towards disturbed families and to mobilize these feelings towards the effective management of the family's problems.
By role playing the general practitioner, students can prepare themselves for their future professional roles in a situation which allows for feedback from colleagues and experimentation. At the same time, when family members are role-played, the process of identification and empathy with patients is enhanced.
The technique is potentially stressful because of the unusual demands that it makes upon the students in terms of personal involvement, but the experience derived from successive groups of students over a 2 year period has been consistently rewarding, and most students have expressed an enthusiastic interest in the exercise.     

Teaching disability and rehabilitation to medical students

Summary. A survey of UK medical schools was undertaken to determine the teaching that was being offered on disability and rehabilitation. In general, teaching on this topic appeared fragmented and inadequate but a number of interesting innovations were identified. These included: a drama workshop run by a group whose members mainly have learning disabilities at St George's Medical School, student-directed learning at the University of Dundee and structured teaching programmes at the Universities of Leeds and Edinburgh. The General Medical Council Education Committee's 1991 discussion document on the undergraduate curriculum specifically mentions disability as an important topic. A number of schools mentioned that they were in the process of revising their curriculum as a consequence. Recommendations arising from the findings of the survey include integration of disability and rehabilitation into clinical teaching, focus of teaching on those types of disability which are common in the community, greater emphasis on functional assessment in teaching the physical examination, and the wider use of standard assessment instruments, for example for activities of daily living, cognitive impairment and locomotor disability. There is a need for improved communication between medical schools to facilitate the spread of educational activities on this topic.     

Attention to gender in communication skills assessment instruments in medical education: a review

Medical Education 2011: 45 : 239–248 Context Gender is increasingly regarded as an important factor in doctor–patient communication education. This review aims to assess if and how gender is addressed by current assessment instruments for communication skills in medical education. Methods In 2009 at Radboud University Nijmegen Medical Centre, an online search was conducted in the bibliographic databases PubMed, PsycINFO and ERIC for references about communication skills assessment instruments designed to be completed by trained faculty staff and used in medical education. The search strategy used the following search terms: ‘consultation skills’; ‘doctor–patient communication’; ‘physician–patient relations’; ‘medical education’; ‘instruments’; ‘measurement’, and ‘assessment’. Papers published between January 1999 and June 2009 were included. The assessment instruments identified were analysed for gender‐specific content. Results The search yielded 21 communication skills assessment instruments. Only two of the 17 checklists obtained explicitly considered gender as a communication‐related issue. Only six of 21 manuals considered gender in any way and none gave specific details to explain which aspects of communication behaviour should be assessed with regard to gender. Conclusions Very few communication assessment instruments in medical education focus on gender. Nevertheless, interest exists in using gender in communication skills assessment. The criteria for and purpose of assessing gender in communication skills in medical education are yet to be clarified.     

居民失能相关健康状态评价

目的：研究如何采用家庭健康访谈数据获取居民的失能信息，以进行不同人群非死亡性健康状况的综合对比和社会学影响因素分析。方法：根据WHO对失能的定义，根据经济发展水平和地理区域分布的不同，采用分层抽样的方法。结果：由于失能状况的存在，人群的平均期望寿命降低了5．101岁，出生时的期望寿命(72．900岁)由于失能的存在而仅相当于在完全健康状态下度过了67．800年。老年人群、女性人群、贫困地区人群的失能率分别高于年轻人群、男性人群和富裕地区人群的失能率。结论：本研究利用家庭健康访谈数据，简单可行地计算了DALE(健康期望寿命)值，对不同人群的非死亡性健康状况进行综合对比，为卫生部门的工作重点和资源配置提供政策性支持。     

Verbal communication skills and patient satisfaction. A study of doctor-patient interviews

This research attempted to quantify specific behaviors in the physician's initial interviewing style and relate them to patients' perception of satisfaction. Five physicians were tape recorded during their initial interviews with 52 adult patients. The patients were asked to complete the Medical Interview Satisfaction Scale, a 29-item instrument with a 7-point response scale. These interviews were transcribed, timed, coded, and analyzed with the use of the Computerized Language Analysis System. Selected variables of the language dimensions were entered as the predictor variables in a multiple regression, along with satisfaction scores as the dependent variables. Twenty-seven percent of the variance (p less than .01) in the satisfaction scores of initial interviews were explained by three aspects of a physician's language style: (a) use of silence or reaction time latency between speakers in an interview, (b) whether there was language reciprocity as determined through the reciprocal use of word-lists, and (c) the reflective use of interruptions within an interview. Considering the complexity of human communication, the fact that three variables were identified, which accounted for 27% of the variance in patients' satisfaction, is considered a substantial finding.     

A framework to support practice teachers in the assessment process

This paper describes a local initiative that aimed to resolve difficulties experienced by practice teachers in assessing the practice of students undertaking a BSc graduate diploma in community nursing. Practice teachers initially raised a concern that they were unable to make a holistic assessment of a student, as they had no criteria that enabled them to address issues relating to values, attitude and behaviour. Practice teachers and academic staff worked together over a period of time to update assessment practices, developing a Practice Assessment Grid (PAG). The PAG identifies a common language with which practice teachers can benchmark their own values, enabling them to justify their decisions. Evaluation to date indicates that the PAG enables practice teachers to break down the intuitive aspect of the assessment process relating to behaviour, so that they can objectively identify component attributes that are essential to becoming a professional and complete a holistic assessment of the student. As such, this grid has improved confidence in the process of assessing practice by addressing a potentially subjective aspect of assessment.     

The development and partial assessment of the medical communication competence scale

The purpose of this research was to develop and partially assess a self-report scale for measuring doctors' and patients' perceptions of self-communication and other communication competence during a medical interview. Previous research into the components of communication competence and medical discourse were used to develop the Medical Communication Competence Scale (MCCS). It was hypothesized that the items of the MCCS would form four clusters: information giving, information seeking, information verifying, and socioemotional communication. The cluster analysis results provided support for the hypothesis. Results of several other analyses provided additional support for the validity of the MCCS.