硕士研究生住院医师规范化培训的实践与成效分析

目的实施硕士研究生住院医师规范化的临床培训,提高住院医师的业务素质与临床技能。力弦探讨硕士研究生住院医师临床培训的运行机制与模式,利用统计描述法对培训成效进行分析。结果2006-2008年度,203位硕士研究生住院医师的阶段培训考核合格率高于80％：品德素质、理论知识、技能操作、病历质量、临床教学与科研能力等指标均达到培训要求。结论明确硕士研究生住院医师规范化培训的目标,探讨适宜的培训运行机制与模式,对实现住院医师规范化培训有积极意义。     

上海市住院医师规范化培训十年评估

搜集了上海市住院医师规范化培训的有关文件与资料,并对该项培训的市级管理者进行了访谈,在此基础上对上海市16所二级医院与16所三级医院住院医师和管理人员进行了问卷式调查,对上海市住院医师规范化培训进行了十年评估。上海市十年间住院医师规范化培训重在规范、重在能力培训、重在实效、重在低成本高效果,取得了一定的成效。但上海市住院医师规范化培训还需进一步加强临床能力的培训和考核;进一步研究二级医院二级学科住院医师赴三级医院培训的合理性;政策仍需配套,以全力推进育人工程;并应开展对临床研究生进行临床技能规范化培训的研究。     

住院医师规范化培训教学查房的实践性探索

随着国家住院医师规范化培训的改革不断深入推进,住院医师规范化培训中的教学查房的作用变得越来越突出。笔者以住院医师规范化培训中的教学查房为基础,针对住院医师规范化培训中教学查房的现状,分析教学查房的特点,并就如何实现住院医师规范化培训临床与教学有机融合提出意见及建议,以促进教学质量和提高住院医师的临床诊疗思维能力、临床实践能力及自学能力等综合实力。     

无锡市麻醉科专业住院医师规范化培训结业临床技能考核分析

目的：分析麻醉科专业住院医师规范化培训结业临床技能考核结果,探讨麻醉科专业住院医师培训方式。方法：分析无锡市麻醉科专业住院医师结业临床技能考核结果。结果：2013~2016年临床技能考核通过率为91.45%,不同学历、不同级别医疗机构的麻醉科专业住院医师考核结果差异无统计学意义（P＞0.05）。临床技能考核成绩均比检查判读和检验报告分析高,差异有统计学意义（P＜0.05）。结论：麻醉科住院医师检查判读和检验报告分析能力不理想,综合能力待提高。     

绩效考核在住院医师规范化培训中的作用

目的：探讨绩效考核在住院医师规范化培训中的作用。方法：以我院在培住院医师规范化培训学员66人为研究对象,比较绩效考核革新前后的学员绩效收入满意度、临床理论知识和技能操作考核评分、住院病历评分等。结果：绩效考核革新后,住培学员对学员收入满意度、临床理论知识和技能操作考核评分、住院病历评分显著高于绩效考核方案革新前,差异均具有统计学意义（p＜0.05）。结论：绩效考核有助于提高住院医师规范化培训学员工作积极性,提高住院医师规范化培训的质量,具有一定的推广价值。     

建立专科医师培训基地是实施专科医师培训制度的基本保障

卫生部自1988年开始住院医师培训试点和1993年颁发并实施《临床住院医师规范化培训试行办法》以来，北京开展住院医师规范化培训已有近20年的历史。实践证明：住院医师规范化培训是青年临床医师成长的必由之路，是优秀临床医师成才不可逾越的培训阶段。本文仅针对培训基地问题，结合北京的实践与同道共同交流和探讨。     

开设住院医师培训理论课程的思考

开设住院医师培训理论课程的思考张顺平，赖豫建１９９３年２月卫生部发布《临床住院医师规范化培训试行办法》，全国临床住院医师培训工作开始转向规范化轨道。根据我校多年来住院医师培训工作实践，我们认为实现规范化需注重以下几方面工作：①组织机构要明确，管理体系...     

住院医师规范化培训中门诊教学的实践与探讨

目的探索住院医师规范化培训中门诊教学的方式方法和效果评价,提高住院医师门诊教学水平。方法探讨和比较中美住院医师规范化培训中门诊教学的差异,分析门诊教学的重要性,结合浙江省人民医院的"螺旋式"住院医师规范化门诊教学经验,展开讨论。结果浙江省人民医院的"螺旋式"住院医师规范化门诊教学能有效地促进住院医师实践能力和临床思维能力,扩大病例接触面,加强责任感和医患沟通技巧等的能力提高。结论门诊教学有助于培养住院医师综合素质,为今后独立从事临床工作打下基础。     

上海市内、外科住院医师临床专业技能培养中存在的问题及对策

作者通过对上海市二、三级医院住院医师临床专业技能（病史质量、带教质量、临床能力、综述与论文撰写能力）的考核，发现：①住院医师外科第二阶段的带教质量、总住院医师临床能力、外科手术能力和综述与论文撰写能力较弱；②二级医院住院医师的病史质量、病程录质量、门、急诊病史质量、第一阶段带教质量、病例分析能力、综述撰写能力较三级医院住院医师低。根据住院医师临床专业技能培养中存在的问题，作者分析了其原因，并提出相应对策：①保证外科住院医师有足够的手术机会；②使每位住院医师有机会进入总住院医师培养阶段；③加强培训基地建设，开展二级学科规范化培训。     

潍坊市住院医师规范化培训实施状况调查

目的建立住院医师规范化培训制度,是我国深化医药卫生体制改革和医学教育改革的重大举措,是保障和改善民生的务实之举。本研究分析潍坊市住院医师规范化培训现状,发现培训过程存在问题并提出针对性的建议。方法选取潍坊医学院附属医院、潍坊市人民医院和潍坊市中医院2016-2017级住院医师规范化培训学员作为调查对象,根据各医院规模以及在培人数,通过方便抽样的方法在每家医院分别抽取70～150位规培医师,调查住院规培学员对培训必要性的认知情况、参加住院医师规范化培训的原因和临床带教的落实情况。结果共抽取272名住院医师规范化培训学员进行调查,81.2%的学员认为有必要参加住院医师规范化培训,11.8%的学员认为住院医师规范化培训可有可无,7.0%的学员认为没有必要参加住院医师规范化培训。79.4%的学员认为住院医师规范化培训能提高临床能力,52.2%的学员是对未来出路的考虑参加住院医师规范化培训,51.5%的学员认为是目前的形势决定的,47.1%的学员认为是就业要求住培证书。不同身份的学员临床带教的落实情况比较,临床基本技能操作(χ~2=17.612,P=0.007)、专人定期督导轮转记录和小结(χ~2=16.733,P=0.010)和出科考核情况(χ~2=23.926,P=0.001),本院职工学员的落实情况优于其他身份的学员。结论住院医师规范化培训应有效把控住培质量,提高住培学员重视程度,从教与学两方面着手,一视同仁对待不同身份的住培学员。     

The effects of medical group practice and physician payment methods on costs of care

OBJECTIVE: To assess the effects of payment methods on the costs of care in medical group practices. DATA SOURCES: Eighty-six clinics providing services for a Blue Cross managed care program during 1995. The clinics were analyzed to determine the relationship between payment methods and cost of care. Cost and patient data were obtained from Blue Cross records, and medical group practice clinic data were obtained by a survey of those organizations. STUDY DESIGN: The effects of clinic and physician payment methods on per member per year (PMPY) adjusted patient costs are evaluated using a two-stage regression model. Patient costs are adjusted for differences in payment schedules; patient age, gender, and ACG; clinic organizational variables are included as explanatory variables. DATA COLLECTION: Patient cost data were extracted from Blue Cross claims files, and patient and physician data from their enrollee and provider data banks. Medical group practice data were obtained by a mailed survey with telephone follow-up. PRINCIPAL FINDINGS: Capitation payment is correlated with lower patient care costs. When combined with fee-for-service with withhold provisions, this effect is smaller indicating that these two clinic payment methods are not interchangeable. Clinics with more physician compensation based on measures of resource use or based on some share of the net revenue of the clinic have lower patient care costs than those with more compensation related to productivity or based on salary. Salary compensation is strongly associated with higher costs. The use of physician profiles and clinical guidelines is associated with lower costs, but referral management systems have no such effect. The lower cost clinics are the smaller, multispecialty clinics. CONCLUSIONS: This study indicates that payment methods at both the medical group practice and physician levels influence the cost of care. However, the methods by which that influence is manifest is not clear. Although the organizational structure of clinics and their use of managed care programs appear to play a role, this influence is less than expected.     

Family physician recognition and treatment of severe hypercholesterolemia

Family physician recognition and treatment of severe hypercholesterolemia was determined in a residency program by chart audit. Two hundred seventeen clinic patients were identified as having cholesterol levels greater than 260 mg/dL. In only 47 percent of cases was the abnormality noted in the clinic record. Sixty-nine percent of the patients received no treatment, 29 percent were treated with diet, and 7 percent with drug therapy. Family physicians were much more likely to recognize and somewhat more likely to treat hypercholesterolemia if the level was greater than 305 mg/dL and, therefore, marked as abnormal on the laboratory report. An educational program to improve physician management of hypercholesterolemia had no significant effect. Although further education using different teaching approaches may be helpful, the use of optimal rather than statistically "normal" cholesterol ranges by the laboratory may be a better way to improve physician performance.     

The Impact of Hospital Acquisition of Physician Practices on Referral Patterns

Multiple parties influence the choice of facility for hospital‐based inpatient and outpatient services. The patient is the central figure, but their choice of facility is guided by their physician and influenced by hospital characteristics. This study estimated changes in referral patterns for inpatient admissions and outpatient diagnostic imaging associated with changes in ownership of three multispecialty clinic systems headquartered in Minneapolis‐St. Paul, MN. These clinic systems were acquired by two hospital‐owned integrated delivery systems (IDSs) in 2007, increasing the probability that hospital preferences influenced physician guidance on facility choice. We used a longitudinal dataset that allowed us to predict changes in referral patterns, controlling for health plan enrollee, coverage, and clinic system characteristics. The results are an important empirical contribution to the literature examining the impact of hospital ownership on location of service. When this change in ownership forged new relationships, there was a significant reduction in the use of facilities historically selected for inpatient admissions and outpatient imaging and an increase in the use of the acquiring IDS's facilities. These changes were weaker in the IDS acquiring two clinic systems, suggesting that management of multiple acquisitions simultaneously may impact the ability of the IDS to build strong referral relationships. Copyright © 2015 John Wiley & Sons, Ltd.     

病例分型应用研究概述

目的运用病例分型理论与方法分析评价临床科室、医师医疗质量。研究内容一是构建病例分型医疗质量评价指标体系；二是制订医疗质量评价指标标准值方法；三是量化考核临床医师医疗质量。方法收集我校三所附属医院2000年1月1日至2004年12月31日所有出院病例病案首页信息进行分型处理，构建病例分型组合，制订控制标准值。对临床科室、医师医疗质量进行描述性统计分析。结果为公正、客观和全面地评价临床科室、医师医疗质量提供了可借鉴的新模式，并有利于奖金分配、评功评奖、职称晋升和人才培养等方面激励措施的完善。     

Patients derogate physicians who use a computer-assisted diagnostic aid.

OBJECTIVE: To ascertain whether a physician who uses a computer-assisted diagnostic support system (DSS) would be rated less capable than a physician who does not. METHOD: Students assumed the role of a patient with a possible ankle fracture (experiment 1) or a possible deep vein thrombosis (experiment 2). They read a scenario that described an interaction with a physician who used no DSS, one who used an unspecified DSS, or one who used a DSS developed at a prestigious medical center. Participants were then asked to rate the interaction on 5 criteria, the most important of which was the diagnostic ability of the physician. In experiment 3, 74 patients in the waiting room of a clinic were randomly assigned to the same 3 types of groups as used in experiment 1. In experiment 4, 131 3rd- and 4th-year medical students read a scenario of a physician-patient interaction and were randomly assigned to 1 of 4 groups: the physician used no DSS, heeded the recommendation of a DSS, defied a recommendation of a DSS by treating in a less aggressive manner, or defied a recommendation of a DSS by treating in a more aggressive manner . RESULTS: The participants always deemed the physician who used no decision aid to have the highest diagnostic ability. CONCLUSION: Patients may surmise that a physician who uses a DSS is not as capable as a physician who makes the diagnosis with no assistance from a DSS.     

Healthcare in the New Vietnam: comparing patients' satisfaction with outpatient care in a traditional neighborhood clinic and a new, western-style clinic in Ho Chi Minh City

As Vietnam opens its economy to privatization, its system of healthcare will face a series of crucial tests. Vietnam's system of private healthcare--once comprised only of individual physicians holding clinic hours in their homes--has come to also include larger customer-oriented clinics based on an American business model. As the two models compete in the expanding private market, it becomes increasingly important to understand patients' perceptions of the alternative models of care. This study reports on interviews with 194 patients in two different types of private-sector clinics in Vietnam: a western-style clinic and a traditional style, after-hours clinic. In bivariate and multivariate analyses, we found that patients at the western style clinic reported both higher expectations of the facility and higher satisfaction with many aspects of care than patients at the after-hours clinic. These different perceptions appear to be based on the interpersonal manner of the physician seen and the clinic's delivery methods rather than perceptions of the physician's technical skill and method of treatment. These findings were unaffected by the ethnicity of physician seen. These findings suggest that patients in Vietnam recognize and prefer more customer-oriented care and amenities, regardless of physician ethnicity and perceive no significant differences in technical skill between the private delivery models.     

A comparison of family practice clinics and free-standing emergency centers: organizational characteristics, process of care, and patient satisfaction

Because of the increasing popularity of free-standing emergency care centers as a source of primary care services, this cross-sectional study was conducted to compare four of them with two family practice centers that provided extended hours. A total of 2,339 patient encounters were examined with data obtained from both physicians and patients. The factors that were found to be a basis for discrimination between the two types of practice were the cost of care and the patient's satisfaction with convenience and personal attention from the physicians. The overall average costs were significantly higher for the free-standing centers ($45) as compared with the family practice clinics ($27). Convenience and time factors, including waiting time, time spent with the physician, time to get an appointment, clinic location, and out-of-pocket cost, all produced a higher level of satisfaction for the free-standing clinic patients. Conversely, the personal concern of the physician and the ability to see the same physician brought higher levels of satisfaction for the family practice clinic patients. The free-standing emergency center is clearly becoming a significant factor in the delivery of primary care with evidence to suggest that patients are willing to pay a premium for convenience.     

四步法在麻醉科住院医师素质培训中的应用

为提高麻醉科住院医师临床操作水平,在临床培训中采四步临床实体教学法。实践显示,四步临床实体教学法效果显著,麻醉科住院医师临床操作水平得到迅速提高,有利于为社会培养更多的优秀医学人才。     

Quality of life in Parkinson's disease: movement disorders clinic vs general medical clinic--a comparative study

OBJECTIVES: to determine the effect of attending a movement disorders (MD) clinic on quality of life (QOL) outcomes for patients with Parkinson's disease (PD). METHODS: Postal questionnaire study of forty-two patients with Parkinson's disease attending either a movement disorders clinic or more conventional general medical clinic were selected consecutively to complete the Parkinson's Disease Quality of Life Questionnaire (PDQL). All patients were diagnosed by a consultant physician with an interest in Parkinson's disease (S.B.R.) and had attended either the movement disorders clinic or the general medical clinic on at least three occasions. Questionnaires were completed independently of the examiners and returned by post. RESULTS: Mean PDQL score was 124.1 [5.16] in the movement disorders clinic and 95.9 [5.86] in the general medical clinic. Analysis of covariance revealed that those subjects attending the MD clinic reported a significantly higher QOL than those subjects in general medical care (F(1,39)= 161.98, P < 0.001). CONCLUSION: These data indicate that the quality of life of respondents attending the movement disorders clinic is significantly higher than those attending the general medical clinic.     

Retention of Physician Assistants in Rural Health Clinics

CONTEXT: Improvement of rural health care access has been a guiding principle of federal and state policy regarding physician assistants (PAs). PURPOSE: To determine the factors that influence autonomous rural PAs (who work less than 8 hours per week with their supervising physician) to remain in remote locations. METHODS: A qualitative exploratory study was undertaken in 8 rural Texas towns, including direct observation of clinics, semi-structured interviews with PAs, and focus groups with community residents. FINDINGS: The major factors contributing to retention among autonomous rural PAs include: confidence in the ability to provide adequate health care, desire for small-town life, residing in the community, and being involved with the community. Both PAs and residents thought the level of their town's health care was moderately good but could be improved. The clinic allowed easy access for primary care and minor injuries. Town residents and PAs also expressed a desire for major improvements including a pharmacy, visiting specialists, and additional medical equipment. Not all residents sought medical care at the clinic, with some electing to travel to physicians in larger towns. CONCLUSIONS: Rural community residents have more confidence in and satisfaction with PAs who have remained in a clinic for several years. In order to increase retention rates, PAs committed to autonomous, rural primary care would benefit from additional training, particularly in emergency medicine, the benefits of community involvement, and adaptation to the local culture.