The Role, Principles and Competencies of Family Medicine 家庭医学的作用、原则和能力

1. The Role, Principles and Competencies of Family Medicine 家庭医学的作用、原则和能力 Chris Jenkins, MD克里斯.金肯医学博士 March 2010 2010年3月

2. Goals of Talk演讲的目的 • Why is general practice an important specialty in a medical system为什么全科医学是医疗体系里的一个重要专科 • Discuss why post graduate GP training is important 讨论为何毕业后的全科培训很重要 • What are the benefits to the community and individual patients 对社区和病人个体有什么益处 • What do GPs do全科医生做什么

3. A Little US Medical History一点美国的医学史 • Prior to 1969 a GP 早在1969年，全科医生： • finished medical school从医学院毕业 • finished a one year rotating internship完成一年的实习医生轮转 • Began practicing开始行医 • Up to early 1900’s most American doctors were GPs 在19世纪初之前大多数美国医生是全科医生 • Up to the 1930’s 80% were GPs and only 20% specialists 到19世纪30年代，医生中80%是全科医生，20%是专科医生

4. A Little US Medical History一点美国的医学史 • 1940’s: an explosion of medical knowledge and an increase in specialization 19世纪40年代：医学知识爆炸，专业化程度提高 • Medical students wanted security: know all about one area of medicine 医学生想要安全感：掌握某个医学领域的全部知识 • There was an increase of specialty residencies and certification boards 专科医师培训项目和资格认证委员会增多 • Board certification was not seen as necessary for general practice 专科资格认证并非全科医疗所必需的

5. Effect of World War II二战的影响 • World War II made the situation for GPs worse二战让全科医生的境遇变差 • Government deferments for medical students going into residencies. There was no residency for GP 政府让医学生延迟进入住院医生培训。当时没有全科住院医生培训。 • Medical school graduates rushed into specialty residencies 医学院毕业生匆匆进入专科住院医生培训。 • After WWII: government paid for medical school and residency training but there were still no GP residency programs 二战以后：政府给医学院和住院医生培训付费，但是仍然没有全科住院医生培训项目。

6. Hard Times for GPs全科医生的困难时期 • 1940 to 1952 specialty residencies grew from 5,200 to 22,000. 1940到1952年，专科住院医生培训项目从5200增加到22000 • Health care was becoming unavailable to many 许多人无法得到卫生保健服务。 • specialists stayed in cities near hospitals专科医生住在医院附近城市 • GPs became fewer in number全科医生数目越来越少

7. Hard Times for GPs全科医生的困难时期 • General practice was getting left behind全科医疗被忽视 • Began to fight back开始反击 • Established the American Academy of General Practice in 1947 1947年建立美国全科医学学会 • Grew quickly快速发展 • High standards高水准 • CME requirement 150 hours every three years (first group to do this)要求每三年完成150小时的继续医学教育（最先开始这样做的人群） • Still had no board certification仍然没有资格认证

8. GPs Struggle to Succeed全科医生奋斗成功 • In mid 1940’s AAGP requested specialty training 19世纪40年代中期，美国全科医学学会要求专科培训 • Better training in diagnosing and treating disease 得到更好的诊断和治疗方面的训练 • Greater awareness of conditions requiring referral or special tests or treatment 更清楚地知道哪些情况下需要转诊或特殊检查及治疗 • Approached major medical schools进入重点医学院 • “Good idea but do it somewhere else”“很好的想法，但到别的地方进行” • All through 1950’s and most of the 1960’s continued to work for improvement 整个19世纪50年代和19世纪60年代的多数时间持续不断地取得工作进步

9. American Medical System Suffered from Over Specialization美国医疗体系曾遭遇过度专业化 • US medical system in the 1960’s19世纪60年代的美国医疗体系 • Increasingly specialized 越来越专业化 • Medical costs rising 医疗花费上升 • Patient care suffering 病人保健遭受到： • No one managing the overall care of the patient 没有人管理病人的总体保健 • No one coordinating care among specialists 没有人综合协调专科医生的治疗 No one focused on preventive care没有人关注预防保健 • No one who could treat most or all of common diseases 没有人能够治疗大部分或是所有的常见病 • Patients had to see many specialists to get routine physical exams 病人不得不去看许多的专科医生以做常规体格检查 • Central Asia worse: 10-12 doctors needed to do preschool physical 中亚情况更糟：做入学前体检需要看10到12个医生 • Increasing number of medical mistakes and missed diagnosis 误诊和漏诊数目增加

10. Medical Community Finally Recognized the Need for Well Trained Generalists医学界终于意识到对受过良好训练全科医生的需求 • The Folsom Report Folsom报告 • The Mills Commission Mills委托代理 • The Willard Committee Willard委员会

11. Acceptance at Last终于接受 • Medical schools now began GP residencies 医学院校现在开始全科住院医生培训 • February 8, 1969 the first residencies started: “specialty in breadth” 1969年2月8日第一个住院医生培训项目开始： “范围宽的专业” • 1970 the ABFP (American Board of Family Practice) offered its first board exam 1970年美国家庭医学认证机构进行了第一次资格认证考试 • 1971 the name changed from GP to FP to signify the change in training 1971年由GP更名为FP以象征在培训方面的变化 • Rapid growth快速发展 • 1970 250 residencies with 3,820 residents 1970年250个住院医师培训项目，包括3,820名住院医生 • 2007 463 residencies with 9,330 residents 2007年有463个住院医师培训项目，包括9,330名住院医生 • Membership in the AAFP: 96,614 (includes residents, etcetera) AAFP的会员数目： 96,614 （包括住院医生，等等）

12. The Importance of Post Graduate Training毕业后培训的重要性 • Medical school alone is not enough仅医学院是不够的 • Medical information is increasing rapidly医学信息飞速增加 • GPs need to know how to diagnose and treat common diseases, not just book knowledge 全科医生需要知道如何诊断和治疗常见病，不仅是知道书本的知识 • Residency provides住院医生培训提供： • Development of diagnostic and procedural skills 诊断和操作能力的发展 • Awareness of developments in other specialties 了解其它专业的发展 • Knowledge of how to use the entire medical system to benefit their patients知道如何使用整个医疗体系以使病人受益 • Understanding of whole person care: bio-psycho-social-spiritual model of health理解全人的照顾：健康的生物-心理-社会-精神模式

13. Primary Care Improves Community Health初级保健使社区健康得到改进 • Better health outcomes健康结局更好 • Increased use of disease-focused preventive care (e.g., blood pressure screening, mammograms, pap smears, etc)疾病为中心的预防保健增多（如血压筛查，乳腺X片，宫颈防癌普查等） • Fewer patients admitted for preventable complications of chronic disease 更少的病人因可预防的慢性病并发症而收入院 • Lower all cause mortality全因死亡率降低 • Fewer consultations with specialists专家会诊减少 • Less use of emergency services 减少使用急救服务

14. Improved Community Health with Primary Care初级保健使社区保健得到改进 • Less re-hospitalization减少再入院 • Better detection of adverse effects of interventions 更好地发现干预措施的不良反应 • Better understanding of psychological aspects of a patient’s problem更好地理解病人问题的心理方面 • Protection against overtreatment避免过度治疗 • More efficient use of resources资源更有效地利用 • Better compliance and lower hospitalization rate 依从性更高，入院率更低 • Other benefits as well还有其它益处 • All well documented 都被很好地记录

15. General Practice has a Unique and Important Role in Health Systems全科医学在健康系统中有独一无二的重要作用 • Advocate for patients in medical system 在医疗体系中支持病人 • Management of patient care病人保健的管理 • Preventive health care and patient education 预防性的健康照顾和病人教育 • Provision of comprehensive health care in a single location在一个处所提供综合性的健康照顾 • Care of entire families over time整个家庭的长期照顾 • Not limited to gender, age, organ system 不局限性别、年龄、器官系统

16. General Practice has a Unique and Important Role in Health Systems全科医学在保健体系中有独一无二的重要作用 • Benefits to communities and individuals 对社区和个人的益处 • Doctor knows patient well医生非常了解病人 • Patients trust their doctor病人信任医生 • Increased patient satisfaction病人满意度提高 • Greater ease of access to medical care医疗照顾更有可及性 • Lower cost更低的费用 • Fewer medical mistakes更少的医疗错误 • Emphasis on prevention强调预防 • Satisfying professional careers for GP doctors 全科医生对职业感到满意

17. What is Family Medicine? It Depends on Who You Ask!家庭医学是什么？不同的国家有不同的回答！ • British英国 • Swedish瑞典 • Australian澳大利亚 • Hong Kong香港 • Canada加拿大 • America美国

18. Family Medicine in China中国的家庭医学 • New in modern China是当代中国的新生物 • Developing – final model not yet decided 发展中－最终模式尚未确定 • Principles of FM has similarities with some aspects of traditional Chinese medicine 家庭医学的原则与传统中医的某些方面有相似之处 • Care for the whole family照顾整个家庭 • Young and old 年轻者和年长者 • Male and female 男性和女性 • All organ systems所有的器官系统 • Listen to patients 倾听患者 • Take time with the patients花时间与病人在一起

19. Family Medicine in China中国的家庭医学 • Major medical centers recognize need for the specialty 大型医学中心认识到对全科的需要 • Major medical centers waiting for Beijing to decide what model and what training program 大型医学中心在等待北京决定用何种模式及何种培训项目

20. What is Family Medicine in the USA?美国的家庭医学是什么？ • Medical specialty医 学 专 业 • Recognized as specialty in the US since 1969自 从 1969 年 起 在 美 国 被 认 定 为 一 种 医 学 专 业 • Over 80,000 family physicians in the US在 美 国 有 超过80,000 多名 全 科 医 生

21. What is Family Medicine in the USA?美国的家庭医学是什么？ • Over 460 training programs(residencies) with over 9,000 residents 超过460 个 住院医师培训项目 , 超过9,000名住 院 医 生 • Can treat 85-90% of medical problems 能 够 治 疗 85-90%的医学问题

22. What is Family Practice in the United States?在 美 国 家 庭 医 学 是 什 么 样 的? • 12% of all US doctors are family practice doctors 12% 的 美 国 医 生 是 家 庭 医 生 • But 25% of all office visits in the US are to family doctors! 但 是 美 国 25% 的 就 诊 都 是 看 全 科 医 生 ！

23. Where Do We Work?我们在哪里工作？ • Clinic 门诊 • Hospital 医院 • Emergency Department 急诊室 • Nursing Homes 养老院 • Other 其他

24. Philosophical Focus of Family Medicine家庭医学的理念 • Continuity of care 照顾的持续性 • Management of care 健康照顾管理 • Treating patient in context of family 在家庭背景下治疗病人 • Preventive care 预防保健 • Team approach 团队探讨 • EBM 循证医学

25. Continuity of Care照顾的持续性 • Seeing patients over an extended period of time 长时间内照顾病人 • Developing the doctor-patient relationship 发展医患关系 • Familiarity with patient health status 熟悉病患的健康状态 • Developing trust 发展信任关系

26. Management of Care保健管理 • Evaluation of the Patient 病人病情的评估 • Diagnostic tests 诊断检查 • Involvement of specialists 专科医生参与 • Treatment plans 诊疗计划

27. Patient Care in the Context of the Family以家庭为背景的病人保健 • Home environment 家庭环境 • Family dynamics 家庭动力学 • Family health beliefs and practices 家庭的健康理念和实践 • Social, work, and religious settings 社会环境，工作环境和宗教环境

28. Preventive Medicine预防医学 • Patient education 病人教育 • Lifestyle modification 生活方式的调整 • Age and gender specific disease screening 根据年龄和性别而特异的疾病筛查 • Medical intervention 医疗干预

29. Team Approach to Health Care健康照顾的团队合作 • Involvement of other health care providers • 其它医疗保健工作者的参与 • Medical and surgical specialists • 内外科专家 • Behavioral medicine • 行为医学 • Physical, occupational, home therapists • 物理治疗 ， 职业理疗师 ， 家庭治疗师 • Dietitians • 营养学家

30. Evidence Based Medicine循证医学 • Knowing the questions to ask 知道要问的问题 • Identifying the best evidence to answer the questions 找出回答问题的最好依据 • Assessing the evidence for validity and usefulness 评估证据的有效性和有用性 • Applying the results to clinical/hospital practice 将结论应用于门诊或住院医疗 • Evaluating the results 评估结果

31. General Practice Competencies全科医学的能力 • There is a wide range of possible skills for GPs 全科医生可掌握的临床技巧很广泛 • Different countries choose different skills to meet their own needs 不同的国家根据本国的需要选择不同的临床技巧 • The basic role of GP remains the same in each country全科医生的基本任务在每个国家仍然是一致的 • This next section will show you some of the skills we train GPs to do in the USA 下一部分将向您介绍美国全科医生被训练的部分技能

32. Whom and what do we treat?我们给谁治疗，治疗什么？All ages and Both sexes所有的年龄和性别

33. Obstetrics产科学(Will go into more detail on each area later if desired如果愿意我们将在后面详细介绍每一方面的内容)

34. Pediatrics...儿科学

35. Internal Medicine内科学 But All Other Specialties as Well及所有其他专业

36. Diagnostic Modalities and Laboratory Evaluations诊断模式和实验室结果评估

37. Procedures: Injections, Dermatological procedures, and Fine needle aspirations操作：注射，皮肤病方面的操作，和细针抽吸

38. Colposcopy, Exercise stress testing, Flexible sigmoidoscopy,and many more!阴道镜检查，运动负荷实验，纤维乙状结肠镜检查，还有更多！

39. Not only Treatment of Disease but also Prevention不但治疗疾病而且预防疾病 • Cancer screening 癌症筛查 • Vaccinations 预防接种 • Lifestyle modification 生活方式的改变

40. Cooperation with other specialists - health care professionals与其他专科医生合作

41. Rural or Urban:农村或城市Do FP belong only in rural areas?家庭医生只属于农村地区吗？ • Needed in Rural areas: villages, towns, small cities在村、镇、小城市等农村地区需要： • Not enough specialists to supply all small towns 没有足够的专家可以为所有小镇提供医疗服务 • Not enough demand to support all the other specialties 没有那样多的对所有专科的医疗需求 • FP/GP needs to be well trained to handle many complex problems and procedures家庭/全科医生需要得到很好的培训以应付很多复杂的问题和操作 • Needed in Urban/city areas在城市也需要 • Specialization is one of the reasons FM is needed 需要家庭医生的一个理由是专科化 • Management of care is even more critica l更为关键的是健康照顾管理 • Cost control费用控制

42. GP is New in Many Countries全科医学在许多国家是新生事物 • New Specialty新的专科 • Challenge of deciding what it will be like 决定全科医学的模式是一个挑战 • Integrating GP with existing medical system 将全科医学和现有的医疗系统一体化 • Gaining acceptance with doctors and patients 得到医生和患者的接受 • Becoming an attractive specialty to medical students 成为对医学生有吸引力的专业

43. The Need for a Good Model一个好的全科医学模式的需求 • Meets patients primary health care needs 满足病人初级卫生保健的需要 • Professionally satisfying 职业的满意度 • High quality training 高质量的培训 • Respect of Colleagues 同行的尊敬 • Trust of Patients 病人的信任 • Financially rewarding 薪酬上的回报

44. Major Lessons – Appropriate Model重要的教训–合适的模式 • model must be appropriate to the region模式必须和地区相适应 • Transplanting models without modification doesn’t work well 不做调整而直接移植模式不能有效运行 • One Specialty, Many models一个专业，很多模式 • American Model • 美国模式 • British Model • 英国模式 • Knowledge base and technology/procedures appropriate to the specialty and the region 知识基础、技术和操作要适合专业和地区

45. Consequences of an Inadequate Model不适当模式的结果 • No interest on the part of medical students医学生没有兴趣 • Inadequate training for the job assignment对于分配的工作没有得到充分的培训 • Feeling unprepared in those who do FP work那些要做全科医疗工作的人感觉没有准备好 • Lack of respect from colleagues缺乏同事的尊重 • Lack of trust from patients缺乏病人的信任 • Low salary低薪酬 • High drop out rate高的放弃率

46. Who is a FP/GP?谁是家庭医生/全科医生？ • Surgical personality!外科特性！ • Internist personality!内科特性！ • Family medicine personality!全科特性！

47. Knowledge Base – Important to Emphasize知识基础-重中之重 • Are three years of training enough?三年的培训足够吗？ • Know what is needed to be known!知道所需要知道的知识 • 25-30% of knowledge cove 85-90% of the diseases “Rapidly progressing glomerulonephritis” not high on the priority list 25-30%知识覆盖85-90%的疾病。 急进性肾小球肾炎不是最优先需要学习的 • 7/1,000,000 发病率 1/142,857 = 1/lifetime of FP…Maybe! 一个全科医生可能在一生中就看一个这样的病例 • Debate over adding a 4th year 是否需要增加第四年的培训仍有争议

48. Knowledge Base知识基础 • FP’s know 20-30% of each of the other specialties knowledge:全科医生应该知道每一个专科知识的20-30% • Specialists see FP from their perspective 专科医生从他们的角度看待全科医生 • FP’s know less than the specialist in his area 在专科领域全科医生的知识不如专科医生 • FP’s know more than the specialist in other areas 在其他的领域全科医生的知识多于专科医生

49. 100 90 80 70 60 50 40 30 20 10 0 Internist 内科 Pediatrics 儿科 Ob-Gyn 妇产科 Surgery 外科 Depth vs. Breadth of Knowledge Base知识基础的深度与广度对比

50. 100 90 80 70 FP全科 60 Internist内科 50 Peds儿科 40 Ob-gyn妇产科. 30 Surgery外科 20 10 0 Total Knowledge Content总知识含量