全科医学 第1讲 FM概论学习课件

Introduction

toFamilyMedicine杜亚uyp@2014.2.24

《全科医学》不仅是一门课程，它是社会和医学发展密切相关的重要组成部分主要问题现状未来（20年后）还存在？经济增长GDP7.7%不可能房价人均35方，“鬼城”现象显现1人2房失业5%8%教育小班化由低到高蔓延总量控制结合调整通胀低于GDP增长，约3%维持现状养老老年化14%更趋严重至25%医疗卫生费用占GDP5%看病难看病贵过去30年和未来20年不变引入新制度化解矛盾哪些民生问题20年后还存在？TextbooksIanRMcWhinney:ATextbookofFamilyMedicineOxfordUniversityPress余海主编：全科医学导论四川科技出版社Terminology全科(家庭)医学General/FamilyMedicine全科(家庭)医疗General/FamilyPractice全科(家庭)医生FamilyPhysician/Doctor通科医生GeneralPractitionerTheOriginsofFMEnglishPartIChapter1(pp1-12)《导论》第一章第一、二节（1-5页）Background-MedicineMedicinehasbeenchangingconstantly,medicinechangesinresponsetomanyinfluences:ScientificprogressTechnicalrenovationSocialdevelopmentBackground-NewdisciplineNewdisciplinesariseinanumberofways:Fromancientcraftskills(surgery,obstetrics)Basedonnewtechnology(otolaryngology,anesthesiology)Basedonneeds(childhealth)FamilymedicinedevelopedunderallofaboveinfluencesNewdisciplinesbegininthreeways:TransformationfromanolderdisciplineDenovoFragmentationfromanlargerdisciplineFamilymedicinehasevolvedfromolderbranchofmedicine-generalpracticeBackground-ChangesinmortalityandmorbiditySuccessfulcontrolofmajorinfectiousdisease-emergenceofnewpatternsofdiseases:chronicdiseases,developmentdisorders,behavioraldisorders,accidentsanddifferentrangeofinfectiousdiseases;Thereducedmortality-increasedpopulationofelderlypeopleinsociety.

Changesinmortalityandmorbidity1900：pneumonia,tuberculosis,diarrhea1990；heartdiseases,cancer,stroke20世纪：新生儿死亡率的下降和平均期望寿命的增加Apersonafflictedwithmortalinfection-diedorrecoveredinashortperiodoftime(lifeordeath);afflictedwithchronicdisorders-toadaptchangedenvironment.Roleofpractitioners-tohelppatientstoachieveanewequilibriumwiththeirenvironmentinthefaceofchronicdiseasesordisability;Themodernmedicalprofessionhasnotexisteduntilthe19thcentury,beforethattimeinEurope:Physicians,smallandelitegroup(精英集团）oflearnedmenpracticedintownsamongtherichandinfluential.Mostwerehealers:craftsmen（匠人）(surgeon)andtradesmen(apothecaries药剂师)servedthepoorerandruralpeople.Surgeonstrainedbyapprenticeship（学徒）,apothecarieswhooriginallydispensedandsolddrugs,inresponsetoneed,graduallytookontheroleofmedicalpractitioner.TheGrowthofSpecializationTheearlycolonieswereservedbyavarietyofpractitioners,butonlyoneinninepractitionershadbeentrainedasaphysician.18thcenturyinNorthAmerica,becauseofheavydemandforhealthserviceandbreakdownofsocialbarriers,allpractitionerswerepracticingasgeneralpractitioner

InBritainby19thcenturysurgicaltrainingimproved(apprenticeship+hospitaltraining)andtheexaminationintheRoyalCollegeofSurgeons(M.R.C.S)wasrequired;1815ApothecariesAct:legalrecognitiontotherightofapothecariestogivemedicaladviceandcompulsorytoundergo5-yapprenticeshipandcoursesByaslowprocesssurgeonsandapothecariesweregraduallyintegratedwithphysicianstoformthemodernmedicalprofessionThetermgeneralpractitionerwasfirstusedintheLancertearlyinthe19thcentury.Thegeneralpractitionerbornin18th-centuryAmericaandnamedin19th-centuryBritain.TheAgeoftheGeneralPractitionerInEuropeandNorthAmericathe19thcenturywastheageofthegeneralpractitioner,mostmembersoftheprofessionweregeneralpractitioners,includingfacultiesofmedicalschools;Bytheendofthe19thcentury(1892)pediatricsbecameaseparatediscipline

Generalpractitioner-FamilydoctorTheageofgeneralpractitionerTheAgeoftheGeneralPractitionerProgressofthesciencesgaveanimpactonmedicine,butmedicaleducationwasdivorcedfromthescientificfoundationsofmedicineandinverypoorquality1889thefoundingofJohnsHopkinsthelandmarkinthedevelopmentofmedicineTheAgeoftheGeneralPractitioner1910AbrahamFlexner’sreportonmedicaleducation(“incompetentphysiciansaremanufacturedbywholesaleinthiscountry”)1910-1930FlexnerreformpavedtheageofspecializationTheAgeofSpecializationThefirsthalfof20thcentury:theemergenceofthemajorspecialtiesofmedicinewithitsdefinedtrainingprogramandqualifyingexamination.MedicaleducationemphasizedlaboratoryscienceandtechnologyPrestigeofspecialistsandvaluationoftechnicalandresearchskilloverpersonalcaremadegeneralpracticeunpopularasacareer.TheAgeofSpecializationTheAgeofSpecializationThefragmentationoftheprofessionandtheemphasisoftechnologyleadstoseriouseffect:deteriorationofthedoctor-patientrelationshipTheneglectofthecaringandpersonalaspectsofmedicinehavenegativeconsequences:increaseinmalpracticesuitsReturnofGeneralPracticeTheneedforanewkindofgeneralists,whohaveawell-differentiatedroleandadefinedsetofskills-differentfromtheoldgeneralpractitionersTheformationofcollegesandacademiesofgeneralpracticeinthe1950sand1960s.Andfamilymedicineintroducedintotheundergraduatecurriculum1972theWorldOrganizationofNationalCollegeandAcademiesofGeneralPractice/FamilyMedicine(WONCA)wasformed

GeneralPracticeorFamilyPracticeChangeofnamefromgeneralpracticetofamilypracticeorfamilymedicineandfromgeneralpractitionerstofamilyphysiciansAcademyofGeneralPracticetoAcademyofFamilyPractice;theCollegeofGeneralPractitionerstotheCollegeofFamilyPhysiciansGeneralPracticeorFamilyPracticeThereasonsforthechange-mixedGeneralpracticeassociatedwithanobsoletetypeofmedicineEmphasisdifferentconceptoffamilypracticefromgeneralpracticeTonameanewbodyofknowledgeonwhichtheclinicaldisciplineisbasedTrainingrequirementTheChangingRoleoftheHospitalSince1960s,threelevelsofhealthcarePrimarylevel:generalpractitionerprovidecontinuingpersonalandcomprehensivecareSecondarylevel:specialistsprovideserviceforspecialfieldsTertiarylevel:highlyspecializedservicesRoleofFamilyDoctorFamilydoctorbecomeakeyfigureintheorganizationofhealthcareIntegrationofservicebecomeessentialtoconserveresourcesandeliminatewaste(familydoctor-”Gatekeeper”).Horizontalintegration-workingasteammemberswithotherhealthprofessionalsVerticalintegration-collaborationbetweenthethreelevelsofcareNewDevelopmentintheBehavioralScienceRecentdevelopmentinbehavioralandsocialsciencesareimportanttomedicineasawholeparticularlytofamilym