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杜绝过度医疗之路难于上青天?

2017-06-02 石 岩 环球医学

医事服务中,常常发生患者“被检查”、“被治疗”、“被手术”的情况。这些患者经过积极处理以后,却没有获得理想的效果,与非积极的姑息或自然疗法的效果一样,甚至还有患者在积极处理后反而出现了许多并发症。小病大治、大病豪治、无病滥检的“过度医疗”不仅会造成严重的医疗资源浪费,而且对患者的病情也起不到积极的作用,甚至适得其反、产生危害。

医事服务中,常常发生患者“被检查”、“被治疗”、“被手术”的情况。这些患者经过积极处理以后,却没有获得理想的效果,与非积极的姑息或自然疗法的效果一样,甚至还有患者在积极处理后反而出现了许多并发症。小病大治、大病豪治、无病滥检的“过度医疗”不仅会造成严重的医疗资源浪费,而且对患者的病情也起不到积极的作用,甚至适得其反、产生危害。

怎样判定过度医疗?

过度医疗是由于多种原因引起的超过疾病实际需要的诊断和治疗的医疗行为或医疗过程。过度医疗包括两层含义:一是这种诊断和治疗对于该疾病是多余的、不必要的,甚至是有害的;二是过度医疗是一种行为或过程,不是指还未成为实践的诊疗计划或设想。在实践中,过度医疗是指医疗机构或医务人员违背临床医学规范和伦理准则,在治疗过程中,不恰当、不规范甚至不道德,脱离病人病情实际而进行的检查、治疗等医疗行为,起码不是诊治病情完全所需的行为。

属于过度医疗的行为:
1、诊断手段超过了诊断该疾病的实际需要,即可以用简便的、一次性能够得到的诊断,却用了复杂昂贵和多次重复的诊断,亦即超越了学术界公认的、可行的、适宜的诊断方法和手段;2、采用了多余的、无效的,甚至有害的治疗方法和手段;3、对疾病诊断和治疗的费用超过了一般标准;4、对病人的诊断和治疗超越了该病人体力和财力的可支持度,虽然这种诊断和治疗符合学术界的公认要求,也应视为过度医疗;5、对通过自身调节能很快得以恢复的、正常生理范围内出现的异常现象,如进行医疗干预,也应视为过度医疗;6、对某些死亡征兆已经很明显或死亡不可逆转的病人仍进行挽救生命的无效治疗。

不应视为过度医疗的行为:
1、对某些复杂和难以诊治的疾病必须重复检查才能确诊的医疗行为;2、为抢救危重病人的生命而采取的某些可能不一定收到实效的治疗;3、在别无选择的情况下,为了探索其他有效的治疗方法而选用的某些实验性治疗;4、为了防范某些疾病传播或病情的扩大,避免更大的风险,对病人采取的某些适度的过度诊断或治疗,但这种举措不能无限扩大,否则也应视为过度医疗;5、眼前虽没有疾病征兆,但为预防病症发生而采取的某些治疗;6、疾病已治愈,但为了防止复发或预防某些并发症的产生而给予的治疗。

虽然过度医疗的定义很明确,但在现实中却又难以界定。因为临床医学非常复杂,每个患者的情况都不一样,即使是同一种病也有不同的表现,同一种病不同时期的治疗方法也不同。因此对过度医疗的判断也就没有一个具体的量化指标。目前,对过度医疗判定的基本准则是:对病人的诊疗总体上是趋好还是伤害。在治疗中,要看医师的目的何在,治疗是否产生预防作用,是否减轻了病人的痛苦,是否能延长病人的寿命。另外要考虑病人的经济能力和心理状况是否能承受,治疗中是否能体现病人的权利。

必须要说的是在不同经济文化背景下,人们对过度医疗的认识也不同。《医学与文化:美国、英国、联邦德国和法国的不同医疗方法》中,比较了四个国家常见的医学诊断,发现差异极大。在这四个国家中,医生开处方的药量会有10~20倍的差别;美国的人均外科手术率是英国的2倍,乳房切除术的比例是英国的3倍,冠状动脉手术是英国的6倍;欧洲使用的抗生素量远远小于美国。医疗中的这种巨大差异是由于文化的差异造成的,这种差异不能视为某个国家就存在普遍的过度医疗。

哪些是过度医疗的表现和特点?

当前的过度医疗存在体制性的特点。这些过度医疗行为往往是由某种体制或政策造成的,不能仅仅视为医生的个人行为或医院的偶然现象;主导者是医方,其中包括医院、医生,甚至是卫生政策与行业管理部门行业性行为的结果;常有科学的外衣作掩护,难以辨别和区分;面广、人多、量大,不是个别现象;持续性、顽固性,不易克服。

与过度医疗相似的是过度保健服务。人们对疾病或健康采取了过多的保护或医疗措施,其中包括对没有必要治疗而可以通过自然康复的小伤小病进行的治疗,包括对需要治疗的疾病采取了过度的治疗,也包括服用没有必要的保健品和其他的保健措施。过度保健服务包含过度医疗,但不仅限于过度医疗。过度保健服务不仅可以发生在医院,还可能发生在家中或其他场所。某些过度的保健服务并不都构成对病人健康的伤害,如医院为病人提供过多的照顾。

过度医疗的对立面:适度医疗或优质医疗

适度医疗是指从一定的社会、技术、经济水平出发,对病人采取适当处置的医疗行为,具备疗效相对最好、伤害最小、痛苦最少、便捷、可承受性等要素。适度医疗是病人对医疗的最基本的要求,是服务者应为病人提供的最基本的服务。当然,社会、经济、医疗技术和人文、民俗等情况不同,国家、社会、经济水平不同,对适度医疗的要求和标准也不同。

我国学者提出了适度医疗的四个要求:安全、高效、便捷、节约,认为适度医疗就是优质化的医疗。而日本学者主张以效益、风险、医疗服务质量三个变量来确认优质医疗。从医学科学的允许度和病人的期待来看,任何疾病的最优化医疗应当包括三个层次:首先是最优的诊治方案,主要目标是疗效最佳、最安全、痛苦最少、便捷和费用低五个要点,其中以疗效和安全最为重要;其次是最优秀的服务,即为实施方案的最优秀的各种服务;再次是在实际上取得了最好的近期和远期效果,方案的最佳疗效只是一种预期效果,而最优化的医疗是不能以预期效果定论的,还必须在实际上取得了的最佳效果。只有这三方面的结合,才能构成一个理想的最优化的医疗服务。

在实际治疗中,怎样避免过度医疗、实现优质医疗是医生、医疗机构和监管部门都应该考虑的问题。只有了解了过度医疗产生的原因,才能在根本上杜绝多余的诊断和治疗给患者带来不便甚至危害的现象。杜绝过度医疗同时还能缓解医患关系、实现医患和谐、改善医疗环境,应该得到政府及有关部门的高度重视。

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    2017-06-04 135****7952平儿

    学了。。。。。。。。。。

    0

  3. 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createdName=139****5926, createdTime=Sat Jun 03 16:15:10 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205999, encodeId=0f8e205999ca, content=有时候,是矛盾,怕过度,也怕漏诊, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220317/1c3b2db4747d42e88e5018b394979434/be0fcebf07344e9ab886c37c502e2f29.jpg, createdBy=6bb22051299, createdName=微笑人参, createdTime=Sat Jun 03 12:08:32 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205988, encodeId=820b2059887d, content=过度医疗可耻啊, beContent=null, objectType=article, channel=null, level=null, likeNumber=114, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6ae02063908, createdName=152****8376, createdTime=Sat Jun 03 11:27:27 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createdName=135****7952平儿, createdTime=Sat Jun 03 10:03:43 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205944, encodeId=76cf205944ee, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Sat Jun 03 09:45:19 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205942, encodeId=ae2320594292, content=跟我们养猪行业一样,猪病了各种推销药品的就来了, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib260FNcic8ThYZTmbW36JHpvHcnIog7VbWIQjibo1kwuH9obXRJJtqHn1hYHHLG0DpIMIBVFPhBBpQOJWDk1rbib2Y/0, createdBy=d27274268, createdName=sillywu, createdTime=Sat Jun 03 09:41:20 CST 2017, time=2017-06-03, status=1, ipAttribution=)]
    2017-06-04 130****4638

    学习了谢谢分享。

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1518785, encodeId=9c0b1518e8568, content=<a href='/topic/show?id=dc85939999c' target=_blank style='color:#2F92EE;'>#过度医疗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=93999, encryptionId=dc85939999c, topicName=过度医疗)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e7ca11178291, createdName=lvliquan, createdTime=Sun Jun 04 12:58:00 CST 2017, time=2017-06-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=206319, encodeId=2cb92063197f, content=学了。。。。。。。。。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=135, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, 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createdName=sillywu, createdTime=Sat Jun 03 09:41:20 CST 2017, time=2017-06-03, status=1, ipAttribution=)]
    2017-06-03 139****5926

    好文章学习了

    0

  5. 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createdName=135****7952平儿, createdTime=Sat Jun 03 10:03:43 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205944, encodeId=76cf205944ee, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Sat Jun 03 09:45:19 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205942, encodeId=ae2320594292, content=跟我们养猪行业一样,猪病了各种推销药品的就来了, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib260FNcic8ThYZTmbW36JHpvHcnIog7VbWIQjibo1kwuH9obXRJJtqHn1hYHHLG0DpIMIBVFPhBBpQOJWDk1rbib2Y/0, createdBy=d27274268, createdName=sillywu, createdTime=Sat Jun 03 09:41:20 CST 2017, time=2017-06-03, status=1, ipAttribution=)]
    2017-06-03 微笑人参

    有时候,是矛盾,怕过度,也怕漏诊

    0

  6. 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createdName=135****7952平儿, createdTime=Sat Jun 03 10:03:43 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205944, encodeId=76cf205944ee, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Sat Jun 03 09:45:19 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205942, encodeId=ae2320594292, content=跟我们养猪行业一样,猪病了各种推销药品的就来了, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib260FNcic8ThYZTmbW36JHpvHcnIog7VbWIQjibo1kwuH9obXRJJtqHn1hYHHLG0DpIMIBVFPhBBpQOJWDk1rbib2Y/0, createdBy=d27274268, createdName=sillywu, createdTime=Sat Jun 03 09:41:20 CST 2017, time=2017-06-03, status=1, ipAttribution=)]
    2017-06-03 152****8376

    过度医疗可耻啊

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1518785, encodeId=9c0b1518e8568, content=<a href='/topic/show?id=dc85939999c' target=_blank style='color:#2F92EE;'>#过度医疗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=93999, encryptionId=dc85939999c, topicName=过度医疗)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=e7ca11178291, createdName=lvliquan, createdTime=Sun Jun 04 12:58:00 CST 2017, time=2017-06-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=206319, encodeId=2cb92063197f, content=学了。。。。。。。。。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=135, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Sun Jun 04 08:39:35 CST 2017, time=2017-06-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=206271, encodeId=b5f92062e15b, content=学习了谢谢分享。, beContent=null, objectType=article, channel=null, level=null, likeNumber=125, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=00501987275, createdName=130****4638, createdTime=Sun Jun 04 07:49:12 CST 2017, time=2017-06-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=206039, encodeId=38992060392e, content=好文章学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=113, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5K1RUfOKQohib4bXhDtxVgOA9VcKY1LUZkCOmr0v3WupxANz2ibibNHkdevtSruvrhyI29IjXdtvUV48/0, createdBy=6ff82057534, createdName=139****5926, createdTime=Sat Jun 03 16:15:10 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205999, encodeId=0f8e205999ca, content=有时候,是矛盾,怕过度,也怕漏诊, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220317/1c3b2db4747d42e88e5018b394979434/be0fcebf07344e9ab886c37c502e2f29.jpg, createdBy=6bb22051299, createdName=微笑人参, createdTime=Sat Jun 03 12:08:32 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205988, encodeId=820b2059887d, content=过度医疗可耻啊, beContent=null, objectType=article, channel=null, level=null, likeNumber=114, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6ae02063908, createdName=152****8376, createdTime=Sat Jun 03 11:27:27 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205958, encodeId=bf3b205958e5, content=学习过了,感谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sat Jun 03 10:09:30 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205948, encodeId=b0ea2059486b, content=好。。。。。。。。。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Sat Jun 03 10:03:43 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205944, encodeId=76cf205944ee, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Sat Jun 03 09:45:19 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205942, encodeId=ae2320594292, content=跟我们养猪行业一样,猪病了各种推销药品的就来了, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib260FNcic8ThYZTmbW36JHpvHcnIog7VbWIQjibo1kwuH9obXRJJtqHn1hYHHLG0DpIMIBVFPhBBpQOJWDk1rbib2Y/0, createdBy=d27274268, createdName=sillywu, createdTime=Sat Jun 03 09:41:20 CST 2017, time=2017-06-03, status=1, ipAttribution=)]
    2017-06-03 明天会更好!

    学习过了,感谢分享!

    0

  8. 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CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205958, encodeId=bf3b205958e5, content=学习过了,感谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160914/IMG57D82E721DB581755.jpg, createdBy=4fc81933929, createdName=明天会更好!, createdTime=Sat Jun 03 10:09:30 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205948, encodeId=b0ea2059486b, content=好。。。。。。。。。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Sat Jun 03 10:03:43 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205944, encodeId=76cf205944ee, content=好, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6d551998554, createdName=1e1c07bdm01(暂无匿称), createdTime=Sat Jun 03 09:45:19 CST 2017, time=2017-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=205942, encodeId=ae2320594292, content=跟我们养猪行业一样,猪病了各种推销药品的就来了, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib260FNcic8ThYZTmbW36JHpvHcnIog7VbWIQjibo1kwuH9obXRJJtqHn1hYHHLG0DpIMIBVFPhBBpQOJWDk1rbib2Y/0, createdBy=d27274268, createdName=sillywu, createdTime=Sat Jun 03 09:41:20 CST 2017, time=2017-06-03, status=1, ipAttribution=)]
    2017-06-03 135****7952平儿

    好。。。。。。。。。。

    0

  9. 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createdName=sillywu, createdTime=Sat Jun 03 09:41:20 CST 2017, time=2017-06-03, status=1, ipAttribution=)]
  10. 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createdName=sillywu, createdTime=Sat Jun 03 09:41:20 CST 2017, time=2017-06-03, status=1, ipAttribution=)]
    2017-06-03 sillywu

    跟我们养猪行业一样,猪病了各种推销药品的就来了

    0

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