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王辰院士:“三级查房”制度应该尽早淘汰

2017-09-03 佚名 华医网

日前,王辰院士再次建议取消“三级查房”制度,实行主诊医师负责制,让医生自己对自己负责。

“传统的三级查房制度应该淘汰,应当更多地推进主诊医师负责制改革。”近日,中日友好医院院长、中国工程院院士王辰在由中国医院协会主办的中国医院大会上再一次提出了自己的重要观点,引起了同行的关注和热议。

“三级查房”制度不科学,建议取消

王辰院士认为,“三级查房”制度是不科学的,也有悖于国际通行做法。

根据国家卫计委2016年发布的《医疗质量管理办法》 规定,“三级查房制度”是18项核心制度之一。作为一项重要的日常医疗活动,“三级查房制度”是提高医疗质量、保障医疗安全的基础。

传统的“三级查房”制度,主要是针对不同资质的医师在查房质量管理中的作用,作了如下分工:一是住院医师查房,每日至少两次,主要观察病人病情变化和处理一般医疗问题;二是主治医师查房,每日一次,主要对患者的日常医疗行为负责;三是正、副主任医师查房,每周1~2次,主要对患者住院期间的医疗质量管理负责。

根据某医学媒体今年6月发布的一篇王辰院士署名的文章,我们可以知道,王院士认为“三级查房”制度一定程度上体现了对于医疗活动的层次管理和互补管理,但是也凸显出很多弊端:一是医疗责任主体不清;二是将有经验的高年资医生“悬置”,既导致住院患者不能直接接受高水平医师的诊疗,又隔绝“三级医师”直接接触患者,影响其对患者的直接观察与临床经验积累;三是延迟年轻医师独立进行诊疗的年限,工作层叠,人员效率低下,对临床医师队伍的成长建设极为不利,会从整体上降低中国临床界的医疗能力。

为什么会出现这种情况呢?王辰院士认为,最根本的原因是我们的医疗职称体系扭曲,混淆了执业定位与学术水平标志。也就是说,住院医师、主治医师、副主任医师、主任医师是学术水平的标志,而什么样的人可以独立接诊病人是“执业定位”问题。

此次会上,王辰院士提到他在去其他地方会诊的时候,发现很多医院的病历上三级医师的签名都是他人代签。“三级查房”制度在部分医院形同虚设的现象并非罕见。国内数篇关于三级查房制度的研究论文结果也在一定程度上印证了该结论。研究者认为,目前国内二、三级医院,包括很多大医院,三级医师查房制度执行都不太好,尤其是主任(副主任)医师级的查房次数不足且质量较差。另外还有很多基层医院因缺乏高级职称医务人员,而无法实行三级查房,这都是非常严重的问题。

主诊医师负责制大有可为

王辰院士认为,应该借鉴国际上通行的做法,实行主诊医师(主治医师,Attendingphysician)负责制。这里的“主治医师”不同于我们通常说的技术职称上的“主治医师”,实际上指的是包括主治医师在内的以上职称的各级医师,包括主治医师、副主任医师、主任医师,即:年资再高、再“大”的医师在临床上管病人时,其角色也是主治医师,也就是主要负责病人治疗的医师。若遇疑难病例,可以请长于此道的医师会诊。

据相关资料显示,国内的主诊医师负责制普遍定义为:由一名Attending(具有副主任医师以上资格)、1名fellow(主治医师以上)、1名resident(住院医师)组成的医疗小组(medical team)全面负责患者从门诊、到住院、手术、会诊和随访的全诊疗过程。

一般的医疗问题由主诊医师全权负责,每位主诊医师还要关心本组的经济运行情况,业务收入、成本消耗、人员结构、人员经费、绩效工资分配等等。主诊医师负责制,体现了各级医生“责、权、利”的统一,责任明确,可以让每个主诊医师明显看到利益所在,医生之间形成强烈的竞争态势,使医生们自觉提高医疗质量和服务水平,显着的提高了医护人员工作的积极性和主动性。

很多医院实行了主诊医师负责制,效果如何?

资料显示,国内公认最早实行主诊医师负责制的浙江邵逸夫医院,1994年建院伊始便由美国罗马琳达大学引入主诊医师负责制,通过不断完善,逐渐建立了一整套考核制度,并将考核结果作为岗位竞争和分配的重要依据,取得了显着效果。效益的不断增长和医院的持续发展引起了同行的广泛关注。很多医院结合自身实际情况,也都实行了主诊医师负责制。

笔者查询资料得知,北京市医管局在2013年曾下发通知,计划北京所有市属医院在当年年底前全面试点主诊医师负责制,每所医院至少在3个科室开展主诊医师试点。王辰院士今年6月在某媒体上公开发表的言论中表示,中日医院自去年8月实行“三级查房”制度以来,取得了良好的效果,医疗效率获得较显着提高。

主诊医师负责制的优点是解放了生产力,使个人的背景和潜能得到充分的发挥。但是这一制度是否完美无缺,笔者持有保留态度。为了利益驱动,主诊组之间团队协作精神减弱、医生过度医疗行为的增加等问题都需要引起我们的重视。

笔者认为,医院在推行主诊医师负责制的过程中,应该注意加强科室间轮转和学术交流,促使各主诊组间形成良性竞争、优势互补;实施期间出现的各种问题要及时发现并积极处理,确保医生稳步成长、科室有序发展。

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    2017-09-05 smartjoy
  5. [GetPortalCommentsPageByObjectIdResponse(id=1689473, encodeId=1e4916894e3fb, content=<a href='/topic/show?id=ad0619e19b0' target=_blank style='color:#2F92EE;'>#三级#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=19719, encryptionId=ad0619e19b0, topicName=三级)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0eeb28833546, createdName=luckyshitiancai_42705693, createdTime=Thu Apr 12 14:02:00 CST 2018, time=2018-04-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1651464, encodeId=9b0c1651464cd, content=<a href='/topic/show?id=3eb5683638a' target=_blank style='color:#2F92EE;'>#王辰院士#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=68363, encryptionId=3eb5683638a, topicName=王辰院士)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=05be24209031, createdName=cy0332, createdTime=Sun Jun 17 00:02:00 CST 2018, time=2018-06-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1993081, encodeId=16df199308172, content=<a href='/topic/show?id=e2e019e31d1' target=_blank style='color:#2F92EE;'>#三级查房#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=19731, encryptionId=e2e019e31d1, topicName=三级查房)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f07c2500133, createdName=12498adam40暂无昵称, createdTime=Sat Feb 24 14:02:00 CST 2018, time=2018-02-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1551884, encodeId=aafd155188416, content=<a href='/topic/show?id=6bbf618e10a' target=_blank style='color:#2F92EE;'>#查房#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=61871, encryptionId=6bbf618e10a, topicName=查房)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a59514235100, createdName=smartjoy, createdTime=Tue Sep 05 02:02:00 CST 2017, time=2017-09-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=240036, encodeId=bd9c24003615, content=说得在理.希望改变, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Q3auHgzwzM4o2XVpJ6449yqDsjibydI5HnJ8MibGxNn4HZiaZib0bdfibbwoz3KQrIyN9AGxq36ZlZRNicYlPfOOWMtwgsajY6mGNFiaPclFdowjD0/0, createdBy=97bd1338592, createdName=清风拂面, createdTime=Sun Sep 03 12:44:28 CST 2017, time=2017-09-03, status=1, ipAttribution=)]
    2017-09-03 清风拂面

    说得在理.希望改变

    0

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