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The Lancet:重建中国医患信任白皮书

2016-08-20 佚名 生物探索

今年五月份,广东省人民医院口腔科的退休主任陈中伟在自己家中被一位患者杀害。而行凶人竟是陈仲伟20多年前的一位患者,不久前曾因为烤瓷牙变黄要求索赔闹事,最后尾随伤者在其家中行凶。而这件令人悲愤的事件只是中国近年来众多医患纠纷事件之一。如何应对中国医患纠纷问题?来自北卡罗来纳大学教堂山分校医学院中国项目组的学者呼吁重建医患信任。该研究小组采用了深入访谈和政策分析的方式,对话患者、医生及其他医护工作

今年五月份,广东省人民医院口腔科的退休主任陈中伟在自己家中被一位患者杀害。而行凶人竟是陈仲伟20多年前的一位患者,不久前曾因为烤瓷牙变黄要求索赔闹事,最后尾随伤者在其家中行凶。而这件令人悲愤的事件只是中国近年来众多医患纠纷事件之一。


如何应对中国医患纠纷问题?来自北卡罗来纳大学教堂山分校医学院中国项目组的学者呼吁重建医患信任。该研究小组采用了深入访谈和政策分析的方式,对话患者、医生及其他医护工作者,以更好地了解在中国这个大环境下的医患信任问题。该团队列出了几个需要改革的领域,其中包括医疗系统、法律、伦理和医学教育。他们的调研结果《重建中国医患信任白皮书》发表在国际著名医学期刊The Lancet上。

研究人员认为信任并不是一个简单的概念,它的重建需要时间、精力和资源。社会舆论不仅要指出这种医患不信任的状况,更需要思考如何改进这种现状。

这个多学科调研小组的成员包括领先的公共卫生官员、哲学家、律师、医生、私营部门的领导人和医学伦理学家。他们提出一系列建议,旨在帮助重建中国的医患信任。

附件:

《重建中国医患信任白皮书》

此白皮书旨在提供重建中国医患信任的可操作性建议。尽管以下政策建议的产生基于中国的现实背景,但建议中的诸多内容不仅适用于中国,对于中低收入国家也具有较强的指导价值。我们主要从医生的维度来提出医患信任的重建措施,但也要认识到其他相关的职业人士(护士、理疗师、药剂师等)也在医患信任重建中发挥者重要作用。在具体内容上,该白皮书主要从医学院的医学教育、伦理倡导、法律体系和医疗制度加以阐述。

医学教育方面的建议:

1)将医学人文教育设置为临床培训的核心内容。将实践的医学人文课程纳入医学生的培训体系之中,使医学生掌握必要的人文技能来应对日益复杂的医疗环境。在设计多样性的医学人文选修课程时,既要包括如《医学人文导论》、《医学伦理学》和《医患沟通》等必修课程,还应加上一些选修课程。设置这些课程旨在提升医学生的医学人文素养,提高其医患沟通技巧,以及培养医学生的职业精神和看护伦理意识。此外,专题讲座和案例学习对医学人文教育也会有所帮助。

2)推广体验实践式学习,建立社区—医学院之间的伙伴关系。体验实践式学习是指通过医学人文实践活动去学习,并鼓励培训对象做批判性反思的过程。作为临床前培训的一部分,医学院可以创造机会给医学生,去探访生病的家庭成员并提供非医学的照顾(比如做饭、洗澡、上厕所)等,帮助医学生去感受患者经历的疾痛。在进入临床培训之前,医学院和医院要引导医学生作为当地社区的志愿者,向社区患者提供健康护理和医疗服务,来自社区负责人或其他非医学专业人士的讲座和混合教学也可以加强医学院和社区的联系。

3)改善医学人文教育的评估机制。采用标准化机制来评估医学生、教学人员以及医学院的医学人文教育效果。评估内容应包括:文化适应能力、医患沟通技巧以及医学职业素养等多方面内容。我们建议,将医学生专业能力和沟通能力作为是否能够完成临床培训和住院医师培训的重要考核内容;同时,建立一个由学生、医师和医学教育工作者组成的专业委员会,以设计具体的衡量标准来评估医学人文教育状况。

伦理倡导方面的建议:

4)鼓励提升医疗实践和卫生系统的透明度,尤其是医生和制药公司之间关系的透明度。我们建议,可以参考美国的经验,建立一个专门信息系统,公开医生从医药公司获取款项、礼物等其它财物的相关信息。

5)鼓励开展与医患关系相关的媒体培训。鼓励媒体客观中立地调查医患纠纷、医患双方的诉求,如实反映医患双方的观点。同时,应强化媒体对医患纠纷和医患冲突事件的深度报道,以有效引导公众理解重建医患的复杂性。

法律框架方面的建议:

6)建立强制性的医疗过失报告制度。法律制度应该成为建立医患信任的第一手段,我们建议,通过建立强制性的医疗过失报告制度,增加医疗信息公开披露和透明度。

7)促进医疗纠纷记录和解决措施的公正透明化。医疗纠纷和解决记录的公正透明化,对于避免医患冲突是必要的。患者应该知道他们的基本权利,并有权选择他们想要的代理人,包括律师。

8)强化处理医疗纠纷的法律措施。采用先有的法律框架来保障医患双方的合法权利,并协商解决医患双方存在的利益冲突。在应用法律措施解决纠纷时,应保障法律应用对医患双方都是公平的,同时也必须医患双方理解为是公平的。

9)深化第三方医疗纠纷调解系统,确保其在处理医患关系时具有中立性,独立于医患双方各自的个人利益。目前只有很小一部分医疗纠纷是通过法律仲裁或者司法途径解决的,大多数医患纠纷事例需要通过独立于医患双方利益之外的第三方调解机构来处处理。中国已经建立了很多调解机构,但也存在很多不足。医疗纠纷调解机构必须是中立的,调解的自愿属性必须被纠纷双方所了解。在调节过程中,患者有权利得到律师或者其他人的帮助。任何存在于调解机构或者仲裁者与医院或者保险公司的联系必须被公开披露。

10)在发生医疗纠纷时,除了医院有限的保安人员外,还要有配套的安保程序。定性研究表明增加医院的保安数量可能反而增加医患之间的不信任。因而医院内保安人员的作用非常有限。在医疗纠纷发生时,必须有足够的安全保障程序和风险预案机制。医院和医疗卫生系统方面的建议:

11)强化医疗卫生系统对看护关爱的重视程度。我们将看护关爱定义成提供情感的、身体的和认知帮助与照顾的基本的人类活动。我们建议,应当健全各种支持看护关爱活动的正式和非正式机制,包括通过财政机制来支持家庭、受过专门训练的护理机构、医院和其他机构来从事看护活动,看护应当被给予全方位地认可和内在价值。

12)增加医务人员的基本工资收入,杜绝医疗系统中的“红包”现象。尽管“红包”现象多次被强制禁止,但是根植于亚洲国家中的历史和文化因素,一些患者想通过红包来表达对医务人员的谢意,使其很难一下子被弃绝。从短期来说,有的医院让医生代表医院接受红包,转而将它做为患者的诊疗费用;有的医院则将红包设立成专项的基金,补贴低收入患者。总之,需要落实新的红包处理方式。从中期来看,增加医生收入可以减少他们致力于从红包中获得额外收入的需求。
13)加强基层医疗保障制度。加大对于工作在社区卫生中心和其他基层的医生培训,进一步细化从基层医疗机构往三级医院的转诊制度。

14)支持起草《患者权利和责任法案》。这一法案的内容应在诊疗过程一开始便呈现出来,以使病人了解他们的权利和义务。制订该法案能增加公众的医疗知识,以及扩大病人对于医疗机构和就诊过程的理解。

15)规定一个病人的医生接诊时间增加到10分钟。医生需要时间用病人容易理解的方式解释病情,并回答病人的问题。

16)建议包括人文素质测试在内的综合临床评估体系。采用标准化方法来衡量病人满意度、医患沟通和职业精神等评估指标。

17)在医院建立非惩罚性的过失报告制度。在允许非惩罚性过失识别系统下,对于医疗过失和非医疗过失的系统性报告能有效提高医疗服务质量。

18)建立独立的医院伦理委员会。伦理委员会成员应由社区成员、医务人员、医院管理者和伦理学家组成。考虑到中国医院现存的伦理委员会在临床研究的方案审查中发挥着重要作用,但在临床伦理方面有待加强。无论是独立的伦理委员会还是现存的机构伦理委员会,加强其在临床伦理培训和医疗纠纷协商中的作用,将有助于改善医患纠纷的结果。

备注:本文编译自MedicalXpress网站,原标题:“Researchers provide recommendations to stop violence against clinicians in China”

附件来自:Rebuilding Patient-Physician Trust in China: A White Paper Towards Educational, Legal, Ethical, and Health Systems Reform

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href='/topic/show?id=da9934342b5' target=_blank style='color:#2F92EE;'>#医患#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=34342, encryptionId=da9934342b5, topicName=医患)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0e3195, createdName=millore, createdTime=Mon Aug 22 02:07:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=101917, encodeId=289c10191ebd, content=学习学习!??, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160817/IMG57B3C3F6DC2FD8753.jpg, createdBy=81321934679, createdName=1e0d99ddm02(暂无匿称), createdTime=Sun Aug 21 12:58:00 CST 2016, time=2016-08-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=101842, encodeId=a4bc10184275, content=有道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/04/04/355c07748bd28246a802dedc6fdf7421.jpg, createdBy=4cfd1732073, createdName=0348, createdTime=Sun Aug 21 06:49:00 CST 2016, time=2016-08-21, status=1, ipAttribution=)]
    2016-08-26 李东泽

    这篇资讯写的真好,带给我们新知识,启发新思维,不论是科研还是临床工作都有很大的帮助。。。

    0

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    2016-08-26 李东泽

    这篇资讯写的真好,带给我们新知识,启发新思维,不论是科研还是临床工作都有很大的帮助。。。

    0

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GetPortalCommentsPageByObjectIdResponse(id=101842, encodeId=a4bc10184275, content=有道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/04/04/355c07748bd28246a802dedc6fdf7421.jpg, createdBy=4cfd1732073, createdName=0348, createdTime=Sun Aug 21 06:49:00 CST 2016, time=2016-08-21, status=1, ipAttribution=)]
    2016-08-22 茶马古道

    理想很丰满......

    0

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GetPortalCommentsPageByObjectIdResponse(id=101842, encodeId=a4bc10184275, content=有道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/04/04/355c07748bd28246a802dedc6fdf7421.jpg, createdBy=4cfd1732073, createdName=0348, createdTime=Sun Aug 21 06:49:00 CST 2016, time=2016-08-21, status=1, ipAttribution=)]
    2016-08-22 茶马古道

    理想很丰满......

    0

  6. 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level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160821/IMG57B9667502B1F9208.jpg, createdBy=7a291940143, createdName=茶马古道, createdTime=Mon Aug 22 10:32:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1466670, encodeId=e84d14666e003, content=<a href='/topic/show?id=741ce17090e' target=_blank style='color:#2F92EE;'>#白皮书#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71709, encryptionId=741ce17090e, topicName=白皮书)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93a16850722, createdName=bbwznl, createdTime=Mon Aug 22 02:07:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1284634, encodeId=fdee128463432, content=<a href='/topic/show?id=da9934342b5' target=_blank style='color:#2F92EE;'>#医患#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=34342, encryptionId=da9934342b5, topicName=医患)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0e3195, createdName=millore, createdTime=Mon Aug 22 02:07:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=101917, encodeId=289c10191ebd, content=学习学习!??, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160817/IMG57B3C3F6DC2FD8753.jpg, createdBy=81321934679, createdName=1e0d99ddm02(暂无匿称), createdTime=Sun Aug 21 12:58:00 CST 2016, time=2016-08-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=101842, encodeId=a4bc10184275, content=有道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/04/04/355c07748bd28246a802dedc6fdf7421.jpg, createdBy=4cfd1732073, createdName=0348, createdTime=Sun Aug 21 06:49:00 CST 2016, time=2016-08-21, status=1, ipAttribution=)]
    2016-08-22 茶马古道

    支持一下!

    0

  7. 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level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160821/IMG57B9667502B1F9208.jpg, createdBy=7a291940143, createdName=茶马古道, createdTime=Mon Aug 22 10:32:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1466670, encodeId=e84d14666e003, content=<a href='/topic/show?id=741ce17090e' target=_blank style='color:#2F92EE;'>#白皮书#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71709, encryptionId=741ce17090e, topicName=白皮书)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93a16850722, createdName=bbwznl, createdTime=Mon Aug 22 02:07:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1284634, encodeId=fdee128463432, content=<a href='/topic/show?id=da9934342b5' target=_blank style='color:#2F92EE;'>#医患#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=34342, encryptionId=da9934342b5, topicName=医患)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0e3195, createdName=millore, createdTime=Mon Aug 22 02:07:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=101917, encodeId=289c10191ebd, content=学习学习!??, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160817/IMG57B3C3F6DC2FD8753.jpg, createdBy=81321934679, createdName=1e0d99ddm02(暂无匿称), createdTime=Sun Aug 21 12:58:00 CST 2016, time=2016-08-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=101842, encodeId=a4bc10184275, content=有道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/04/04/355c07748bd28246a802dedc6fdf7421.jpg, createdBy=4cfd1732073, createdName=0348, createdTime=Sun Aug 21 06:49:00 CST 2016, time=2016-08-21, status=1, ipAttribution=)]
    2016-08-22 bbwznl
  8. 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level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160821/IMG57B9667502B1F9208.jpg, createdBy=7a291940143, createdName=茶马古道, createdTime=Mon Aug 22 10:32:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1466670, encodeId=e84d14666e003, content=<a href='/topic/show?id=741ce17090e' target=_blank style='color:#2F92EE;'>#白皮书#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71709, encryptionId=741ce17090e, topicName=白皮书)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93a16850722, createdName=bbwznl, createdTime=Mon Aug 22 02:07:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1284634, encodeId=fdee128463432, content=<a 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GetPortalCommentsPageByObjectIdResponse(id=101842, encodeId=a4bc10184275, content=有道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/04/04/355c07748bd28246a802dedc6fdf7421.jpg, createdBy=4cfd1732073, createdName=0348, createdTime=Sun Aug 21 06:49:00 CST 2016, time=2016-08-21, status=1, ipAttribution=)]
    2016-08-22 millore
  9. 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GetPortalCommentsPageByObjectIdResponse(id=101842, encodeId=a4bc10184275, content=有道理, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2018/04/04/355c07748bd28246a802dedc6fdf7421.jpg, createdBy=4cfd1732073, createdName=0348, createdTime=Sun Aug 21 06:49:00 CST 2016, time=2016-08-21, status=1, ipAttribution=)]
    2016-08-21 1e0d99ddm02(暂无匿称)

    学习学习!??

    0

  10. 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level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160821/IMG57B9667502B1F9208.jpg, createdBy=7a291940143, createdName=茶马古道, createdTime=Mon Aug 22 10:32:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1466670, encodeId=e84d14666e003, content=<a href='/topic/show?id=741ce17090e' target=_blank style='color:#2F92EE;'>#白皮书#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71709, encryptionId=741ce17090e, topicName=白皮书)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=93a16850722, createdName=bbwznl, createdTime=Mon Aug 22 02:07:00 CST 2016, time=2016-08-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1284634, encodeId=fdee128463432, content=<a 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    2016-08-21 0348

    有道理

    0

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