At present, China's medical system reform generally emphasizes the role of the market. But the market-oriented medical system needs market support. Even the financial resources of many developed countries in Europe are not enough to support the development of the medical market, let alone China. Facing the special national conditions, the future of medical system reform in China is still worth pondering.
Since the founding of People's Republic of China (PRC), China has made remarkable achievements in the medical and health field. According to the data recently released by WHO, China's health investment ranks as 139 in the world, but its comprehensive health level ranks 82nd in the world. Compared with the United States, China's medical and health investment accounts for 5.62% of GDP, and the United States accounts for 14%. The total GDP of the United States is about 10 times that of China. Therefore, the absolute amount of resources actually invested in the medical and health field is about 30 times that of China, but the number of people in the United States who need care is only one sixth of ours. Even so, the American health care system is in jeopardy, the government's financial burden is increasing day by day, and the people. China's medical service can increase the average life expectancy of residents year by year, and the maternal and infant mortality rate is decreasing year by year, which is quite difficult. This is due to the superior socialist system and the efforts of medical workers.
However, achievements can't hide the gap. Through rational research, it is not difficult to find that there is indeed a big gap between China's medical level and the international first-class.
I. Medical education
1, the academic system and degree system are chaotic.
Medical education in China has a five-year system, that is, three years, five years, six years, seven years and eight years. This academic system has caused confusion in the training standards of medical talents. More importantly, it is difficult to formulate accurate and targeted training objectives and standards, which leads to inaccurate distinction of talent specifications, difficult to fully guarantee the quality of training, and is not conducive to the management of human resources. Furthermore, this system is not comparable with other countries' medical education systems, which will inevitably hinder the internationalization of China's health undertakings.
Since 198 1, there is only one medical degree system in China, namely, bachelor (5-year system as the main body), master (7-year system or master's degree) and doctor (8-year system or doctor), and the types and specifications are relatively simple. This system, which confuses scientific degrees with professional degrees that focus on cultivating scientific research ability and clinical practical work ability, not only leads to the limitation of training objectives of different specifications and the convergence of training methods, but also does not reflect the characteristics of the majors engaged in by degree winners. Of course, it is not difficult to understand the rumor that "doctoral students will not see a doctor".
2. The educational model is out of date.
(1) The teaching content is outdated and the teaching methods have remained basically unchanged for decades. Looking carefully at the curriculum of medical college, compared with 20 years ago, it is found that the curriculum is almost the same; Looking through the current medical textbooks carefully, compared with 20 years ago, it is found that the content is similar. The only change is that today's multimedia has replaced a large number of blackboard books in the past, but a closer look shows that multimedia is just a pre-written "blackboard book". The past twenty years have witnessed the explosion of medical knowledge and the rapid development of medical technology. Great changes have taken place in the medical system and social environment, and the requirements of society and patients for medicine and doctors have also changed greatly. It is obviously very limited to train new doctors in 2 1 century by the old methods.
(2) The curriculum is unreasonable. I have studied the teaching plan of a representative medical college in China, the United States, Britain, France and Germany, and found that although the total hours of medical education in China are not low, reaching about 5,000 hours, the hours actually spent on medical basics and clinics only account for more than 60%, while France and Germany usually account for about 90%. There are three main reasons for the lack of hours in medical-related courses: First, special general education courses such as physical education, foreign languages and computers offered in seven-year programs in China are not offered in other countries. Second, the foundation of natural science takes up a lot of class hours. After obtaining a bachelor's degree, American medical students have a solid knowledge base in natural science and humanities and social sciences, and begin to study medical courses directly from a high starting point. Although the enrollment of British medical schools began in high school, the entrance examination is equivalent to the level of freshmen in China, so courses such as mathematics, physics and chemistry are no longer arranged. France and Germany recruit medical students from high schools, and both offer natural science courses, accounting for about 10% of the total class hours. The 7-year natural science courses in China account for about 14% of the total class hours. Third, most countries arrange clinical practice after graduation, while China's seven-year program has to arrange graduation practice for about 48 weeks. Compared with the international long-term medical education, the seven-year medical education in China needs two years to arrange various basic courses teaching and graduation practice, and its professional teaching requirements are only equivalent to the international five-year medical education.
(3) Insufficient clinical skills training. China's medical education does not pay enough attention to the cultivation of medical students' skills and operations, and the number of practical hours is relatively insufficient compared with foreign medical education systems. At present, due to various new situations and contradictions, students' practical operation opportunities are greatly reduced. The promulgation of the Law on Medical Practitioners challenges the legality of the clinical operation of interns who have not yet obtained the qualification of medical practitioners, especially after the promulgation of the Measures for Handling Medical Accidents, interns have less and less opportunities to start working. In large teaching hospitals, even residents and senior doctors rarely have the opportunity to operate. With the progress of society and the improvement of legal concept, patients' awareness of self-protection is getting stronger and stronger, sometimes exceeding the reasonable level. For example, a teaching hospital was sued for not letting interns avoid gynecological examination. In my opinion, in order to protect the fundamental interests of patients and ensure that doctors get better clinical skills training, relevant laws and regulations should be formulated to ensure the quality of medical graduates.
(4) Medical education lacks the organic combination with humanities and social sciences. Since the Renaissance, scientism has dominated, basic medicine and clinical medicine have become the dominant medical education courses, and biomedical models have been established and dominated, which has promoted the development of medicine. However, medicine has since embarked on the road of relying on experimental technology and ignoring humanistic spirit. With the development of society, the disadvantages of biomedical model are exposed. Social factors such as accelerated work pace, intensified competition, environmental pollution, resource crisis and ecological destruction are increasingly threatening human survival and health, and the disease spectrum and cause of death have changed. This change has prompted people's perspective to change from simply considering biological factors that cause diseases to integrating biological, psychological, social and environmental factors. Medicine is developing in a holistic, comprehensive and diversified direction, involving knowledge and methods of social, psychological, ethical, philosophical, environmental, economic, legal and other humanities and social disciplines. Only by better cooperation with humanities and social sciences can medicine play a better role and seek its own development. In this regard, we have not done enough.
3. The continuing education system, especially the resident training system, is not perfect.
1956, Professor Buerwell, Dean of Harvard Medical School, once said that half of the knowledge that medical students received at school was proved to be wrong or incomplete within 10 years. But the problem is that no teacher will know at that time which half will be proved wrong or inapplicable later. This shows that with the passage of time, our existing clinical knowledge and skills are gradually outdated. The importance of continuing medical education goes without saying.
The most important part of continuing medical education is the training of residents. According to my working experience in China and the United States, when medical students in China just graduated, the gap between medical knowledge and clinical skills was not big, but after residency training, the gap increased obviously.
The first is the training system. Only a few hospitals in the United States provide resident training. These hospitals must have a certain scale and number of cases for teaching, and must have enough teachers. Most clinicians in charge of teaching have college degrees. Hospitals have special personnel in charge of training, and hospitals that do not teach well will be disqualified from training. Therefore, every hospital and doctor in charge of training go all out to do a good job in teaching. After the residency training, they can find jobs all over the country, and only a few people stay in our hospital.
However, in China, any medical institution can train residents, and medical graduates will be trained in any hospital, regardless of whether the hospital has the corresponding conditions and qualifications. Training methods are often mentoring. Although the Ministry of Health also has guidance on the training of residents, it has not been well implemented. After the residency training, almost 100% stayed in our hospital regardless of the level.
Followed by the residents themselves. American residents have a heavy workload, great mental stress and long working hours (80- 100 hours/week). Every resident also has a reading task and a physical examination. After completing the training, residents should take the national unified examination to obtain a diploma. A considerable number of examination questions involve some rare or rare diseases that seriously threaten patients' lives. We can only learn from the experience of our predecessors from books. If this kind of case is not handled properly, the patient will die at the hands of the doctor. Doctors can't pass the exam without reading. Residents who do not perform well in training will be punished or even forced to leave.
Graduates majoring in clinical medicine in domestic medical colleges become employees and residents after finding jobs, and are guided by superiors. Residents who are eager to learn are basically willing to read some teaching materials, while residents who are not easy to learn are very satisfied with their daily work. Residents don't study hard and hospitals can't dismiss them. Under this system, residents do not have much pressure to improve their level.
Second, medical research.
The problems existing in medical scientific research are:
1, micro orientation, macro orientation
The understanding of life science and the progress of medicine are based on the correct understanding of the micro-world and macro-world of human body. Cell theory was put forward in the 65438-30' s, and cell biology developed on this basis. 1953 DNA molecular double helix structure model puts forward that the understanding of life phenomena has entered the molecular stage. The Human Genome Project was launched in 1990, and gradually showed the wonderful microscopic world of life to the medical community. However, it seems that too many clinicians are attracted by wonderful cells, molecules and genes and are willing to put in a lot of ineffective or repetitive work. In fact, even in the genetic age, the understanding of medical macro-laws is still of unique significance, especially for clinical medicine. The year before last, after the outbreak of SARS, the basic epidemiological characteristics and early clinical characteristics, such as the source of infection, transmission route, incubation period, etc., were the ultimate guidance for prevention. Unfortunately, this important information was not released until a few months after the outbreak of S ARS, and a lot of manpower and material resources were invested in the early vaccine war and gene sequencing competition. Today, more than two years after the outbreak of the disease, most laboratories have already retired and returned in vain.
2. Pay more attention to short-term output rather than long-term benefits.
The current promotion system of doctors' professional titles objectively encourages scientific research for quick success and instant benefit, and fewer and fewer medical researchers are willing to sharpen their swords for ten years. On the contrary, many "smart" researchers unilaterally pursue the number of papers, divide a complete research into several parts, and write many papers for publication. Of course, the quality of the paper is sacrificed. Another important reason that drives researchers to pay too much attention to recent output is the graduate education system. The academic system of master students in China is too long, and the requirements for master's thesis are too high, while the academic system of doctoral students is too short and inflexible.
3. Pay more attention to laboratory work than bedside research.
As we all know, many developments and discoveries of modern medicine are based on bedside research. A considerable number of papers published in top international clinical medical journals, such as New England Journal of Medicine and Lancent, do not have high-tech laboratory work, and their research data only come from ordinary clinical observation. In real life, patients' demands for medical services are getting higher and higher, and their awareness of self-protection is getting stronger and stronger, which brings certain difficulties to bedside research. But only when researchers realize that "the patient is the best teacher and the patient is the most reliable and true research object" can they attach importance to bedside research subjectively and make research that really solves clinical practical problems.
4. Pay more attention to individual roles than teamwork.
China has the richest clinical resources, especially patient resources. However, the largest sample comprehensive study of some important diseases is often not available in China. Nowadays, multi-center research across cities and borders has become a common practice in developed countries. And all our researchers have to be PI (project leader) and bosses, and they are independent and dominate each other, wasting valuable clinical and scientific research resources.
5. There are many researches on following the trend and imitating, but few are original.
It is unrealistic to expect all the research to be original. However, in the current medical research, there are not a few studies that blindly follow the trend, simply repeat or even copy. The "trace element fever" appeared in the 1980s. In just three or four years, trace elements in almost all diseases in China were measured by the same channel. However, there are few research results that can really play a clinical guiding role. Since then, there have been "oxygen free radical fever", "nitric oxide fever", "PCR fever" and so on. These are precisely the reflection of academic naivety of some medical researchers.
Third, clinical services.
1. The overall quality of doctors needs to be further improved.
(1) The professional knowledge of doctors is too narrow. This is mainly due to the premature division of disciplines and the failure to implement the training plan for residents and specialists. More and more "specialist" doctors only use one system or even one organ, but people are a whole. In order to avoid medical mistakes, they can only consult frequently in the hospital, wasting resources, increasing costs and affecting efficiency.
(2) Doctors lack team spirit. Modern medicine needs multidisciplinary teamwork more and more, but Dr. China is better at singles than doubles, and even more unwilling to play team games.
(3) Lack of understanding of diagnosis and treatment norms. Foreign doctors regard the standard of diagnosis and treatment as a "Bible" and dare not cross the line easily. There are routine diagnosis and treatment methods in China, but they are often ignored. When I was working in America, there were six doctors in one department. They graduated from six different medical schools in different years. When you look at the same patient, there won't be much difference between them. There is also a department with six doctors in China. They almost graduated from the same school, even brought out by the same teacher, but there is a big difference between what tests they need to do and what drugs they prescribe to see the same patient.
2. Hospital reform does not adapt to economic and social development.
(1) Medical system and investment mechanism. At present, there are two major medical systems in the world. The market-oriented model represented by the United States, that is, public hospitals and private hospitals compete equally in the market. In addition to strict supervision, the government is only responsible for "paying the bill" for medical care for the poor and the elderly. In the medical imperfect competition market, the market-led result is better and better service, but the price is higher and higher. The other model is government-led, represented by Britain and Canada. Public hospitals are completely invested by the government, and ordinary people are free to see a doctor. Rich people need special services and can go to private hospitals. Under this model, medical care is cheap and universal, and the government investment is relatively small. Medical expenses in the United States account for about 0.4% of GDP 65438+, while in Britain it is only about 7%.
At present, China's medical system reform generally emphasizes the role of the market. But it should be noted that the market-oriented medical system needs the support of the market. The annual per capita medical expenses in the United States are about $50,000, while the per capita GDP in China is only 1000. Even the financial resources of many developed countries in Europe are not enough to support the development of the medical market, let alone China. Facing the special national conditions, the future of medical system reform in China is still worth pondering.
The problem of input mechanism should start with the medical price. It is reported that in the past 20 years, employees' wages have increased by 20 times, while medical expenses have increased by 200 times. The common cold often costs hundreds or even hundreds of yuan, which is equivalent to the income of farmers who have worked hard for a year-the so-called "ambulance rings and raises a pig for nothing". According to the third national health service survey released not long ago, 48.9% people in China are sick and don't go to see a doctor, and 29.6% people should be hospitalized instead of hospitalized.
The reason is that medical technology is getting more and more advanced and medical expenses are getting higher and higher. Of course, the medical effect is getting better and better, which is reasonable. But it does not rule out the influence of institutional factors. At present, there are three sources of book income of public hospitals as market players: drug income accounts for about 45-55% of total income, medical income accounts for about 40-50% of total income, and government financial subsidies account for about 5% of total income. Therefore, the price difference between drug wholesale and retail has become a long-term and stable income guarantee for hospitals. Without this income, the hospital will close down.
To fundamentally solve the problem of difficult and expensive medical treatment, an important problem is to solve the problem of hospital investment mechanism and compensation mechanism.
(2) Extensive internal management and lack of cost awareness. On the one hand, hospitals emphasize economic benefits, on the other hand, internal management is extensive and waste is common.
Paying more attention to scale than efficiency is an important feature of extensive hospital management. According to reports, the number of hospital beds with 654.38+10,000 beds in China is much higher than that in the United States and most developed countries, and even the number of county-level hospitals in some economically developed areas exceeds 654.38+10,000. In the United States, there are only a handful of large hospitals with more than 65,438+0,000 beds. In Massachusetts General Hospital, which ranks among the best in the United States, the number of beds has been reduced from 1.200 to 800 in the past decade. At the same time, the number of discharged patients and surgical patients has increased (44,000 and 32,000 respectively in 2004). The key is to reduce the number of beds to reduce operating costs. The average length of stay in tertiary hospitals in China is about 15 days, while that in similar hospitals in the United States is about 6 days. The efficiency of each bed is 2.5 times that of ours. Similarly, there are too many operating rooms in our country. Overseas operating rooms are crowded from 6 am to late at night, while our operating rooms are gradually sparsely populated after the morning rush hour, with low utilization rate and high operating costs.
(3) The allocation of human resources is unreasonable, and the proportion of doctors and nurses is seriously unbalanced. In 2004, the total number of nurses and doctors in China was 6.5438+0.3078 million, and the total number of doctors was 6.5438+0.9048 million (including 6.5438+0.565438+10,000). According to the statistics of WHO 1998, although the proportion of doctors per thousand population in China has reached the level of many countries in the world, the number of nurses is far from enough. In 200 1 year, the ratio of doctors and nurses in China is only 1: 0.6 1, which is far below the world average (1: 2.7). Judging from the ratio of nurses per thousand population, most countries have reached more than 3 in 1998, some developed countries even reached more than 30, and China only has 1. There are many reasons for the shortage of nurses. The direct reason is that nursing education lags behind the development of medical care. Of course, the social status of nurses has not been reasonably recognized, and the high labor intensity and low income are also important reasons.
(4) Hospitals pay more attention to hardware construction than human resources investment. In recent years, a small number of medical staff have indeed committed illegal acts of "accepting red envelopes" and "taking kickbacks". But at the same time, they don't pay enough attention to the income of medical staff. At present, the standard income of medical staff in China is far from that of foreign counterparts or domestic emerging industries and foreign-funded enterprises. In foreign countries, the salary of medical staff often ranks first in all industries. Even in developing countries with less developed medical technology and economy than China, the salary level of medical staff is much higher than that of China.
In addition, personnel can enter but not leave, so it is difficult to survive the fittest; People in different levels of hospitals cannot flow; Difficult diseases such as unclear internal management rewards and punishments are also common in hospitals.
To sum up, the current medical level in China is second to none not only in medical education, scientific research or clinical services, but also in the world.