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如何作个好医生Prof.YeanL.LimAMMDPhDFRACPUniversityofMelbourne,Australia“如何建設覆盖城乡居民的基本卫生保健制度…..讓人民平等地享受基本卫生保健?”胡錦涛主席乡鎮老百姓的基本卫生保健ImportanceofHistoryTakingHistory•70yrfarmer,awoke6amwithanorexia,epigastricpain,coughing•S/BvillageLMO730am,given2pillsforSxrelief;toldtogototeachinghospitalifSxnotimproved•Traveled1hrbybustoEDofatertiaryteachingHospitalinthenearestcity•12md,Dxaslungdisease,admittedtoresp.ward•230pmECGrevealedacuteanteriorMI•330pmurgentPPCI,stentingofLAD;PtsurvivedPatient,Disease,Lesion病人-病-病变•Patient病人70yrfarmer,marriedwith1childsufferingAMIduetosuddenLADocclusion•Disease病70manwithsinglevesselLADdisease•Lesion病变Coronaryangiogramshowing100%LADocclusion(Targetfortherapy)三等醫生醫生-治病人醫匠-治病“醫死”-治“病變”(圖象)中国心脏介入医生的培訓“3Knows”ofPCI(介入三知)1KnowthePatient(知病人)ClinicalIndications&secondaryfactors(Cultural,Financialetc)2KnowtheEvidence(知證据)LatestClinicalTrialresults3KnowOneself(知已)Knowyourresults(Hospital&Individualoperators)医疗-中国第一社会問題”看病難,看病貴”看病難(管理制度问題–治标)看病貴(医务質量问題–治本)“医疗卫生体制攺革,既要治标,又要治本”北京主管卫生副巿长丅向阳看病貴看病貴•医匠非医生ExpensiveMedicalConsultations(DoctorsratherthanTechnocrats)•檢查医學,非臨床医學InvestigativeMedicine(MachineoverMan)MoreThinkingLessTestingMcAllenHospital•Worsemedicine;•Fragmentedcare•High-costLow-quality($15600/diseaseRx)•Profit(Quantity)driven•Practitioner-orientated•MoretestinglessThinkingMayoClinic•Bestmedicine•Coordinatedcare•Lowcosthighquality($6688/diseaseRx)•Outcome(Quality)driven•Patient-orientated•MoreThinkingLessTestingNewYorker2009“大医看大病小医看小病”看病難普通医生(小医)培訓專家學院4-8年內外科其他特專設區私人医生診所政府註册全囩通行医疗執照專家医生(大医)培訓医學院本科大學5-6年硏究生4年本科4年医學院4年澳洲医疗体制普通家庭医生公立,私立医院私人医生診所家庭医生/專家轉診医疗制度專家医生OslerLibrary–McGillUniversity,Montreal,CanadaOsleratCliffordAlbutt’sresidenceThe3portraitsintheOslerLibraryMcGillUniversity,MontrealEssentialQualitiesofaDoctor医生本質Literature書寫(Linacre)Science科學(Harvey)Practice臨床(Sydenham)Humanity仁心(Osler)•Competence合格•Knowledge智識•Wisdom智慧•Compassion憐憫•Integrity誠实•Leadership領導医生基本條件EssentialQualitiesofaDoctor•ArtofDetachment中立•VirtueofMethod系統•Thoroughness仔细•Humility謙卑•Equanimity隠重HealingwithoutHumanism“Abookishmanmayneversucceed;hisfailureisnotbecausehestudiedbooksmuch,butbecausehehasnotstudiedman”.Osler’sGoodDoctor•AphysicianmaypossessthescienceofHarveyandtheArtofSydenham,andyetlackingthosefinerqualitiesofheartandheadwhichcountforsomuchinlife.•ThephysicianneedsaclearheadandakindheartAGoodDoctormustpossess:Head(Knowledge)Hand(Skill)Heart(Humanity)GoodDoctorDuncanMain:ScottishPhysicianFounderofZhejiangMedicalUniversity1890sHumanity&Medicine•HealingwithScienceisSuperstition•HealingwithHumanismisTechnology•HealingwithScienceandHumanismisMedicine仁智的醫生“醫生要有求智的熱情誠實與謙卑的精神,辦別是非的能力.不只追求科技與知識,更要有內涵的智慧,有仁愛的心,怜憫的精神.仁與智可作為醫生所追求的總結.總結Doctor(Educated/LearnedMen)1A“Good”Doctor(onewhotreatssickpeople)2“Docrats”orTechnocratDoctor(onewhotreatsdiseases)“Agooddoctortreatspatientsnotlesions;andbringsGoodnessnitGrieftohispatientsandrelatives”LimYLTwo-foldNatureofMedicalEducation医學的双重教育•SpecialEducation外在教育Aknowledgeofdiseaseanditscure,aknowledgethatwillmakeyoupractitionersofmedicine;extrinsic,accomplishedbytext,teachersandtongue.•InnerEducation內在教育Aknowledgeofyourself,aknowledgeofthatmaymakeyouatrulygoodman;intrinsic,mentalsalvationwroughtoutbyeachoneforhimself,andachievedthroughpersonalcontactwithmenofhighpurposeandcharacter.“Thefirstwithoutthesecond,anactivepractitioner,butthroughlifeyouhavebeenafool;thesecondwithoutthefirst,youmayhavetheendowmentsofheartandheadthatmakethelittleofwhatyoupossessgoveryfar.Thedesireistohaveadueproportionofeach”InnerEducationofaCultivatedPractitioner•“Medicineisseenatitsbestinmenwhosefacultieshavehadthehighestandmostharmonioustraining”•“Professionalworkofanysorttendstonarrowthemind•Thepractitionerneedscultureaswellaslearning,thewiderandfreeraman’sgeneraleducation,thebetterpractitionerwillhebe”.“IamgladIknowwhatgreatmenare.IamgladIknowofwhattheyaremadeandhowtheymadethemselvesgreat”DrBassettGeneralPractitionerBirmingham,AlabamaTheAlabamaStudentTwo-foldNatureofMedicalEducation•SpecialEducationAknowledgeofdiseaseanditscure,aknowledgethatwillmakeyoupractitionersofmedicine;extrinsic,accomplishedbytext,teachersandtongue.•InnerEducationAknowledgeofyourself,aknowledgeofthatmaymakeyouatrulygoodman;intrinsic,mentalsalvationwroughtoutbyeachoneforhimself,andachievedthroughpersonalcontactwithmenofhighpurposeandcharacter.“Thefirstwithoutthesecond,anactivepractitioner,butthroughlifeyouhavebeenafool;thesecondwithoutthefirst,youmayhavetheendowmentsofheartandheadthatmakethelittleofwhatyoupossessgoveryfar.Thedesireistohaveadueproportionofeach”DialoguebetweenHuangdi黄帝&Chi-Po歧伯“HUANGDINEIJING黃帝內經”(InnerCanon)200BC(PrincipleandTheoryofChineseMedicine)SpecialEducationHistoryTakinginMedicine望Inspection闻Auscultation切Palpation&Percussion问HistoryTakingClinicalorBedsideSkillsMostimportantSpecialSkillofaDoctor(ExtrinsicEducation)醫生非醫匠(畫家非畫匠)“DoctornotTechnician;ArtistnotArtisan”ACompleterDoctor“頭手心”医生ADoctorwithHead(Knowledge)Hand(Technicalskill)Heart(Humanity)冠動脈图天地現1杰出的科研2杰出的临床医疗3杰出的专业培训医生/醫院的學術卓越Work“Workhardwhileitisday”•“Yourbu