减少医师自卫医学行为的对策研究

根据自卫医学行为产生的原因,减少自卫医学行为有两个思路,一个是减轻医师的法律责任,另一个是化解医师在法律责任下所面临的风险。根据第二个思路,应该采取下面的措施:建立医师责任保险制度;建立医疗责任保险制度;实施医疗风险管理;提高医师个人的执业素养。     

对影响患者安全行为的医院内部追责机制探讨

患者安全是未来医学发展的方向。对影响患者安全行为进行医院内部追责是保障患者安全、提高医疗服务质量的重要环节。通过分析美国法律体系中医疗责任承担方式的演进规律,结合对我国医事法律责任的梳理,明确依据主诊医师负责制对影响患者安全行为进行内部追责具有可行性,且能够兼顾医疗不良事件报告"不惩罚原则",起到保障患者安全、提高医疗服务质量的作用。但应注意,国内医疗机构引入主诊医师负责制的同时,不应削弱我国传统质控制度对患者安全的积极作用。     

医疗风险防范与化解新趋向

新的《医疗事故处理条例》实施以后,患者的自我保护意识不断增强、高精尖医疗器械的应用、新技术的不断开展等均增加了医疗行为的风险,医疗风险管理显示出日益重要的作用。新形势下医疗风险管理的新趋向是建立自愿的医疗责任保险、组织患者参加医疗风险保险、建立强制性医疗责任保险制度、卫生行政部门代理保险业务、建立医疗援助基金等方式,提出了在风险控制的基础上,加强风险融资的措施。     

论医疗责任保险的外部条件

推广医疗责任保险是近年来卫生领域的一项重要政策。但是迄今的运行实践表明,医疗责任保险有名无实,既不能有效减轻医疗机构的负担,也不能对医疗纠纷的解决发挥预期作用。从美国与德国在医疗责任保险实施效果上的严重反差来看,医疗责任保险的推行,需要有完善的法制与社会保障制度作为支撑。未来应当将医疗责任保险与医疗意外保险同步推行,建立特殊的医疗风险社会保障制度,减轻患者的经济负担,才可能实现医疗责任保险的良好运行。     

患者视角:医生应该告知医疗差错吗?——全国10城市4000名住院患者问卷调查研究报告之三

通过问卷调查和访谈,了解患者对医疗差错的认知以及对医师告知医疗差错的态度和评价.结果发现,大多数患者对医师告知医疗差错有强烈的要求,但认为其合理要求在现实中没有得到充分满足.大部分患者表示,如果医师主动告知医疗差错有可能会原谅医生,但医师出于对个人利益的过多考虑和专业精神的缺乏往往不能主动揭露差错.建议通过推行不良事件报告制度、规范医疗责任保险、加强风险意识宣传、开展告知技能培训以及专业精神教育,以促进医师正确对待医疗差错,实施诚信医疗,维护医患和谐.     

临床医师医学人文认知情况的问卷分析——大连医科大学、哈尔滨医科大学、南京医科大学、河北医科大学、重庆医科大学联合调查之一

调查5个城市24所附属或教学医院的1 836名在职医师对医学人文的认知情况,结果表明,从总体来看,医学人文的问题已经开始引起医师们的重视,医师对医学人文的诸多问题有相当清楚的认识,医生们认为医学人文的核心思想是关爱、敬畏、呵护生命;实现医疗人性化的目标,更为重要的是临床诊疗实践中的人性化;在医院管理中落实医疗人性化,最主要的是优化行政管理,为医师们减轻压力;医学人文教育存在的最主要问题是医学人文教育与临床实践脱节;等等.     

福建省医疗责任保险述评

福建省医疗责任保险已经推行多年,并在各个地方形成各具特色的模式。对福建省医疗责任保险现行规定进行梳理,并从医疗责任保险的主体、运行模式以及法定条款三个方面的现状展开研究和分析,结合医患纠纷调解机制、互助基金制度与《侵权责任法》等配套制度加以阐释,指出福建省医疗责任保险运行过程中存在的风险防控能力薄弱、调解机制不健全、侵权法有关界定不明晰等问题,未来应推动医疗责任保险与医患纠纷调解的有效衔接,进一步完善法律法规和相关配套制度。     

基于相互制医疗责任保险思考医疗纠纷解决机制

符合医疗行业特点的保险模式和制度设计是医疗责任保险制度成功的关键。与商业性的责任保险相比,相互制医疗责任保险具有成本低、减少信息不对称以及风险控制和维护行业利益等多方面的优势。相互制医疗保险制度的构建应当在组织构成和保单条款等方面符合其相互性特点和医疗行业的实际需要。相互制医疗保险组织在分散医疗机构责任风险的同时,应当代替医疗机构全面介入医疗纠纷解决过程,从而提高解决医疗纠纷的质量和效率,促进医患关系的和谐。     

"开颅戒毒"的伦理困境

卫生部叫停"开颅戒毒"手术后,最紧要的工作应是:切实做好对人们健康权的保护工作,改变医患之间信息极不对称的现状,改善医学伦理委员会人员结构,依法规范专家资质,制定统一审查程序,明确审查行为的法律责任,以保障医疗工作更加安全.     

论医师社会责任意识行为的社会基础

医师作为一种职业,必然要和医师本人的经济利益发生关系.一旦医师的行为和经济利益发生关系,就有可能和医师的社会责任发生冲突.市场的调控作用不能很有效地调节和监控医师的行为,需要通过制度影响医师的经济利益,引导医师负起社会责任.讨论医师的市场准入资格的审定;讨论医师的行医方式和报酬制度的建设;讨论政府主导作用的弱化对医师行为的影响;讨论公立医院运行机制市场化倾向对医师行为的影响,并提出改进意见.     

Synergistic interaction between ankle and knee during hopping revealed through induced acceleration analysis

The forces produced by the muscles can deliver energy to a target segment they are not attached to, by transferring this energy throughout the other segments in the chain. This is a synergistic way of functioning, which allows muscles to accelerate or decelerate segments in order to reach the target one. The purpose of this study was to characterize the contribution of each lower extremity joint to the vertical acceleration of the body’s center of mass during a hopping exercise. To accomplish this, an induced acceleration analysis was performed using a model with eight segments. The results indicate that the strategies produced during a hopping exercise rely on the synergy between the knee and ankle joints, with most of the vertical acceleration being produced by the knee extensors, while the ankle plantar flexors act as stabilizers of the foot. This synergy between the ankle and the knee is perhaps a mechanism that allows the transfer of power from the knee muscles to the ground, and we believe that in this particular task the net action of the foot and ankle moments is to produce a stable foot with little overall acceleration.     

Common and specific gait patterns in people with varying anatomical levels of lower limb amputation and different prosthetic components

The present study’s aim was to identify the kinematic and kinetic gait patterns and to measure the energy consumption in people with amputation according to both the anatomical level of amputation and the type of prosthetic components in comparison with a control group matched for the gait speed. Fifteen subjects with unilateral transtibial amputation (TTA), forty with unilateral transfemoral amputation (TFA) (9 with mechanical, 17 with CLeg and 14 with Genium prosthesis) and forty healthy subjects were recruited. We computed the time-distance gait parameters; the range of angular motion (RoM) at hip, knee and ankle joints, and at the trunk and pelvis; the values of the 2 peaks of vertical force curve; the full width at half maximum (FWHM) and center of activity (CoA) of vertical force; the mechanical behavior in terms of energy recovery (R-step) and energy consumption. The main results were: i) both TTA and TFA show a common gait pattern characterized by a symmetric increase of step length, step width, double support duration, pelvic obliquity, trunk lateral bending and trunk rotation RoMs compared to control groups. They show also an asymmetric increase of stance duration and of Peak1 in non-amputated side and a decrease of ankle RoM in amputated side; ii) only TFA show a specific gait pattern, depending on the level of amputation, characterized by a symmetric reduction of R-step and an asymmetric decrease of stance duration, CoA and FWHM and an increase of Peak1 in the amputated side and of hip and knee RoM, CoA and FWHM in the non-amputated side; iii) people with amputation with Genium prosthesis show a longer step length and increased hip and knee RoMs compared to people with amputation with mechanical prosthesis who conversely show an increased pelvic obliquity: these are specific gait patterns depending of the type of prosthesis. In conclusion, we identified both common and specific gait patterns in people with amputation, either regardless of, or according to their level of amputation and the type of prosthetic component.     

医学模式的转变与循证医学

生物-心理-社会医学模式是20世纪70年代末提出的医学模式理念,但目前我国仍未完成医学模式的转变.在20世纪最后10年,西方发达国家医学界又提出了循证医学这一概念.这就给我国医学和相关学科工作者,在认识上造成了一些混乱.就二者的关系、医学模式转变困难的客观原因进行讨论.     

Eccentric loading and range of knee joint motion effects on performance enhancement in vertical jumping

The aim of the study was to determine the effects of variations in eccentric loading and knee joint range of motion on performance enhancement associated with the stretch-shortening cycle in vertical jumping. Seventeen male elite volleyball players performed three variations of the vertical jump which served as the research model: the squat jump (SJ), countermovement jump (CMJ) and drop jump from a height of 30 cm (DJ30). Knee joint angle (70 degrees and 90 degrees of flexion) at the commencement of the propulsive phase for each jump type was experimentally controlled, with the trunk kept as erect as possible. Force and motion data were recorded for each performance and used to compute a range of kinematic and kinetic variables, including hip, knee and ankle angles, angular velocities, work done, net joint moments and a number of temporal variables. The average of 12 trials for each participant was used in a series of repeated measures ANOVA's (jump xk nee, alpha=.05). From both knee joint angles, an increase in eccentric loading resulted in a significant increase in jump height (DJ30>CMJ>SJ; p<.05). These enhancements were significantly greater (p<.05) for 70 degrees in comparison to 90 degrees of knee flexion. From 70 degrees of knee flexion, these enhancements were due to significant increases in work done at all three joints; while from 90 degrees of knee flexion, only the hip and ankle joints appeared to contribute (p<.05). The amount of enhancement associated with employing the SSC in jumping is dependent upon the interaction of the magnitude of eccentric loading and the range of motion used.     

Coordination and timing of spine and hip joints during full body reaching tasks

Coupling of spine and hip joints during full body reaching tasks was investigated in 16 participants (8 male and 8 female) who performed reaching tasks at comfortable and fast-paced movement speeds to three targets located in a para-sagittal plane. The participants paused at target contact for 500ms and then returned to an upright posture. Three-dimensional joint motions of the spine and hip were recorded using an electromagnetic tracking device. We found an effect of movement phase (i.e., reach and return) on the onset timing of the spine and hip joints. For most target locations and movement speeds, spine motion onset preceded hip motion onset during the reaching phase of the movement task. In the reach phase, when averaged across all movement conditions, spine joint motion preceded hip joint motion by an average of 48.9ms. In contrast, in the return phase, hip joint motion preceded spine joint motion by an average of 63.0ms. Additionally, when participants were instructed to use either a knee flexion or knee extension strategy to perform the reaching tasks there was no effect of movement strategy on timing of the spine and hip. There was also no effect of target height on the spine-hip ratio, but as movement speed increased, the spine/hip ratio decreased for all target locations due primarily to an increase in hip joint excursion. The findings indicate clear differences in onset timing of the spine and hip joints during reaching tasks that necessitate some forward bending of the trunk and that onset timing is reversed for the return to an upright posture.     

4～6岁儿童对“偶得物品”与“拥有物品”的分享行为

采用被试内设计法,在三种实验条件下考察180名4～6岁儿童的分享判断及其对“偶得物品”与“拥有物品”的分享行为的发展。结果发现:(1)儿童在对分享故事情境进行不充当角色的判断时,90%的4岁儿童和100%的5岁、6岁儿童能做出正确判断。当他们进行充当故事中人物角色的判断时,4岁儿童判断的正确率降低到81%,5岁和6岁儿童的判断无变化。(2)4岁儿童中大约四分之一的人能够把在实验室情境中偶然得到的、自己喜欢的物品让给未得到该物品的同伴分享,能够这样做的5岁儿童大约有一半,而6岁儿童能够这样做的人达到七成以上,从4岁到6岁,发展趋势非常明显。(3)在对“自己拥有的”物品的分享上,大多数4～6岁儿童都不能将其让给在竞赛中失败、未获得该物品的同伴一同分享。(4)儿童在对分享情境的判断与他们的真实分享行为之间存在着不一致现象。     

农村留守儿童心理健康水平变迁的横断历史研究

研究选取2004年至2017年中采用MHT量表的90篇文献,进行了横断历史元分析,探究留守儿童心理健康状况随年代的变化趋势。结果表明:(1)学习焦虑、过敏倾向与年代呈正相关,其余因子均与年代呈负相关,年代对各因子变异的解释率在14%~23%之间;(2)对人焦虑、身体症状、恐怖倾向、冲动倾向平均下降范围在0.06~0.73个标准差间;学习焦虑得分增加了3.44分,解释率为23%;(3)女性留守儿童的对人焦虑、恐怖倾向、冲动倾向改善优于男性;(4)初中留守儿童学习焦虑和过敏倾向较小学留守儿童在历年呈下降趋势;(5)中部地区和东部地区的留守儿童心理健康状况改善速度快于西部。整体看来,留守儿童的学习焦虑在逐渐增加,但总体心理健康状况在逐步提升。     

Simple lower extremity two-joint synergy

The purpose of this study was to describe the existence of a simple synergy in the lower extremity. Subjects performed discrete knee flexion or extension movements or ankle plantar or dorsiflexion movements in a sagittal plane, moving one of the joints "as fast as possible." Joint angles and electromyographic (EMG) signals from the biceps femoris, rectus femoris, soleus, and tibialis anterior were recorded. Typically, EMG patterns in both muscle pairs acting at the joints demonstrated the "triphasic" pattern. The knee flexor (biceps femoris) and ankle plantar flexor (soleus) tended to show simultaneous EMG bursts, while the knee extensor (rectus femoris) and ankle dorsiflexor (tibialis anterior) had similar patterns of activation. A two-joint simple synergy previously established for upper extremities seems pertinent for lower extremities as well. Such a synergy is used by the central nervous system to simplify control of the postural component of a motor task.     

Limb and gender differences in the development of coordination in early infancy

Young infants produce a variety of spontaneous arm and leg movements in the first few months of life. Coordination of leg joints has been extensively investigated, whereas arm joint coordination has mainly been investigated in the sitting position in the context of early reaching and grasping. The current study investigated arm and leg joint coordination of movements produced in the supine position in 10 fullterm infants aged 6, 12 and 18 weeks. Longitudinal comparisons within limbs (intralimb) as well as between limbs (interlimb, ipsilateral and contralateral) were made as well as an exploration of differences in the development for boys and girls. The relationship between the joint angles was examined by measuring pair-wise cross-correlation functions for the angular displacement curves of the leg (hip, knee and ankle) and arm (shoulder, elbow and wrist) joints of both the right and left side. Both the arms and legs were found to follow a similar pattern of intralimb coordination, although the leg joints were more tightly coupled than the arm joints, particularly the proximal with the middle joint. In support of earlier findings, differences in the development of the right and left side were identified. In addition, gender differences in joint coordination were found for both intralimb and interlimb coordination. This contrasts with the view that gender differences in motor development may be primarily a result of environmental influences.     

Medical Ethics,Bioethics and Research Ethics Education Perspectives in South East Europe in Graduate Medical Education

Ethics has an established place within the medical curriculum. However notable differences exist in the programme characteristics of different schools of medicine. This paper addresses the main differences in the curricula of medical schools in South East Europe regarding education in medical ethics and bioethics, with a special emphasis on research ethics, and proposes a model curriculum which incorporates significant topics in all three fields. Teaching curricula of Medical Schools in Bulgaria, Bosnia and Herzegovina, Croatia, Serbia, Macedonia and Montenegro were acquired and a total of 14 were analyzed. Teaching hours for medical ethics and/or bioethics and year of study in which the course is taught were also analyzed. The average number of teaching hours in medical ethics and bioethics is 27.1 h per year. The highest national average number of teaching hours was in Croatia (47.5 h per year), and the lowest was in Serbia (14.8). In the countries of the European Union the mean number of hours given to ethics teaching throughout the complete curriculum was 44. In South East Europe, the maximum number of teaching hours is 60, while the minimum number is 10 teaching hours. Research ethics topics also show a considerable variance within the regional medical schools. Approaches to teaching research ethics vary, even within the same country. The proposed model for education in this area is based on the United Nations Educational, Scientific and Cultural Organization Bioethics Core Curriculum. The model curriculum consists of topics in medical ethics, bioethics and research ethics, as a single course, over 30 teaching hours.