浅析当前临床科学决策的几个影响因素

随着循证医学在我国的发展和"医疗举证责任倒置"等相关法律的实施,我国临床医生在进行诊治决策时已逐步向临床科学决策迈进.而防御性医疗、不健全的医疗制度及相关法律等却严重影响着这一科学决策的转变过程.只有有效解决了导致干扰科学决策的各种社会影响因素,如扩大基本医疗保险的覆盖率,实施医疗风险保险制度,提高医务人员认知和职业素质,保障行医安全等,临床科学决策的真正落实就大有希望.     

《医疗事故处理条例》的法律缺陷与立法对策

《医疗事故处理条例》（以下简称《条例》）实施3年以来,其在医疗事故预防、医疗事故鉴定、医疗事故赔偿等方面发挥了积极的作用。随着我国相关立法的发展和完善,《条例》在医疗实践中的法律缺陷越来越明显。针对我国目前医疗侵权损害赔偿的现状,制定一部统一的关于医疗侵权损害赔偿的法律已是当务之急。     

警惕临床中科学决策的“陷阱”

科学决策是一种体系,包括科学思维、科学程序、科学手段以及对决策结果的科学处理等方面,而不是单指某一方面。认为包含科学成份的决策是科学决策,这是对科学决策的一种误解。决策介于科学与非科学之间,因此便会产生很多陷阱。陷阱形似"科学",常常令人深信不疑、毫无防范而跌入陷阱。临床医疗中最大失误就是决策上的失误,而精准的科学决策又是一项复杂的系统工程。因此也就需要做整体把握,修正决策偏差,在个体化层面实现整体的科学决策。     

澳大利亚“国家电子医疗战略”对我国的启示

电子医疗对于推动医疗信息互联互通、创新医疗模式、提升卫生服务水平具有重要意义。澳大利亚"国家电子医疗战略"确立了加强基础设施建设、利益相关者参与等7项实施原则,并围绕电子医疗消费者、提供者和管理者三个利益群体确定了较为详细的战略实施目标。战略实施分为短期、中期和长期三个阶段,每个阶段都规定了较为详细的具体内容。目前澳大利亚已经初步取得了较为理想的实施效果,形成了政府服务国民健康体系的核心基础。澳大利亚的相关政策措施对我国的医疗改革及"电子医疗"建设具有一定的启示意义。     

对手术同意书的法律思考

手术同意书是现代医疗制度中的重要医疗文书.从法律角度看,它具有医务人员职务行为、履行注意义务、履行告知义务及医疗行为合法性等证明效力的法律属性,也具有患者自愿作出选择并授权医方实施手术法律效力,但不具有免除医疗机构责任的效力.由此,需要对手术同意书签字权、内容和形式、手术相关情况的告知过程等加以完善.     

多元化建构医学生的临床决策能力——以麻醉专业学生为例

文章从多维视角对建构医学生的临床决策能力进行了研究和探讨,突出从科学决策(博学、信息层面、实践累积和思维模式)、伦理学和法律、心理学(个体和群体心理)以及经济学四个维度揭示了医学生临床决策能力建构的多元化,优化了构建医学生临床决策能力的培养模式,在麻醉专业学生取得了较好的效果,有助于综合素质的培养,能够更好地构建麻醉专业学生的临床决策能力,遵循临床决策的基本原则,保障医疗质量和安全、改善医患关系、提升医学生今后从事麻醉医疗服务能力。     

美国、新西兰、澳大利亚医疗风险管理体系比较研究

通过对美国、新西兰、澳大利亚三国医疗风险管理的概述及比较分析.认识到各国医疗风险管理各具特色.美国故障模式影响分析法,报告系统及信息化决策系统的灵活运用,新西兰良好的法律支持环境和医疗诉讼体系改革,澳大利亚临床风险管理程序及危险和差错管理方案的实施.最终寻求适合我国医疗风险管理的可借鉴之处.     

英国侵权法视野下中国医疗过失的流变与展望

医疗过失是判断医疗损害的重要构成要件,所以对其研究意义重大。而随着《侵权责任法》的实施,司法实践中医师是否尽到注意义务已然成为认定医疗过失的重要标准。通过英国侵权法中医疗过失与注意义务的演进规律,结合我国从《医疗事故处理办法》、《医疗事故处理条例》,到《侵权责任法》医疗过失的立法流变过程,展望我国司法实践中医疗过失的特点和趋势:法院会加强对医疗技术鉴定意见进行个案的充分质证与审查;法院应根据具体案情区别适用判决或调解结案;法律必将加速"家父主义"向"患者中心主义"的转变。     

对影响“临床决策”负面因素的剖析与探讨

临床决策是医疗实践过程中的中心环节,直接关系到病人的治疗效果。在决策形成和实施过程中受到各方面因素的制约,主要包括两个方面医生自身方面因素,如医生素质、技术水平、决策思维能力等;医生自身以外的因素,如卫生政策、药品及其它医疗器材的流通环节、医保制度、医院经营方针,其它因素如社会、伦理、法律、经济等无不影响着医疗决策的正确实施。因此,要排除干扰,努力实施科学的临床决策,不仅要加强医生本身的素质和技术层面的培养和提高,更需要全社会、患者和广大公众给予理解和支持。     

对影响"临床决策"负面因素的剖析与探讨

临床决策是医疗实践过程中的中心环节,直接关系到病人的治疗效果.在决策形成和实施过程中受到各方面因素的制约,主要包括两个方面:医生自身方面因素,如医生素质、技术水平、决策思维能力等;医生自身以外的因素,如卫生政策、药品及其它医疗器材的流通环节、医保制度、医院经营方针,其它因素如社会、伦理、法律、经济等无不影响着医疗决策的正确实施.因此,要排除干扰,努力实施科学的临床决策,不仅要加强医生本身的素质和技术层面的培养和提高,更需要全社会、患者和广大公众给予理解和支持.     

An outcomes model of medical decision making

In the traditional fix-it model of medical decision making, the identified problem is typically characterized by a diagnosis that indicates a deviation from normalcy. When a medical problem is multifaceted and the available interventions are only partially effective, a broader vision of the health care endeavor is needed. What matters to the patient, and what should matter to the practitioner, is the patient's future possibilities. More specifically, what is important is the character of the alternative futures that the patient could have and choosing among them so as to achieve the best future possible, with the ranking of outcomes determined by the patient's preferences. This paper describes the fix-it model, presents and defends the outcomes-based model, and demonstrates that the latter is useful in developing normative conceptions of informed consent and decision making and in establishing a basis for societal involvement in the decision making process. Finally, several shortcomings of the model will be acknowledged.     

当前临床决策的问题及对策

随着传统生物医学模式向生物-心理-社会医学模式的转变,临床决策也应由目前以经验医学为主导的经验决策向以循证医学为基础的科学决策转变。     

The Harm Principle Cannot Replace the Best Interest Standard: Problems With Using the Harm Principle for Medical Decision Making for Children

For many years the prevailing paradigm for medical decision making for children has been the best interest standard. Recently, some authors have proposed that Mill’s “harm principle” should be used to mediate or to replace the best interest standard. This article critically examines the harm principle movement and identifies serious defects within the project of using Mill’s harm principle for medical decision making for children. While the harm principle proponents successfully highlight some difficulties in present-day use of the best interest standard, the use of the harm principle suffers substantial normative and conceptual problems. A medical decision-making framework for children is suggested, grounded in the four principles. It draws on the best interest standard, incorporates concepts of harm, and provides two questions that can act as guide and limit in medical decision making for children.     

临床决策偏差中的心理效应

临床决策是临床工作的核心。科学正确的临床决策是保证医疗服务质量的重要环节。现代心理学对临床决策的研究发现,由于决策双思维系统运转模式的存在,一些心理效应常常会导致临床决策出现系统性偏差或失误,这些心理效应包括易得性、拆分效应、锚定效应、框架效应、单次-重复博弈效应和后见之明效应等。医务人员了解这些心理效应的表现,熟悉它们对临床决策的潜在影响,并在进行重大临床决策时有效避免之,将会显著提升临床决策质量。     

羊水栓塞诊断的临床决策

临床决策已成为临床医学的重要内容,但目前仍被许多妇产科医师所忽视。通过阐述临床决策的概念及意义,分析了羊水栓塞诊断中应该注意的问题,探讨了如何建立科学的羊水栓塞诊断的临床决策。为了提高临床决策的效率和准确性,减少或避免各种失误,需要建立一套合理的临床思维方法和科学的处理程序,为羊水栓塞的治疗提供科学的决策方法。     

Does young adults’ preferred role in decision making about health,money, and career depend on their advisors’ leadership skills?

Few empirical data exist on how decision making about health differs from that in other crucial life domains with less threatening consequences. To shed light on this issue we conducted a study with 175 young adults (average age 19 years). We presented the participants with scenarios involving advisors who provided assistance in making decisions about health, money, and career. For each scenario, participants were asked to what extent they wanted the advisor to exhibit several leadership styles and competencies and what role (active, collaborative, or passive) they preferred to play when making decisions. Results show that decision making about health is distinct from that in the other domains in three ways. First, most of the participants preferred to delegate decision making about their health to their physician, whereas they were willing to collaborate or play an active role in decision making about their career or money. Second, the competencies and leadership style preferred for the physician differed substantially from those desired for advisors in the other two domains: Participants expected physicians to show more transformational leadership—the style that is most effective in a wide range of environments—than those who provide advice about financial investments or career. Finally, participants’ willingness to share medical decision making with their physician was tied to how strongly they preferred that the physician shows an effective leadership style. In contrast, motivation to participate in decision making in the other domains was not related to preferences regarding advisors’ leadership style or competencies. Our results have implications for medical practice as they suggest that physicians are expected to have superior leadership skills compared to those who provide assistance in other important areas of life.     

Cognitive functioning as a contraindication to organ transplant surgery: Dilemmas encountered in medical decision making

A case is presented to illustrate some of the difficulties encountered when providing psychological consultation to evaluate the readiness of patients for pediatric heart-lung transplantation. The outcome of complex medical decision making can often hinge on information provided by the psychological consultant who is attempting to simultaneously serve the needs of the patient as well as the transplant team. Ethical dilemmas frequently arise when medical decision making is driven by limited health care resources and cost constraints. The utility of cognitive functioning as a variable in pediatric transplant decision making is discussed. Recommendations are made for further work in this area on both conceptual and empirical grounds to guide the integration of psychological information into transplant decision making as health care delivery continues to evolve in the future.     

A study of the foundations of ethical decision making of clinical medical ethicists

A study of clinical medical ethicists was conducted to determine the various philosophical positions they hold with respect to ethical decision making in medicine and their various positions' relationship to the subjective-objective controversy in value theory. The study consisted of analyzing and interpreting data gathered from questionnaires from 52 clinical medical ethicists at 28 major health care centers in the United States. The study revealed that most clinical medical ethicists tend to be objectivists in value theory, i.e., believe that value judgments are knowledge claims capable of being true or false and therefore expressions of moral requirements and normative imperatives emanating from an external value structure or moral order in the world. In addition, the study revealed that most clinical medical ethicists are consistent in the philosophical foundations of their ethical decision making, i.e., in decision making regarding values they tend not to hold beliefs which are incompatible with other beliefs they hold about values.     

Dispositional optimism,self‐framing and medical decision‐making

Self‐framing is an important but underinvestigated area in risk communication and behavioural decision‐making, especially in medical settings. The present study aimed to investigate the relationship among dispositional optimism, self‐frame and decision‐making. Participants (N = 500) responded to the Life Orientation Test‐Revised and self‐framing test of medical decision‐making problem. The participants whose scores were higher than the middle value were regarded as highly optimistic individuals. The rest were regarded as low optimistic individuals. The results showed that compared to the high dispositional optimism group, participants from the low dispositional optimism group showed a greater tendency to use negative vocabulary to construct their self‐frame, and tended to choose the radiation therapy with high treatment survival rate, but low 5‐year survival rate. Based on the current findings, it can be concluded that self‐framing effect still exists in medical situation and individual differences in dispositional optimism can influence the processing of information in a framed decision task, as well as risky decision‐making.